Severe street and mountain bicycling injuries in adults: a comparison of the incidence, risk factors and injury patterns over 14 years.

PubMed

Roberts, Derek J; Ouellet, Jean-Francois; Sutherland, Francis R; Kirkpatrick, Andrew W; Lall, Rohan N; Ball, Chad G

2013-06-01

Street and mountain bicycling are popular recreational activities and prevalent modes of transportation with the potential for severe injury. The purpose of this investigation was to compare the incidence, risk factors and injury patterns among adults with severe street versus mountain bicycling injuries. We conducted a retrospective cohort study using the Southern Alberta Trauma Database of all adults who were severely injured (injury severity score [ISS] ≥ 12) while street or mountain bicycling between Apr. 1, 1995, and Mar. 31, 2009. Among 11 772 severely injured patients, 258 (2.2%) were injured (mean ISS 17, hospital stay 6 d, mortality 7%) while street (n = 209) or mountain bicycling (n = 49). Street cyclists were often injured after being struck by a motor vehicle, whereas mountain bikers were frequently injured after faulty jump attempts, bike tricks and falls (cliffs, roadsides, embankments). Mountain cyclists were admitted more often on weekends than weekdays (61.2% v. 45.0%, p = 0.040). Injury patterns were similar for both cohorts (all p > 0.05), with trauma to the head (67.4%), extremities (38.4%), chest (34.1%), face (26.0%) and abdomen (10.1%) being common. Spinal injuries, however, were more frequent among mountain cyclists (65.3% v. 41.1%, p = 0.003). Surgical intervention was required in 33.3% of patients (9.7% open reduction internal fixation, 7.8% spinal fixation, 7.0% craniotomy, 5.8% facial repair and 2.7% laparotomy). With the exception of spine injuries, severely injured cyclists display similar patterns of injury and comparable outcomes, regardless of style (street v. mountain). Helmets and thoracic protection should be advocated for injury prevention.

Terrain Park Injuries

PubMed Central

Moffat, Craig; McIntosh, Scott; Bringhurst, Jade; Danenhauer, Karen; Gilmore, Nathan; Hopkins, Christy L.

2009-01-01

Background: This study examined demographics, injury pattern, and hospital outcome in patients injured in winter resort terrain parks. Methods: The study included patients ≥12 years of age who presented to a regional trauma center with an acute injury sustained at a winter resort. Emergency department (ED) research assistants collected patient injury and helmet use information using a prospectively designed questionnaire. ED and hospital data were obtained from trauma registry and hospital records. Results: Seventy-two patients were injured in a terrain park, and 263 patients were injured on non-terrain park slopes. Patients injured in terrain parks were more likely to be male [68/72 (94%) vs. 176/263 (67%), p<0.0001], younger in age [23 ± 7 vs. 36 ± 17, p<0.0001], live locally [47/72 (65%) vs. 124/263 (47%), p=0.006], use a snowboard [50/72 (69%) vs. 91/263 (35%), p<0.0001], hold a season pass [46/66 (70%) vs. 98/253 (39%), p<0.0001], and sustain an upper extremity injury [29/72 (40%) vs. 52/263 (20%), p<0.001] when compared to patients injured on non-terrain park slopes. There were no differences between the groups in terms of EMS transport to hospital, helmet use, admission rate, hospital length of stay, and patients requiring specialty consultation in the ED. Conclusions: Patients injured in terrain parks represent a unique demographic within winter resort patrons. Injury severity appears to be similar to those patients injured on non-terrain park slopes. PMID:20046245

The impact of specialist trauma service on major trauma mortality.

PubMed

Wong, Ting Hway; Lumsdaine, William; Hardy, Benjamin M; Lee, Keegan; Balogh, Zsolt J

2013-03-01

Trauma services throughout the world have had positive effects on trauma-related mortality. Australian trauma services are generally more consultative in nature rather than the North American model of full trauma admission service. We hypothesized that the introduction of a consultative specialist trauma service in a Level I Australian trauma center would reduce mortality of the severely injured. A 10-year retrospective study (January 1, 2002-December 31, 2011) was performed on all trauma patients admitted with an Injury Severity Score (ISS) > 15. Patients were identified from the trauma registry, and data for age, sex, mechanism of injury, ISS, survival to discharge, and length of stay were collected. Mortality was examined for patients with severe injury (ISS > 15) and patients with critical injury (ISS > 24) and compared for the three periods: 2002-2004 (without trauma specialist), 2005-2007 (with trauma specialist), and 2008-2011 (with specialist trauma service). A total of 3,869 severely injured (ISS > 15) trauma patients were identified during the 10-year period. Of these, 2,826 (73%) were male, 1,513 (39%) were critically injured (ISS > 24), and more than 97% (3,754) were the victim of blunt trauma. Overall mortality decreased from 12.4% to 9.3% (relative risk, 0.75) from period one to period three and from 25.4% to 20.3% (relative risk, 0.80) for patients with critical injury. A 0.46% per year decrease (p = 0.018) in mortality was detected (odds ratio, 0.63; p < 0.001). For critically injured (ISS > 24), the trend was (0.61% per year; odds ratio, 0.68; p = 0.039). The introduction of a specialist trauma service decreased the mortality of patients with severe injury, the model of care should be considered to implement state- and nationwide in Australia. Epidemiologic study, level III.

Effectiveness of early administration of tranexamic acid in patients with severe trauma.

PubMed

Shiraishi, A; Kushimoto, S; Otomo, Y; Matsui, H; Hagiwara, A; Murata, K

2017-05-01

A reduction in mortality with the early use of tranexamic acid has been demonstrated in severely injured patients who are bleeding. However, the modest treatment effect with no reduction in blood transfusion has raised concerns. The aim of the present study was to estimate the effectiveness of regular use of tranexamic acid in severely injured patients. This multicentre observational study used retrospectively collected data from consecutive injured patients (Injury Severity Score at least 16) treated in 15 Japanese academic institutions in 2012. A propensity score-matched analysis compared patients who did or did not receive tranexamic acid administration within 3 h of injury. Study outcomes included 28-day all-cause and cause-specific mortality, and need for blood transfusion. Of 796 eligible subjects, 281 were treated with tranexamic acid. Propensity score matching selected a total of 500 matched subjects (250 in each group). Tranexamic acid administration was associated with lower 28-day mortality (10·0 versus 18·4 per cent; difference -8·4 (95 per cent c.i. -14·5 to -2·3) per cent) and lower 28-day mortality from primary brain injury (6·0 versus 13·2 per cent; difference -7·2 (-12·3 to -2·1) per cent). However, there was no significant difference between groups in the need for blood transfusion (33·2 versus 34·8 per cent; difference -1·6 (-9·9 to 6·7) per cent). Early tranexamic acid use was associated with reduced mortality in severely injured patients, in particular those with a primary brain injury. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

A stratified response system for the emergency management of the severely injured.

PubMed

Lloyd, D A; Patterson, M; Robson, J; Phillips, B

2001-01-01

A decade ago, there were justifiable criticisms of the delivery of emergency care for injured patients in accident and emergency departments in the UK. To address this, a trauma management system was developed in 1991 at Alder Hey Hospital, Liverpool. This includes a trauma team, communication system, management guidelines and quality assurance. On admission to the accident and emergency department, injured patients are triaged to one of three levels of injury severity, and a multidisciplinary team lead by a paediatric surgeon or senior accident and emergency department physician is activated. The level of injury severity determines the composition of the trauma team. A care pathway based on ATLS/APLS principles has been developed. The response process as well patient management are documented and reviewed at a monthly audit meeting. Currently, more than 80% of eligible patients are managed using the trauma system, with an over-triage rate of about 25%. Regular modifications to the trauma system since its inception in 1991 have resulted in an efficient and effective management structure. Stratification of the trauma response has minimised unnecessary use of the multidisciplinary trauma team and ensures that mobilisation and use of hospital staff and resources are tailored to the needs of the injured patient. Although developed in a specialist children's hospital, the system could be adapted for any acute hospital.

A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions.

PubMed

Cotton, Bryan A; Podbielski, Jeanette; Camp, Elizabeth; Welch, Timothy; del Junco, Deborah; Bai, Yu; Hobbs, Rhonda; Scroggins, Jamie; Hartwell, Beth; Kozar, Rosemary A; Wade, Charles E; Holcomb, John B

2013-10-01

To determine whether resuscitation of severely injured patients with modified whole blood (mWB) resulted in fewer overall transfusions compared with component (COMP) therapy. For decades, whole blood (WB) was the primary product for resuscitating patients in hemorrhagic shock. After dramatic advances in blood banking in the 1970s, blood donor centers began supplying hospitals with individual components [red blood cell (RBC), plasma, platelets] and removed WB as an available product. However, no studies of efficacy or hemostatic potential in trauma patients were performed before doing so. Single-center, randomized trial of severely injured patients predicted to large transfusion volume. Pregnant patients, prisoners, those younger than 18 years or with more than 20% total body surface area burns (TBSA) burns were excluded. Patients were randomized to mWB (1 U mWB) or COMP therapy (1 U RBC+ 1 U plasma) immediately on arrival. Each group also received 1 U platelets (apheresis or prepooled random donor) for every 6 U of mWB or 6 U of RBC + 6 U plasma. The study was performed under the Exception From Informed Consent (Food and Drug Administration 21 code of federal regulations [CFR] 50.24). Primary outcome was 24-hour transfusion volumes. A total of 107 patients were randomized (55 mWB, 52 COMP therapy) over 14 months. There were no differences in demographics, arrival vitals or laboratory values, injury severity, or mechanism. Transfusions were similar between groups (intent-to-treat analysis). However, when excluding patients with severe brain injury (sensitivity analysis), WB group received less 24-hour RBC (median 3 vs 6, P = 0.02), plasma (4 vs 6, P = 0.02), platelets (0 vs 3, P = 0.09), and total products (11 vs 16, P = 0.02). Compared with COMP therapy, WB did not reduce transfusion volumes in severely injured patients predicted to receive massive transfusion. However, in the sensitivity analysis (patients without severe brain injuries), use of mWB significantly reduced transfusion volumes, achieving the prespecified endpoint of this initial pilot study.

Is trauma centre care helpful for less severely injured patients?

PubMed

Helling, Thomas S; Nelson, Paul W; Moore, B Todd; Kintigh, Denise; Lainhart, Kathy

2005-11-01

Trauma centres have been shown to reduce the number of preventable deaths from serious injuries. This is due largely to the rapid response of surgeons and health care teams to resuscitate, evaluate, and operate if necessary. Less is known about the effectiveness of trauma centre care on those patients who have not incurred immediate life-threatening problems and may not be as critically injured. The purpose of this study was to review the use of physician and hospital resources for this patient population to determine whether trauma team and trauma centre care is helpful or even needed. This was a retrospective study of consecutive trauma patients (n=1592) admitted from 1998 to 2002 to the trauma service of an urban level I trauma centre and recorded in the hospital trauma registry. Patients were triaged in a tiered response to more or less severely injured. All patients' care was directed by trauma surgeons. Of the 1592 patients, 398 (25%) received a full trauma team response (Class I), 1194 were less seriously injured (Class II). The ISS for the Class I patients was 19+/-18 and for Class II patients 10+/-10. Nineteen percent of Class II patients had an ISS>15. Overall mortality in Class II patients was 2% including 20 unexpected deaths. Four hundred and three Class II patients (34%) had multisystem injuries. Of the Class II patients 423 (35%) were sent to the ICU or OR from the ED, 106 of whom required an immediate operation and 345 required an operation prior to discharge. Complications developed in 129 patients (11%), the majority of which were pulmonary. A large proportion of those patients thought initially to be less severely injured required resources available in a trauma centre, including specialty care, intensive care, and operating room accessibility. Over one-third of these patients had multisystem injuries and almost 20% were considered major trauma, needing prioritisation of care and expertise ideally found in a trauma centre environment. Complications developed in a sizable number of patients. This patient population, because of its heterogeneity and propensity for critical illness, deserves the resources of a trauma centre.

Short-term outcome and differences between rural and urban trauma patients treated by mobile intensive care units in Northern Finland: a retrospective analysis.

PubMed

Raatiniemi, Lasse; Liisanantti, Janne; Niemi, Suvi; Nal, Heini; Ohtonen, Pasi; Antikainen, Harri; Martikainen, Matti; Alahuhta, Seppo

2015-11-05

Emergency medical services are an important part of trauma care, but data comparing urban and rural areas is needed. We compared 30-day mortality and length of intensive care unit (ICU) stay for trauma patients injured in rural and urban municipalities and collected basic data on trauma care in Northern Finland. We examined data from all trauma patients treated by the Finnish Helicopter Emergency Medical Services in 2012 and 2013. Only patients surviving to hospital were included in the analysis but all pre-hospital deaths were recorded. All data was retrieved from the national Helicopter Emergency Medical Services database, medical records, and the Finnish Causes of Death Registry. Patients were defined as urban or rural depending on the type of municipality where the injury occurred. A total of 472 patients were included. Age and Injury Severity Score did not differ between rural and urban patients. The pre-hospital time intervals and distances to trauma centers were longer for rural patients and a larger proportion of urban patients had intentional injuries (23.5% vs. 9.3%, P <0.001). The 30-day mortality for severely injured patients (Injury Severity Score >15) was 23.9% in urban and 13.3% in rural municipalities. In the multivariate regression analysis the odds ratio (OR) for 30-day mortality was 2.8 (95% confidence interval 1.0 to 7.9, P = 0.05) in urban municipalities. There was no difference in the length of ICU stay or scores. Twenty patients died on scene or during transportation and 56 missions were aborted because of pre-hospital death. The severely injured urban trauma patients had a trend toward higher 30-day mortality compared with patients injured in rural areas but the length of ICU stay was similar. However, more pre-hospital deaths occurred in rural municipalities. The time before mobile ICU arrival appears to be critical for trauma patients' survival, especially in rural areas.

Our Treatment Approaches in Severe Maxillofacial Injuries Occurring After Failed Suicide Attempts Using Long-Barreled Guns.

PubMed

Kucuker, Ismail; Şimşek, Tekin; Keles, Musa Kemal; Yosma, Engin; Aksakal, Ibrahim Alper; Demir, Ahmet

2016-03-01

Maxillofacial traumas with long-barreled guns may sometimes cause catastrophic results by means of smashing in facial structures. In these patients, reconstruction strategies of both fragmented/lost soft and hard tissues still remain controversial. In their clinic, the authors treated 5 patients with severely injured face after failed suicide attempt between 2008 and 2013. In this study, the authors aimed to present their clinical experiences on these severely injured maxillofacial gunshot traumas and offer a treatment algorithm to gain a result as possible as satisfactory in terms of functionality and appearance.

Effects of a radiation dose reduction strategy for computed tomography in severely injured trauma patients in the emergency department: an observational study.

PubMed

Kim, Soo Hyun; Jung, Seung Eun; Oh, Sang Hoon; Park, Kyu Nam; Youn, Chun Song

2011-11-03

Severely injured trauma patients are exposed to clinically significant radiation doses from computed tomography (CT) imaging in the emergency department. Moreover, this radiation exposure is associated with an increased risk of cancer. The purpose of this study was to determine some effects of a radiation dose reduction strategy for CT in severely injured trauma patients in the emergency department. We implemented the radiation dose reduction strategy in May 2009. A prospective observational study design was used to collect data from patients who met the inclusion criteria during this one year study (intervention group) from May 2009 to April 2010. The prospective data were compared with data collected retrospectively for one year prior to the implementation of the radiation dose reduction strategy (control group). By comparison of the cumulative effective dose and the number of CT examinations in the two groups, we evaluated effects of a radiation dose reduction strategy. All the patients met the institutional adult trauma team activation criteria. The radiation doses calculated by the CT scanner were converted to effective doses by multiplication by a conversion coefficient. A total of 118 patients were included in this study. Among them, 33 were admitted before May 2009 (control group), and 85 were admitted after May 2009 (intervention group). There were no significant differences between the two groups regarding baseline characteristics, such as injury severity and mortality. Additionally, there was no difference between the two groups in the mean number of total CT examinations per patient (4.8 vs. 4.5, respectively; p = 0.227). However, the mean effective dose of the total CT examinations per patient significantly decreased from 78.71 mSv to 29.50 mSv (p < 0.001). The radiation dose reduction strategy for CT in severely injured trauma patients effectively decreased the cumulative effective dose of the total CT examinations in the emergency department. But not effectively decreased the number of CT examinations.

Implementation of a nationwide trauma network for the care of severely injured patients.

PubMed

Ruchholtz, Steffen; Lefering, Rolf; Lewan, Ulrike; Debus, Florian; Mand, Carsten; Siebert, Hartmut; Kühne, Christian A

2014-06-01

Regional differences in the care of severely injured patients remain problematic in industrial countries. In 2006, the German Society for Trauma Surgery initiated the foundation of regional networks between trauma centers in a TraumaNetwork (TNW). The TNW consisted of five major elements as follows: (a) a whitebook on the treatment of severely injured patients; (b) evidence-based guidelines (S3); (c) local audits; (d) contracts of interhospital cooperation among all participating hospitals; and (e) TraumaRegister documentation. TNW hospitals are classified according to local audit results as supraregional (STC), regional (RTC), or local (LTC) trauma centers by criteria concerning staff, equipment, admission capacity, and responsibility. Five hundred four German trauma centers (TCs) were certified by the end of December 2012. By then, 37 regional TNWs, with a mean of 13.6 TCs, were established, covering approximately 80% of the country's territory. Of the hospitals, 92 were acknowledged as STCs, 210 as RTCs, and 202 as LTCs.In 2012, 19,124 patients were documented by the certified TCs. Fifty-seven percent of the patients were treated in STCs, 34% in RTCs, and 9% in LTCs. The mean (SD) Injury Severity Score (ISS) was highest in STCs (21 [13]), compared with 18 (12) in RTCs and 16 (10) in LTCs. There were differences in expected mortality (based on Revised Injury Severity Classification) according to the differences in the severity of trauma among the different categories, but in all types, the expected mortality was significantly higher than the observed mortality (differences in STCs, 1.8%; RTCs, 1.4%; LTCs, 2.0%). According to our findings, it is possible to successfully structure and standardize the care of severely injured patients in a nationwide trauma system. Better outcomes than expected were observed in all categories of TNW hospitals. Epidemiologic study, level III. Therapeutic/care management study, level IV.

[Diagnostics and treatment strategies for multiple trauma patients].

PubMed

Pfeifer, R; Pape, H-C

2016-02-01

Severe trauma is still one of the leading causes of death worldwide. The initial treatment and diagnostics are of immense importance in polytraumatized patients. The initial approach mainly focuses on the advanced trauma life support (ATLS) concept. This includes the identification of life-threatening conditions and application of life-saving interventions. Depending on the physiological condition of the patient, the surgical treatment strategies of early total care (ETC) or damage control orthopedics (DCO) can be chosen. Appropriate surgical management can reduce the incidence of associated delayed systemic complications. This review summarizes the most commonly used definitions of polytrauma (including the Berlin polytrauma definition) and classification systems of severely injured patients. Moreover, the recently introduced treatment strategy of the safe definitive surgery concept for severely injured patients is also discussed in this article.

Ceftizoxime use in trauma celiotomy: pharmacokinetics and patient outcomes.

PubMed

Rosemurgy, A S; Dillon, K R; Kurto, H A; Albrink, M H

1995-11-01

Seriously injured patients undergo vigorous resuscitation upon arrival at the emergency department and through the immediate perioperative period. Although resuscitation leads to volume loading and fluid shifts, drug dosing and dosing intervals are often not altered to account for changes in total body volume or circulatory volume. To address this, a prospective study of pharmacokinetics of ceftizoxime in 53 injured adults who underwent emergency celiotomy was conducted. Further, the relationship between serum ceftizoxime concentrations and infectious outcomes was evaluated. Per protocol, injured adults undergoing emergency celiotomy received prophylactic ceftizoxime treatment according to standard dosing regimens. Of the patients, 6 (11.5%) experienced postoperative infections and had lower peak serum ceftizoxime levels in the recovery room than patients not experiencing infection. For severely injured adults with extensive blood loss or undergoing lengthy operations requiring rigorous volume resuscitation, doses of ceftizoxime, and indeed all antibiotics, may need to be increased beyond conventional standards to minimize infectious complications.

Outcome after severe multiple trauma: a retrospective analysis

PubMed Central

2013-01-01

Background Aim of this study was to evaluate prognosis of severely injured patients. Methods All severely injured patients with an Injury Severity Score (ISS) ≥ 50 were identified in a 6-year-period between 2000 and 2005 in German Level 1 Trauma Center Murnau. Data was evaluated from German Trauma Registry and Polytrauma Outcome Chart of the German Society for Trauma Surgery and a personal interview to assess working ability and disability and are presented as average. Results 88 out of 1435 evaluated patients after severe polytrauma demonstrated an ISS ≥ 50 (6.5%), among them 23% women and 77% men. 66 patients (75%) had an ISS of 50-60, 14 (16%) 61-70, and 8 (9%) ≥ 70. In 27% of patients trauma was caused by motor bike accidents. 3.6 body regions were involved. Patients had to be operated 5.3 times and were treated 23 days in the ICU and stayed 73 days in hospital. Mortality rate was 36% and rate of multi-organ failure 28%. 15% of patients demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. 25% recovered well or at least moderately. 29 out of 56 survivors answered the POLO-chart. A personal interview was performed with 13 patients. The state of health was at least moderate in 72% of patients. In 48% interpersonal problems and in 41% severe pain was observed. In 57% of patients problems with working ability regarding duration, as well as quantitative and qualitative performance were observed. Symptoms of post-traumatic stress disorder were found in 41%. The more distal the lesions were located (foot/ankle) the more functional disability affected daily life. In only 15%, working ability was not impaired. 8 out of 13 interviewed patients demonstrated complete work disability. Conclusions Even severely injured patients after multiple trauma have a good prognosis. The ISS is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score. PMID:23675931

Major influence of interobserver reliability on polytrauma identification with the Injury Severity Score (ISS): Time for a centralised coding in trauma registries?

PubMed

Maduz, Roman; Kugelmeier, Patrick; Meili, Severin; Döring, Robert; Meier, Christoph; Wahl, Peter

2017-04-01

The Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) find increasingly widespread use to assess trauma burden and to perform interhospital benchmarking through trauma registries. Since 2015, public resource allocation in Switzerland shall even be derived from such data. As every trauma centre is responsible for its own coding and data input, this study aims at evaluating interobserver reliability of AIS and ISS coding. Interobserver reliability of the AIS and ISS is analysed from a cohort of 50 consecutive severely injured patients treated in 2012 at our institution, coded retrospectively by 3 independent and specifically trained observers. Considering a cutoff ISS≥16, only 38/50 patients (76%) were uniformly identified as polytraumatised or not. Increasing the cut off to ≥20, this increased to 41/50 patients (82%). A difference in the AIS of ≥ 1 was present in 261 (16%) of possible codes. Excluding the vast majority of uninjured body regions, uniformly identical AIS severity values were attributed in 67/193 (35%) body regions, or 318/579 (55%) possible observer pairings. Injury severity all too often is neither identified correctly nor consistently when using the AIS. This leads to wrong identification of severely injured patients using the ISS. Improving consistency of coding through centralisation is recommended before scores based on the AIS are to be used for interhospital benchmarking and resource allocation in the treatment of severely injured patients. Copyright © 2017. Published by Elsevier Ltd.

Sexuality and sexual dysfunction in spinal cord-injured men in Turkey.

PubMed

Akman, Ramazan Yavuz; Coşkun Çelik, Evrim; Karataş, Metin

2015-01-01

To provide a comprehensive evaluation of sexual function and dysfunction in spinal cord-injured men based on self-reports of patients. Forty-seven spinal cord-injured men who completed the spinal shock and rehabilitation period were included. Patients were asked to complete a questionnaire developed to assess social status, sexual activities, abilities, and sexuality education after injury. Neurologic levels of patients were classified according to American Spinal Cord Injury Association protocol. Erectile function was evaluated by International Index of Erectile Function-5 (IIEF-5) questionnaire. Patients were aged between 20 and 62 years (mean: 35.2). Twenty-eight patients had T10 and above, 15 between T11 and L2, and 4 cauda conus injury. While 61.7% of the patients declared sexual activity, 93.6% declared some degree of erection. Mean IIEF-5 score was 5.3 and 87.3% of the patients had moderate to severe erectile dysfunction. Continuation of sexual activity after injury is very important and has a great impact on quality of life and interpersonal relationships for spinal cord-injured men. More attention must be given to sexuality after spinal cord injury. A very high rate of sexual dysfunction in spinal cord-injured patients was found and the importance of sexual education was emphasized in this study.

Severe extremity amputations in surviving Palestinian civilians caused by explosives fired from drones during the Gaza War.

PubMed

Heszlein-Lossius, Hanne; Al-Borno, Yahya; Shaqoura, Samar; Skaik, Nashwa; Giil, Lasse Melvær; Gilbert, Mads

2018-02-21

During four separate Israeli military attacks on Gaza (2006, 2009, 2012, and 2014), about 4000 Palestinians were killed and more than 17 000 injured (412 killed and 1264 injured in 2006; 1383 killed and more than 5300 injured in 2009; 130 killed and 1399 injured in 2012; and 2251 killed and 11 231 injured in 2014). An unknown number of people had traumatic amputations of one or more extremities. Use of unmanned Israeli drones for surveillance and armed attacks on Gaza was evident, but exact figures on numbers of drone strikes on Gaza are not available. The aim of this study was to explore the medical consequences of strikes on Gaza with different weapons, including drones. We studied a cohort of civilians in the Gaza Strip who had one of more traumatic limb amputation during the Israeli military attacks between 2006 and 2016. The study was done at The Artificial Limb and Polio Center (ALPC) in the Gaza Strip where most patients are treated and trained after amputation. We used standardised forms and validated instruments to record date and mechanism of injury, self-assessed health, socioeconomic status, anatomical location and length of amputation, comorbidity, and the results of a detailed clinical examination. The studied cohort consisted of 254 Paletinian civilians (234 [92%] men, 20 [8%] women, and 43 [17%] children aged 18 years and younger) with traumatic amputations caused by different weapons. 216 (85%) people had amputations proximal to wrist or ankle, 131 (52%) patients had more than one major amputation or an amputation above the knee, or both, and 136 (54%) people were injured in attacks with Israeli drones, including eight (40%) of the women. The most severe amputations were caused by drone attacks (p=0·0001). Extremity injuries after drone attacks led to immediate amputation more often than with other weapons (p=0·014). Patients injured during cease-fire periods were younger than patients injured during periods of declared Israeli military operations (p=0·0001). Weapons fired on the Gaza Strip from Israeli drones caused severe injuries in surviving Palestinian civilians. Drone-fired missiles resulted in major amputations in almost all victims who had limb losses. Substantially more severe injuries were inflicted by the drone-launched explosives than by other weapons used during the Gaza War. Traumatic amputations caused by drones were often immediately complete. One limitation of our study is that it does not elucidate injury patterns in victims with fatal injuries. None. Copyright © 2018 Elsevier Ltd. All rights reserved.

First installation of a dual-room IVR-CT system in the emergency room.

PubMed

Wada, Daiki; Nakamori, Yasushi; Kanayama, Shuji; Maruyama, Shuhei; Kawada, Masahiro; Iwamura, Hiromu; Hayakawa, Koichi; Saito, Fukuki; Kuwagata, Yasuyuki

2018-03-05

Computed tomography (CT) embedded in the emergency room has gained importance in the early diagnostic phase of trauma care. In 2011, we implemented a new trauma workflow concept with a sliding CT scanner system with interventional radiology features (IVR-CT) that allows CT examination and emergency therapeutic intervention without relocating the patient, which we call the Hybrid emergency room (Hybrid ER). In the Hybrid ER, all life-saving procedures, CT examination, damage control surgery, and transcatheter arterial embolisation can be performed on the same table. Although the trauma workflow realized in the Hybrid ER may improve mortality in severe trauma, the Hybrid ER can potentially affect the efficacy of other in/outpatient diagnostic workflow because one room is occupied by one severely injured patient undergoing both emergency trauma care and CT scanning for long periods. In July 2017, we implemented a new trauma workflow concept with a dual-room sliding CT scanner system with interventional radiology features (dual-room IVR-CT) to increase patient throughput. When we perform emergency surgery or interventional radiology for a severely injured or ill patient in the Hybrid ER, the sliding CT scanner moves to the adjacent CT suite, and we can perform CT scanning of another in/outpatient. We believe that dual-room IVR-CT can contribute to the improvement of both the survival of severely injured or ill patients and patient throughput.

Recovery of injured arcuate fasciculus in the dominant hemisphere in a patient with an intracerebral hemorrhage.

PubMed

Jang, Sung Ho; Lee, Han Do

2014-12-01

This study reports on a patient with an intracerebral hemorrhage who showed recovery of an injured arcuate fasciculus (AF) in the dominant hemisphere, using follow-up diffusion tensor tractography. A 43-year-old right-handed man presented with severe aphasia and hemiparesis resulting from a spontaneous intracerebral hemorrhage in the left parietotemporal lobes. The patient showed severe aphasia at 1 month after onset, with an aphasia quotient of 5% on the Korean-Western Aphasia Battery. He underwent comprehensive rehabilitative therapy until 22 months after onset and his aphasia showed improvement, with an aphasia quotient of 58% on the Korean-Western Aphasia Battery. On 1-month diffusion tensor tractography, only the thin ascending part of the left AF from the Wernicke area remained. In contrast, on 16-month diffusion tensor tractography, the injured left AF was thickened and elongated to around the left Broca area; however, discontinuation of the left AF was observed around the left Broca area, and this continuation was elongated to the left Broca area on 22-month diffusion tensor tractography. This study reports on a patient who showed recovery from injury of the left AF along with improvement of aphasia. Recovery of the injured AF in the dominant hemisphere appears to be one of the mechanisms for recovery from aphasia.

Surgery in the air--evacuating Finnish tsunami victims from Thailand.

PubMed

Leppäniemi, A; Vuola, J; Vornanen, M

2005-01-01

In connection with the Asian tsunami disaster on December 26, 2004, a specially equipped Finnair B-757 airplane capable of evacuating badly injured patients was remodeled into an ambulance airplane. The vehicle could take up to 22 severely injured or ill patients and intensive care and limited surgical procedures could be provided to the patients. The plane was manned with a civilian medical team of 37 physicians and nurses. The plane left for Thailand to evacuate the most severely injured Finnish citizens within 10 hours of the evacuation decision. A total of 14 patients including 4 critically ill (two on ventilator) were transferred to Helsinki within 32 hours of takeoff. The medical team included a general, an orthopedic and a plastic surgeon. Soft tissue wounds, some of them severely infected, were the most common injuries, followed by extremity fractures and head injuries. The surgical procedures that were performed mid-air included wound surgery, to remove necrotic tissue, and external fixation and fasciotomy for a lower extremity fracture. The facilities under these circumstances would allow performing life-saving procedures to maintain airway and breathing, and surgical procedures of the soft tissues, extremity and pelvic fractures. Cavitary surgery would require additional equipment and resources.

Blunt Cardiac Injury in the Severely Injured – A Retrospective Multicentre Study

PubMed Central

Hanschen, Marc; Kanz, Karl-Georg; Kirchhoff, Chlodwig; Khalil, Philipe N.; Wierer, Matthias; van Griensven, Martijn; Laugwitz, Karl-Ludwig; Biberthaler, Peter; Lefering, Rolf; Huber-Wagner, Stefan

2015-01-01

Background Blunt cardiac injury is a rare trauma entity. Here, we sought to evaluate the relevance and prognostic significance of blunt cardiac injury in severely injured patients. Methods In a retrospective multicentre study, using data collected from 47,580 patients enrolled to TraumaRegister DGU (1993-2009), characteristics of trauma, prehospital / hospital trauma management, and outcome analysis were correlated to the severity of blunt cardiac injury. The severity of cardiac injury was assessed according to the abbreviated injury score (AIS score 1-6), the revised injury severity score (RISC) allowed comparison of expected outcome with injury severity-dependent outcome. N = 1.090 had blunt cardiac trauma (AIS 1-6) (2.3% of patients). Results Predictors of blunt cardiac injury could be identified. Sternal fractures indicate a high risk of the presence of blunt cardiac injury (AIS 0 [control]: 3.0%; AIS 1: 19.3%; AIS 2-6: 19.1%). The overall mortality rate was 13.9%, minor cardiac injury (AIS 1) and severe cardiac injury (AIS 2-6) are associated with higher rates. Severe blunt cardiac injury (AIS 4 and AIS 5-6) is associated with a higher mortality (OR 2.79 and 4.89, respectively) as compared to the predicted average mortality (OR 2.49) of the study collective. Conclusion Multiple injured patients with blunt cardiac trauma are at high risk to be underestimated. Careful evaluation of trauma patients is able to predict the presence of blunt cardiac injury. The severity of blunt cardiac injury needs to be stratified according to the AIS score, as the patients’ outcome is dependent on the severity of cardiac injury. PMID:26136126

How to define severely injured patients? -- an Injury Severity Score (ISS) based approach alone is not sufficient.

PubMed

Paffrath, Thomas; Lefering, Rolf; Flohé, Sascha

2014-10-01

Multiple injured patients, polytrauma or severely injured patients are terms used as synonyms in international literature describing injured patients with a high risk of mortality and cost consuming therapeutic demands. In order to advance the definition of these terms, we analysed a large trauma registry. In detail, we compared critically ill trauma patients first specified on a pure anatomical base according to the ISS or NISS, second in the original "polytrauma definition" with two body regions affected and finally all of them combined with a physiological component. Records that were collected in the TraumaRegister DGU(®) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) between 1993 and 2011 (92,479 patients) were considered for this study. All patients with primary admission from scene with a minimum hospital stay of 48 h and an Injury Severity Score (ISS)≥ 16 were included. Pre-hospital and early admission data were used to determine physiological risk factors and calculate individual risk of death using the Revised Injury Severity Classification (RISC). 45,350 patients met inclusion criteria. The overall hospital mortality rate was 20.4%. The predicted mortality according to the RISC-Score was 21.6%. 36,897 patients (81.4%) had injuries in several body regions. The prevalence of the five physiological risk factors varied between 17% (high age) and 34% (unconsciousness). There were 17,617 patients (38.8%) without any risk factor present on admission, while 30.6% (n=13,890) of the patients had one and 30.5% (n=13,843) had two or more factors present. Patients with ISS ≥ 16 but no physiological risk factor present had a very low mortality rate of 3.1% (542 of 17,617). With an increasing number of physiological factors there was an almost linear increase in mortality up to an 86% rate in patients with all five factors present. The 'polytrauma' definition of Butcher and colleagues with AIS ≥ 3 in at least two different body regions would apply to only 56.2% of patients in the present group with ISS ≥ 16. The mortality in this subgroup is only marginally higher (21.8%; 5559 of 25,494) than in the group of patients with only one severely affected body region (18.5%; 3675 of 19,875). In our opinion the principle of sharpening an anatomically based definition by a defined physiological problem will help to specify the really critically ill trauma patients. Copyright © 2014 Elsevier Ltd. All rights reserved.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®).

PubMed

Bieler, Dan; Franke, Axel; Lefering, Rolf; Hentsch, Sebastian; Willms, Arnulf; Kulla, Martin; Kollig, Erwin

2017-01-01

The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome. In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock. Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation. This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times. Copyright © 2016 Elsevier Ltd. All rights reserved.

Horse-related injuries in children - unmounted injuries are more severe: A retrospective review.

PubMed

Wolyncewicz, Grace E L; Palmer, Cameron S; Jowett, Helen E; Hutson, John M; King, Sebastian K; Teague, Warwick J

2018-05-01

Horse-related injuries account for one quarter of all paediatric sports fatalities. It is not known whether the pattern of injury spectrum and severity differ between children injured whilst mounted, compared with those injured unmounted around horses. We aimed to identify any distinctions between the demographic features, spectrum and severity of injuries for mounted versus unmounted patients. Trauma registry data were reviewed for 505 consecutive paediatric patients (aged<16years) admitted to a large paediatric trauma centre with horse-related injuries over a 16-year period. Patients were classified into mounted and unmounted groups, and demographics, injury spectrum, injury severity, and helmet usage compared using odds ratios and Wilcoxon rank-sum tests. More patients (56%) were injured in a private setting than in a sporting or supervised context (23%). Overall, head injuries were the most common horse-related injury. Mounted patients comprised 77% of the cohort. Mounted patients were more likely to sustain upper limb fractures or spinal injuries, and more likely to wear helmets. Unmounted were more likely to be younger males, and more likely to sustain facial or abdominal injuries. Strikingly, unmounted children had significantly more severe and critical Injury Severity Scores (OR 2.6; 95% CI 1.5, 4.6) and longer hospital stay (2.0days vs 1.1days; p<0.001). Unmounted patients were twice as likely to require intensive care or surgery, and eight times more likely to sustain a severe head injury. Horse-related injuries in children are serious. Unmounted patients are distinct from mounted patients in terms of gender, age, likelihood of personal protective equipment use, severity of injuries, and requirement for intensive or invasive care. This study highlights the importance of vigilance and other safety behaviours when unmounted and around horses, and proposes specific targets for future injury prevention campaigns, both in setting of organised and private equestrian activity. Copyright © 2017 Elsevier Ltd. All rights reserved.

Lessons learnt from the Wenchuan earthquake: performance evaluation of treatment of critical injuries in hardest-hit areas.

PubMed

Jiang, Jie; Li, Youping; Huang, Xiaolin; Li, Bing; Su, Lin; Zhong, Dake; Shi, Chenghu; Li, Mingxu; Shan, Juan; Chen, Yin

2012-08-01

Critical injury treatment in the hardest-hit areas after a great earthquake was retrospectively analyzed to determine how best to reduce mortality and disability and increase the rehabilitation rate through postquake medical relief. Retrospective analysis, primary sources, and secondary sources were comprehensively retrieved and analyzed. According to incomplete data, 30,620 injured were rescued by themselves among the hardest-hit areas in the 72 hours immediately following the earthquake. Critically injured patients accounted for 22% of total inpatients. Mortality rates declined with greater distance from the epicenter: rates were 12.21% for municipal healthcare centers in the hardest-hit areas, 4.50% for municipal medical units in peripheral quake-hit areas, 2.50% for provincial medical units in peripheral quake-hit areas, and 2.17% for Ministry of Health-affiliated hospitals in peripheral quake-hit areas. The number of injured with fractures on body, limbs or unknown-parts, severe conditions as well as other kinds of non-traumatic diseases received in second-line hospitals was much more than those treated in first-line hospitals with more severe injuries. Among 10,373 injured in stable condition transferred to third-line hospitals, 99.07% were discharged from hospitals within four months, while the mortality rate was 0.017%. The medical relief model of "supervising body helping subordinate unit, severely stricken areas assisting hardest-hit areas, least-hit areas supporting both hardest-hit and severely stricken areas, and self help and mutual assistance applied between hardest-hit areas" was roughly established for injured from severely stricken areas after the Wenchuan Earthquake. The "four-centralization" treatment principle, which referred to concentrating patients, experts, resources and treatment for those injured in critical condition effectively reduced the mortality from 15.06% to 2.9%. Timely, scientific, and standard on-site triage and postmedical transfer guided by accurate injury information determine rescue effect for the injured, while there is large space to fulfill as for treatment for critical diseases among the hardest-hit areas under extreme conditions after the Wenchuan earthquake. © 2012 Wiley Publishing Asia Pty Ltd and Chinese Cochrane Center, West China Hospital of Sichuan University.

Aorta Balloon Occlusion in Trauma: Three Cases Demonstrating Multidisciplinary Approach Already on Patient’s Arrival to the Emergency Room

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hörer, Tal M., E-mail: tal.horer@orebroll.se; Hebron, Dan; Swaid, Forat

PurposeTo describe the usage of aortic balloon occlusion (ABO), based on a multidisciplinary approach in severe trauma patients, emphasizing the role of the interventional radiologist in primary trauma care.MethodsWe briefly discuss the relevant literature, the technical aspects of ABO in trauma, and a multidisciplinary approach to the bleeding trauma patient. We describe three severely injured trauma patients for whom ABO was part of initial trauma management.ResultsThree severely injured multi-trauma patients were treated by ABO as a bridge to surgery and embolization. The procedures were performed by an interventional radiologist in the early stages of trauma management.ConclusionsThe interventional radiologist and themore » multidisciplinary team approach can be activated already on severe trauma patient arrival. ABO usage and other endovascular methods are becoming more widely spread, and can be used early in trauma management, without delay, thus justifying the early activation of this multidisciplinary approach.« less

Analyses of demographical and injury characteristics of adult and pediatric patients injured in Syrian civil war.

PubMed

Er, Erhan; Çorbacıoğlu, Şeref Kerem; Güler, Sertaç; Aslan, Şahin; Seviner, Meltem; Aksel, Gökhan; Bekgöz, Burak

2017-01-01

Aimed to analyze demographical data and injury characteristics of patients who were injured in the Syrian Civil War (SCW) and to define differences in injury characteristics between adult and pediatric patients. Patients who were injured in the SCW and transferred to our emergency department were retrospectively analyzed in this study during the 15-month period between July 2013 and October 2014. During the study period, 1591 patients who were the victims of the SCW and admitted to our emergency department due to war injury enrolled in the study. Of these patients, 285 were children (18%). The median of the injury severity score was 16 (interquartile range [IQR]: 9-25) in all patients. The most frequent mechanism of injury was blunt trauma (899 cases, 55%), and the most frequently-injured region of the body was the head (676 cases, 42.5%). Head injury rates among the children's group were higher than those of the adult group (P < .001). In contrast, injury rates for the abdomen and extremities in the children's group were lower than those in the adult group (P < .001, P < .001). The majority of patients were adults, and the most frequent mechanism of injury was blunt trauma. Similarly, the children were substantially affected by war. Although the injury severity score values and mortality rates of the child and adult groups were similar, it was determined that the number of head injuries was higher, but the number of abdomen and extremity injuries was lower in the children's group than in the adult group. Copyright © 2016 Elsevier Inc. All rights reserved.

Improving Survival and Promoting Respiratory Motor Function After Cervical Spinal Cord Injury

DTIC Science & Technology

2017-09-01

ventilator in order to survive. Use of the ventilator severely limits the quality of life of those injured and dramatically increases the demand for health...care for cervical SCI patients so as to lead to an improved quality of life , better-quality health care management, and improved functional outcomes...mechanical ventilator in order to survive. Use of the ventilator severely limits the quality of life of those injured and dramatically increases the

Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients.

PubMed

Bliemel, Christopher; Lefering, Rolf; Buecking, Benjamin; Frink, Michael; Struewer, Johannes; Krueger, Antonio; Ruchholtz, Steffen; Frangen, Thomas Manfred

2014-02-01

Because of a lack of evidence, the appropriate timing of surgical stabilization of thoracic and lumbar spine injuries in severely injured patients is still controversial. Data of a large international trauma register were analyzed to investigate the medical care situation of unstable spinal column fractures in patients with multiple injuries, so as to examine the outcome related to timing of surgical stabilization. Data sets of the Trauma Registry of German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (1993-2010) were analyzed. The Trauma Registry of DGU is a prospective, multicenter register that provides information on severely injured patients. All patients with an Injury Severity Score (ISS) of 16 or greater caused by blunt trauma, subsequent treatment of 7 days or more, 16 years or older, and thoracic or lumbar spine injuries (spine Abbreviated Injury Scale [AIS] score ≥ 2) were included in our analysis. Patients with relevant spine injuries classified as having a spine AIS score of 3 or greater were further analyzed in terms of whether they got early (<72 hours) or late (>72 hours) surgical treatment due to unstable spinal column fractures. Of 24,974 patients, 8,994 (36.0%) had documented spinal injuries (spine AIS score ≥ 2). A total of 1,309 patients who sustained relevant thoracic spine injuries (spine AIS score ≥ 3) and 994 patients who experienced lumbar spine trauma and classified as having spine AIS score of 3 or greater were more precisely analyzed. Of these, 68.2% and 71.0%, respectively, received an early thoracic or lumbar spine fixation. With an increase in spinal injury severity, an increase in early stabilization in the thoracic and lumbar spine was seen. In the group of patients with early surgical stabilization, significantly shorter hospital stays, shorter intensive care unit stays, fewer days on mechanical ventilation, and lower rates of sepsis were seen. In the case that additional body regions were affected, for example, when patients were critically ill, a delayed spinal stabilization was more often performed. A spinal stabilization at an early stage (<72 hours) is presumed to be beneficial. Although some patients may require delay due to necessary medical improvement, every reasonable effort should be made to treat patients with instable spinal column fractures as soon as possible. If an early surgical treatment is feasible, severely injured patients may benefit from a shorter period of hospital treatment and a lower rate of complications. Therapeutic study, level III.

Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres.

PubMed

Metcalfe, D; Bouamra, O; Parsons, N R; Aletrari, M O; Lecky, F E; Costa, M L

2014-07-01

Centralization of complex healthcare services into specialist high-volume centres is believed to improve outcomes. For injured patients, few studies have evaluated the centralization of major trauma services. The aim of this study was to evaluate how a regional trauma network affected trends in admissions, case mix, and outcomes of injured patients. A retrospective before-after study was undertaken of severely injured patients attending four hospitals that became major trauma centres (MTCs) in March 2012. Consecutive patients with major trauma were identified from a national registry and divided into two groups according to injury before or after the launch of a new trauma network. The two cohorts were compared for differences in case mix, demand on hospital resources, and outcomes. Patient volume increased from 442 to 1326 (200 per cent), operations from 349 to 1231 (253 per cent), critical care bed-days from 1100 to 3704 (237 per cent), and total hospital bed-days from 7910 to 22,772 (188 per cent). Patient age increased on MTC designation from 45.0  years before March 2012 to 48.2 years afterwards (P = 0.021), as did the proportion of penetrating injuries (1.8 versus 4.1 per cent; P = 0.025). Injury severity fell as measured by median Injury Severity Score (16 versus 14) and Revised Trauma Score (4.1 versus 7.8). Fewer patients required secondary transfer to a MTC from peripheral hospitals (19.9 versus 16.1 per cent; P = 0.100). There were no significant differences in total duration of hospital stay, critical care requirements or mortality. However, there was a significant increase, from 55.5 to 62.3 per cent (P < 0.001), in the proportion of patients coded as having a 'good recovery' at discharge after institution of the trauma network. MTC designation leads to an increased case volume with considerable implications for operating theatre capacity and bed occupancy. Although no mortality benefit was demonstrated within 6 months of establishing this trauma network, early detectable advantages included improved functional outcome at discharge. © 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.

Disproportionately severe memory deficit in relation to normal intellectual functioning after closed head injury.

PubMed Central

Levin, H S; Goldstein, F C; High, W M; Eisenberg, H M

1988-01-01

The presence of disproportionate memory impairment with relatively preserved intellectual functioning was examined in 87 survivors of moderate or severe closed head injury. Approximately one-fourth of the patients tested at 5 to 15 and/or 16 to 42 months after injury manifested defective memory on both auditory and pictorial measures despite obtaining Wechsler Verbal and Performance Intelligence Quotients within the average range. The findings indicate that disproportionately severe memory deficit persists in a subgroup of closed head injured survivors which is reminiscent in some cases of the amnesic disturbance arising from other causes. Evaluation of long term memory in relation to cognitive ability could potentially identify important distinctions for prognosis and rehabilitation in head injured patients. PMID:3225586

Children and terror casualties receive preference in ICU admissions.

PubMed

Peleg, Kobi; Rozenfeld, Michael; Dolev, Eran

2012-03-01

Trauma casualties caused by terror-related events and children injured as a result of trauma may be given preference in hospital emergency departments (EDs) due to their perceived importance. We investigated whether there are differences in the treatment and hospitalization of terror-related casualties compared to other types of injury events and between children and adults injured in terror-related events. Retrospective study of 121 608 trauma patients from the Israel Trauma Registry during the period of October 2000-December 2005. Of the 10 hospitals included in the registry, 6 were level I trauma centers and 4 were regional trauma centers. Patients who were hospitalized or died in the ED or were transferred between hospitals were included in the registry. All analyses were controlled for Injury Severity Score (ISS). All patients with ISS 1-24 terror casualties had the highest frequency of intensive care unit (ICU) admissions when compared with patients after road traffic accidents (RTA) and other trauma. Among patients with terror-related casualties, children were admitted to ICU disproportionally to the severity of their injury. Logistic regression adjusted for injury severity and trauma type showed that both terror casualties and children have a higher probability of being admitted to the ICU. Injured children are admitted to ICU more often than other age groups. Also, terror-related casualties are more frequently admitted to the ICU compared to those from other types of injury events. These differences were not directly related to a higher proportion of severe injuries among the preferred groups.

Multiple Trauma and Emergency Room Management.

PubMed

Frink, Michael; Lechler, Philipp; Debus, Florian; Ruchholtz, Steffen

2017-07-24

The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment. We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016. The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo - dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized. The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.

Recovery of an injured fornix in a stroke patient.

PubMed

Yeo, Sang Seok; Jang, Sung Ho

2013-11-01

Knowledge about recovery of an injured fornix following brain injury is limited. We describe here a patient who showed recovery of an injured fornix following stroke. A 57-year-old female patient underwent coiling for a ruptured anterior communicating cerebral artery aneurysm, and conservative management for subarachnoid and intraventricular haemorrhage. The patient showed severe cognitive impairment 6 weeks after onset. However, her cognition showed continuous improvement with time; based on the Mini-Mental State Examination and the Memory Assessment Scale, her cognition was within the normal range 7 months after onset. Findings from diffusion tensor tractography at 6 weeks and 7 months showed discontinuations in both columns of the fornix. The proximal portion of both crus also showed discontinuation on diffusion tensor tractography at 6 weeks and 7 months; however, on 7-month diffusion tensor tractography, the end of the fornical body was shown to be connected to the splenium of the corpus callosum and then branched to the right medial temporal lobe and right thalamus. The unusual neural connection between the injured fornix and the thalamus appears to be a recovery phenomenon, which allows the injured fornix and the medial temporal lobe to obtain cholinergic innervation from cholinergic nuclei in the brainstem rather than from cholinergic nuclei in the basal forebrain.

Behavioral change in patients with severe self-injurious behavior: a patient's perspective.

PubMed

Kool, Nienke; van Meijel, Berno; Bosman, Maartje

2009-02-01

Semistructured interviews were conducted with 12 women who had successfully stopped self-injuring to gain an understanding of the process of stopping self-injury. The data were analyzed based on the grounded theory method. The researchers found that the process of stopping self-injury consists of six phases. Connection was identified as key to all phases of the process. Nursing interventions should focus on forging a connection, encouraging people who self-injure to develop a positive self-image and learn alternative behavior.

The evolution of trauma surgery at a high-volume Canadian centre: implications for public health, prevention, clinical care, education and recruitment.

PubMed

Ball, Chad G; Das, Debanjana; Roberts, Derek J; Vis, Christine; Kirkpatrick, Andrew W; Kortbeek, John B

2015-02-01

Trauma centres continue to evolve with respect to clinical care and their impact on public health. Despite improvements in patient outcomes, operative volumes, and therefore maintenance of surgical skills, has become a challenging issue. We sought to determine whether injury demographics and treatments at a high-volume centre changed over time. We used the Alberta Trauma Registry to analyze all severely injured (injury severity score [ISS] ≥ 12) patient admissions over a 16-year period (1995-2011). Of the 12,879 severely injured patients requiring admission, there was a 1.5- fold increase in the annual admission rate despite population normalization (p = 0.001). Over the 16-year interval, patients were older with a subsequent lower mortality (p = 0.001) and length of hospital stay (p = 0.007). In patients with the most severe ISS (≥ 48), there was no change in mortality (27%, p = 0.26). In 2011, falls were the most common mechanism compared with motor vehicle crashes (41% v. 23%; p < 0.001); this was a complete reversal compared with 1995 (25% v. 41%). Motorized recreational vehicle and motorcycle injuries also increased (p < 0.001). The mean number of operations performed by trauma surgeons decreased (laparotomies: 67 [17%] in 1995 v. 47 [5%] in 2011, p < 0.001). Thoracotomies and tracheostomies remained unchanged (p = 0.19). Clinical care has improved despite an increasing overall volume of severely injured patient admissions. The number of operative interventions performed by trauma surgeons continues to decrease concurrent to a change in injury mechanisms. Despite these improvements, maintenance of technical skills among trauma surgeons has become an important issue.

Association of an In-House Blood Bank with Therapy and Outcome in Severely Injured Patients: An Analysis of 18,573 Patients from the TraumaRegister DGU®.

PubMed

Debus, Florian; Lefering, Rolf; Lechler, Philipp; Schwarting, Tim; Bockmann, Benjamin; Strasser, Erwin; Mand, Carsten; Ruchholtz, Steffen; Frink, Michael

2016-01-01

Hemorrhagic shock remains one of the most common causes of death in severely injured patients. It is unknown to what extent the presence of a blood bank in a trauma center influences therapy and outcome in such patients. We retrospectively analyzed prospectively recorded data from the TraumaRegister DGU® and the TraumaNetzwerk DGU®. Inclusion criteria were Injury Severity Score (ISS) ≥ 16, primarily treated patients, and hospital admission 2 years before or after the audit process. Complete data sets of 18,573 patients were analyzed. Of 457 hospitals included, 33.3% had an in-house blood bank. In trauma centers with a blood bank (HospBB), packed red blood cells (PRBCs) (21.0% vs. 17.4%, p < 0.001) and fresh frozen plasma (FFP) (13.9% vs. 10.2%, p <0.001) were transfused significantly more often than in hospitals without a blood bank (Hosp0). However, no significant difference was found for in-hospital mortality (standard mortality ratio [SMR, 0.907 vs. 0.945; p = 0.25). In patients with clinically apparent shock on admission, no difference of performed transfusions were present between HospBB and Hosp0 (PRBCs, 51.4% vs. 50.4%, p = 0.67; FFP, 32.7% vs. 32.7%, p = 0.99), and no difference in in-hospital mortality was observed (SMR, 0.907 vs. 1.004; p = 0.21). In HospBB transfusions were performed more frequently in severely injured patients without positively affecting the 24h mortality or in-house mortality. Easy access may explain a more liberal transfusion concept.

Mortality following helicopter versus ground transport of injured children.

PubMed

Polites, Stephanie F; Zielinski, Martin D; Fahy, Aodhnait S; Wagie, Amy E; Moir, Christopher R; Jenkins, Donald H; Zietlow, Scott P; Habermann, Elizabeth B

2017-05-01

Injured children may be transported to trauma centers by helicopter air ambulance (HAA); however, a benefit in outcomes to this expensive resource has not been consistently shown in the literature and there is concern that HAA is over-utilized. A study that adequately controls for selection biases in transport mode is needed to determine which injured children benefit from HAA. The purpose of this study was to determine if HAA impacts mortality differently in minimally and severely injured children and if there are predictors of over-triage of HAA in children that can be identified. Children ≤18 years of age transported by HAA or ground ambulance (GA) from scene to a trauma center were identified from the 2010-2011 National Trauma Data Bank. Analysis was stratified by Injury Severity Score (ISS) into low ISS (≤15) and high ISS (>15) groups. Following propensity score matching of HAA to GA patients, conditional multivariable logistic regression was performed to determine if transport mode independently impacted mortality in each stratum. Rates and predictors of over-triage of HAA were also determined. Transport by HAA occurred in 8218 children (5574 low ISS, 2644 high ISS) and by GA in 35305 (30506 low ISS, 4799 high ISS). Overall mortality was greater in HAA patients (4.0 vs 1.4%, p<0.001). After propensity score matching, mortality was equivalent between HAA and GA for low ISS patients (0.2 vs 0.2%, p=0.82) but, for high ISS patients, mortality was lower in HAA (9.0 vs 11.1% p=0.014). On multivariable analysis, HAA was associated with decreased mortality in high ISS patients (OR=0.66, p=0.017) but not in low ISS patients (OR=1.13, p=0.73). Discharge within 24h of HAA transport occurred in 36.5% of low ISS patients versus 7.4% high ISS patients (p<0.001). Based on a national cohort adjusted for nonrandom assignment of transport mode, a survival benefit to HAA transport exists only for severely injured children with ISS >15. Many children with minor injuries are transported by helicopter despite frequent dismissal within 24h and no mortality benefit. Copyright © 2016 Elsevier Ltd. All rights reserved.

Focus on Clinical Research: Cognitive Rehabilitation of Severely Closed-Head-Injured Patients Using Computer-Assisted and Noncomputerized Treatment Techniques.

ERIC Educational Resources Information Center

Batchelor, J.; And Others

1988-01-01

The study compared computer assisted cognitive retraining of 47 patients with severe closed head injury with comparable noncomputerized treatment techniques. Results on neuropsychological tests did not support the increased effectiveness of the computer assisted cognitive therapy. (DB)

Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX).

PubMed

Eckert, Matthew J; Wertin, Thomas M; Tyner, Stuart D; Nelson, Daniel W; Izenberg, Seth; Martin, Matthew J

2014-12-01

Early administration of tranexamic acid (TXA) has been associated with a reduction in mortality and blood product requirements in severely injured adults. It has also shown significantly reduced blood loss and transfusion requirements in major elective pediatric surgery, but no published data have examined the use of TXA in pediatric trauma. This is a retrospective review of all pediatric trauma admissions to the North Atlantic Treaty Organization Role 3 hospital, Camp Bastion, Afghanistan, from 2008 to 2012. Univariate and logistic regression analyses of all patients and select subgroups were performed to identify factors associated with TXA use and mortality. Standard adult dosing of TXA was used in all patients. There were 766 injured patients 18 years or younger (mean [SD] age, 11 [5] years; 88% male; 73% penetrating injury; mean [SD], Injury Severity Score [ISS], 10 [9]; mean [SD] Glasgow Coma Scale [GCS] score, 12 [4]). Of these patients, 35% required transfusion in the first 24 hours, 10% received massive transfusion, and 76% required surgery. Overall mortality was 9%. Of the 766 patients, 66 (9%) received TXA. The only independent predictors of TXA use were severe abdominal or extremity injury (Abbreviated Injury Scale [AIS] score ≥ 3) and a base deficit of greater than 5 (all p < 0.05). Patients who received TXA had greater injury severity, hypotension, acidosis, and coagulopathy versus the patients in the no-TXA group. After correction for demographics, injury type and severity, vitals, and laboratory parameters, TXA use was independently associated with decreased mortality among all patients (odds ratio, 0.3; p = 0.03) and showed similar trends for subgroups of severely injured (ISS > 15) and transfused patients. There was no significant difference in thromboembolic complications or other cardiovascular events. Propensity analysis confirmed the TXA-associated survival advantage and suggested significant improvements in discharge neurologic status as well as decreased ventilator dependence. TXA was used in approximately 10% of pediatric combat trauma patients, typically in the setting of severe abdominal or extremity trauma and metabolic acidosis. TXA administration was independently associated with decreased mortality. There were no adverse safety- or medication-related complications identified. Therapeutic study, level IV.

Medical consequences of terrorist bombs containing spherical metal pellets: analysis of a suicide terrorism event.

PubMed

Kluger, Yoram; Mayo, Ami; Hiss, Jehuda; Ashkenazi, Eitamar; Bendahan, Jose; Blumenfeld, Amir; Michaelson, Moshe; Stein, Michael; Simon, Daniel; Schwartz, Ivan; Alfici, Ricardo

2005-02-01

Various metal objects added to explosives increase and diversify the wounding from bombing; especially favoured are spherical missiles for their special injuring characteristics. Our objective was to study the medical consequences and ballistic effects on human tissue of spherical metal pellets used in terrorist bombings. The clinical and forensic data of all bodily injured casualties of a suicide terrorist bombing in a crowded hotel dining room were analysed retrospectively. Of the 250 people at the scene, 164 were injured, with 91 (55.5%) suffering bodily injuries; 30 of them died. The immediately deceased had disseminated tissue damage and their bodies were saturated with steel spheres. Thirty-two immediate survivors sustained severe injuries (Injury Severity Score > or =16), and all suffered tissue penetration by the pellets. Twenty-three (32%) underwent surgery and 15 (21%) required intensive care. Metal pellets propelled by the explosion enhanced the secondary pattern of injury and injured even patients remote from the origin. Tissue destruction and specific organ injuries among survivors were limited. To evaluate and manage victims of terrorist bombings properly, medical teams should become familiar with these severe injuries.

[Diagnosis and treatment of patients with closed injury of abdominal cavity organs in combination with craniocerebral trauma].

PubMed

Kravets, A V; Kravets, V P

2003-07-01

Results of diagnosis and treatment of 114 injured persons with closed abdominal trauma, combined with craniocerebral trauma were suggested. In 34 (29.8%) observations the injury of two or more organs of peritoneal cavity was diagnosed, the parenchymatous organs trauma--in 35 (30.7%) and the hole organs trauma--in 45 (39.5%). Cerebral concussion was established in 61 (53.5%) of injured persons, cerebral contusion--in 26 (22.8%), cerebral compression on the contusion background--in 16 (14%) and subdural hematoma--in 11 (9.7%). In all the injured persons the operative intervention was performed. In 32 (28%) the blood of their own was transfused. To reduce the endogenous intoxication severity there were performed the forced diuresis, hemosorption--in 10 (8.7%), the blood ultraviolet irradiation--in 41 (35.9%), intravenous laserotherapy--in 40 (35%). After the operation 14 (12.3%) of patients died. High mortality in combined cranioabdominal trauma is caused by the injury severity, the traumatic shock and mutual burden syndrome presence.

Predicting the need for massive transfusion in trauma patients: the Traumatic Bleeding Severity Score.

PubMed

Ogura, Takayuki; Nakamura, Yoshihiko; Nakano, Minoru; Izawa, Yoshimitsu; Nakamura, Mitsunobu; Fujizuka, Kenji; Suzukawa, Masayuki; Lefor, Alan T

2014-05-01

The ability to easily predict the need for massive transfusion may improve the process of care, allowing early mobilization of resources. There are currently no clear criteria to activate massive transfusion in severely injured trauma patients. The aims of this study were to create a scoring system to predict the need for massive transfusion and then to validate this scoring system. We reviewed the records of 119 severely injured trauma patients and identified massive transfusion predictors using statistical methods. Each predictor was converted into a simple score based on the odds ratio in a multivariate logistic regression analysis. The Traumatic Bleeding Severity Score (TBSS) was defined as the sum of the component scores. The predictive value of the TBSS for massive transfusion was then validated, using data from 113 severely injured trauma patients. Receiver operating characteristic curve analysis was performed to compare the results of TBSS with the Trauma-Associated Severe Hemorrhage score and the Assessment of Blood Consumption score. In the development phase, five predictors of massive transfusion were identified, including age, systolic blood pressure, the Focused Assessment with Sonography for Trauma scan, severity of pelvic fracture, and lactate level. The maximum TBSS is 57 points. In the validation study, the average TBSS in patients who received massive transfusion was significantly greater (24.2 [6.7]) than the score of patients who did not (6.2 [4.7]) (p < 0.01). The area under the receiver operating characteristic curve, sensitivity, and specificity for a TBSS greater than 15 points was 0.985 (significantly higher than the other scoring systems evaluated at 0.892 and 0.813, respectively), 97.4%, and 96.2%, respectively. The TBSS is simple to calculate using an available iOS application and is accurate in predicting the need for massive transfusion. Additional multicenter studies are needed to further validate this scoring system and further assess its utility. Prognostic study, level III.

[Optimized resource mobilization and quality of treatment of severely injured patients through a structured trauma room alarm system].

PubMed

Spering, C; Roessler, M; Kurlemann, T; Dresing, K; Stürmer, K M; Lehmann, W; Sehmisch, S

2017-12-12

The treatment of severely injured patients in the trauma resuscitation unit (TRU) requires an interdisciplinary and highly professional trauma team approach. The complete team needs to be waiting for the patient in the TRU on arrival. Treating severely injured patients in the TRU, the trauma team connects the initial preclinical emergency stabilization with the subsequent sophisticated treatment. Thus, the trauma team depends on concise information from the emergency personnel at the scene to provide its leader with further information as well as an accurate alarm including all departments necessary to stabilize the patient in the TRU. Aiming at an accurate and most efficient trauma team alarm, this study was designed to provide and analyze an alarm system which mobilizes the trauma team in a stepwise fashion depending on the pattern of injuries and the threat to life. The trauma team alarm system was analyzed in a prospective data acquisition at a level I trauma center over a period of 12 months. Evaluation followed the acquisition phase and provided comparison to the status prior to the establishment of the alarm system. All items underwent statistical testing using t‑tests (p < 0.05). The data of 775 TRU patients showed a significant reduction of false information on the patients status prior to arrival. It also showed an increase in punctual arrival in the TRU of the emergency teams. False alarms were significantly reduced (from 11.9% to 2.7%, p > 0.01). The duration from arrival of the patient in the TRU to the initial multislice computed tomography (CT) scan was reduced by 6 min while the total period of treatment in the TRU was reduced by 17 min. After the alarm system to gradually mobilize the trauma team was put into action, team members left the TRU if unneeded prior to finishing the initial treatment in only 4% of the cases. The patient fatality rate was 8.8% (injury severity score, ISS = 23 points) after establishment of the alarm system compared to 12.9% (ISS = 25 points) before. The implementation of an accurate and patient status-based alarm system to mobilize the trauma team can improve the quality of treatment while the duration of treatment of the severely injured patients in the TRU can be decreased. It also provides a most efficient mobilization of personnel resources while sustaining patient safety.

Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review.

PubMed

van Rein, Eveline A J; Houwert, R Marijn; Gunning, Amy C; Lichtveld, Rob A; Leenen, Luke P H; van Heijl, Mark

2017-08-01

Prehospital trauma triage ensures proper transport of patients at risk of severe injury to hospitals with an appropriate corresponding level of trauma care. Incorrect triage results in undertriage and overtriage. The American College of Surgeons Committee on Trauma recommends an undertriage rate below 5% and an overtriage rate below 50% for prehospital trauma triage protocols. To find the most accurate prehospital trauma triage protocol, a clear overview of all currently available protocols and corresponding outcomes is necessary. The aim of this systematic review was to evaluate the current literature on all available prehospital trauma triage protocols and determine accuracy of protocol-based triage quality in terms of sensitivity and specificity. A search of Pubmed, Embase, and Cochrane Library databases was performed to identify all studies describing prehospital trauma triage protocols before November 2016. The search terms included "trauma," "trauma center," or "trauma system" combined with "triage," "undertriage," or "overtriage." All studies describing protocol-based triage quality were reviewed. To assess the quality of these type of studies, a new critical appraisal tool was developed. In this review, 21 articles were included with numbers of patients ranging from 130 to over 1 million. Significant predictors for severe injury were: vital signs, suspicion of certain anatomic injuries, mechanism of injury, and age. Sensitivity ranged from 10% to 100%; specificity from 9% to 100%. Nearly all protocols had a low sensitivity, thereby failing to identify severely injured patients. Additionally, the critical appraisal showed poor quality of the majority of included studies. This systematic review shows that nearly all protocols are incapable of identifying severely injured patients. Future studies of high methodological quality should be performed to improve prehospital trauma triage protocols. Systematic review, level III.

Prevention of delirium in trauma patients: Are we giving thiamine prophylaxis a fair chance?

PubMed Central

Blackmore, Christopher; Ouellet, Jean-Francois; Niven, Daniel; Kirkpatrick, Andrew W.; Ball, Chad G.

2014-01-01

Background Delirium is associated with increased morbidity and mortality in injured patients. Wernicke encephalopathy (WE) is delirium linked to malnutrition and chronic alcoholism. It is prevented with administration of thiamine. Our primary goal was to evaluate current blood alcohol level (BAL) testing and thiamine prophylaxis in severely injured patients. Methods We retrospectively reviewed the cases of 1000 consecutive severely injured patients admitted to hospital between Mar. 1, 2009, and Dec. 31, 2009. We used the patients’ medical records and the Alberta Trauma Registry. Results Among 1000 patients (mean age 48 yr, male sex 70%, mean injury severity score 23, mortality 10%), 627 underwent BAL testing at admission; 221 (35%) had a BAL greater than 0 mmol/L, and 189 (30%) had a BAL above the legal limit of 17.4 mmol/L. The mean positive BAL was 41.9 mmol/L. More than 4% had a known history of alcohol abuse. More patients were assaulted (20% v. 9%) or hit by motor vehicles (10% v. 6%) when intoxicated (both p < 0.05). Most injuries occurred after falls (37%) and motor vehicle collisions (33%). Overall, 17% of patients received thiamine prophylaxis. Of the 221 patients with elevated BAL, 44% received thiamine prophylaxis. Of those with a history of alcohol abuse, 77% received thiamine prophylaxis. Conclusion Despite the strong link between alcohol abuse, trauma and WE, more than one-third of patients were not screened for alcohol use. Furthermore, a minority of intoxicated patients received adequate prophylaxis against WE. Given the low risk and cost of BAL testing and thiamine prophylaxis and the high cost of delirium, standard protocols for prophylaxis are essential. PMID:24666443

Assessing the validity of using serious game technology to analyze physician decision making.

PubMed

Mohan, Deepika; Angus, Derek C; Ricketts, Daniel; Farris, Coreen; Fischhoff, Baruch; Rosengart, Matthew R; Yealy, Donald M; Barnato, Amber E

2014-01-01

Physician non-compliance with clinical practice guidelines remains a critical barrier to high quality care. Serious games (using gaming technology for serious purposes) have emerged as a method of studying physician decision making. However, little is known about their validity. We created a serious game and evaluated its construct validity. We used the decision context of trauma triage in the Emergency Department of non-trauma centers, given widely accepted guidelines that recommend the transfer of severely injured patients to trauma centers. We designed cases with the premise that the representativeness heuristic influences triage (i.e. physicians make transfer decisions based on archetypes of severely injured patients rather than guidelines). We randomized a convenience sample of emergency medicine physicians to a control or cognitive load arm, and compared performance (disposition decisions, number of orders entered, time spent per case). We hypothesized that cognitive load would increase the use of heuristics, increasing the transfer of representative cases and decreasing the transfer of non-representative cases. We recruited 209 physicians, of whom 168 (79%) began and 142 (68%) completed the task. Physicians transferred 31% of severely injured patients during the game, consistent with rates of transfer for severely injured patients in practice. They entered the same average number of orders in both arms (control (C): 10.9 [SD 4.8] vs. cognitive load (CL):10.7 [SD 5.6], p = 0.74), despite spending less time per case in the control arm (C: 9.7 [SD 7.1] vs. CL: 11.7 [SD 6.7] minutes, p<0.01). Physicians were equally likely to transfer representative cases in the two arms (C: 45% vs. CL: 34%, p = 0.20), but were more likely to transfer non-representative cases in the control arm (C: 38% vs. CL: 26%, p = 0.03). We found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory.

Prehospital endotracheal intubation and chest tubing does not prolong the overall resuscitation time of severely injured patients: a retrospective, multicentre study of the Trauma Registry of the German Society of Trauma Surgery.

PubMed

Kulla, Martin; Helm, Matthias; Lefering, Rolf; Walcher, Felix

2012-06-01

The aim of this study was to determine whether prehospital endotracheal intubation (ETI) and chest tube placement is unnecessarily time consuming in severely injured patients. A retrospective, multicentre study including all adult patients (ISS ≥9; 2002-7) of the Trauma Registry of the German Society of Trauma Surgery who were not secondarily transferred to a trauma centre and received a definitive airway and a chest tube. Creating four groups: AA (n=963) receiving ETI and chest tube on scene, AB (n=1547) ETI performed in the prehospital setting but chest tubing later in the emergency department (ED) and BB (n=640) receiving both procedures in the ED. The BA collective (ETI performed in the ED, but chest tubing on scene) was excluded from the study because of the small sample size (n=41). The trauma resuscitation time (TRT), demographic data, injuries, treatment and outcome of the remaining three collectives were compared. The prehospital TRT of the AA collective was longer than the AB and BB subgroups (80±37 min vs 77±44 min 65±46 min; p<0.01). Although the AA and AB subgroups were more severely injured (ISS 35±15 vs 38±15 vs 31±12; p<0.01) and showed poorer vital parameters on scene, the overall TRT (accident until end of ED treatment) were equal for all three groups (152±59 min vs 151±62 min vs 148±68 min; p=0.07). The TRISS adjusted mortality was also equal in all three groups. In a physician-based emergency medical service, prehospital ETI and chest tube placement do not prolong the total TRT of severely injured patients.

Vision-related quality of life in patients with ocular chemical burns.

PubMed

Le, Qihua; Chen, Yan; Wang, Xin; Li, Yimin; Hong, Jiaxu; Xu, Jianjiang

2011-11-21

To assess vision-related quality of life in patients with ocular chemical burns by the application of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25). Eighty-seven patients with ocular chemical burns were enrolled in the study from January 1 through May 31, 2010. Apart from the collection of sociodemographic and clinical data, NEI VFQ-25 with an additional appendix question, being translated to Chinese, was administered to all subjects. Main outcome measures were comparison of the NEI VFQ-25 subscale item scores among subgroups and multivariate analysis of the NEI VFQ-25 subscale scores. Fifty-five subjects were bilaterally burned and the rest were unilaterally injured. The mean age of enrolled subjects was 39.4 ± 11.6 years, with the majority being male (98.9%) and worker (77.0%); the mean composite score of all subjects was 40.4 ± 23.8. The composite score and majority subscale scores of binocularly injured patients were significantly lower than those of monocularly injured patients. Further comparisons among groups divided by either clinical severity classification or best-corrected visual acuity (BCVA) produced similar results. The BCVA of both the better-seeing eye and the worse-seeing eye strongly correlated with the NEI VFQ-25 composite score (ρ = 0.664 and 0.498, both P = 0.000). Multivariate regression analysis revealed that the VFQ-25 composite score correlated significantly with the following independent variables: BCVA of the better-seeing eye and the worse-seeing eye, the injury classification of the less severely injured eye, and correct and immediate irrigation after injury as well. Ocular chemical burns have a significant and extensive impact on patients' visual function outcomes and vision-related quality of life.

[Peculiarities of laparoscopic diagnosis of the closed hepatic traumatic damage].

PubMed

Kapshitar', A A; Kapshitar', A V; Syrbu, I F

2008-01-01

Diagnostic possibilities of laparoscopy were studied in 24 injured persons, suffering closed hepatic damage in noninformity of results of clinical, laboratory-biochemical, roentgenologic, ultrasound investigations and diagnostic peritoneal lavage as well, were studied. Isolated trauma was revealed in 8 injured persons, the multiple one in 7 and the combined--in 9. Open operation was performed in 21 patients, relaparotomy--in 3, laparoscopic intervention with curative intent--in 3 hepatic wound tamponade, using hemostatic sponge with ambene, lubricated by dicinon. Three patients died due to severe combined trauma.

Disaster triage after the Haitian earthquake.

PubMed

Smith, R M; Dyer, G S M; Antonangeli, K; Arredondo, N; Bedlion, H; Dalal, A; Deveny, G M; Joseph, G; Lauria, D; Lockhart, S H; Lucien, S; Marsh, S; Rogers, S O; Salzarulo, H; Shah, S; Toussaint, R J; Wagoner, J

2012-11-01

In the aftermath of the devastating Haitian earthquake, we became the primary relief service for a large group of severely injured earthquake victims. Finding ourselves virtually isolated with extremely limited facilities and a group of critically injured patients whose needs vastly outstripped the available resources we employed a disaster triage system to organize their clinical care. This report describes the specific injury profile of this group of patients, their clinical course, and the management philosophy that we employed. It provides useful lessons for similar situations in the future. Copyright © 2011 Elsevier Ltd. All rights reserved.

Cytokine levels (IL-4, IL-6, IL-8 and TGFβ) as potential biomarkers of systemic inflammatory response in trauma patients.

PubMed

Volpin, Gershon; Cohen, Miri; Assaf, Michael; Meir, Tamar; Katz, Rina; Pollack, Shimon

2014-06-01

Much research is now being conducted in order to understand the role of cytokines in the development of the inflammatory response following trauma. The purpose of this study was to evaluate whether serum levels of certain cytokines, measured immediately after initial injury, can be used as potential biomarkers for predicting the development and the degree of severity of the systemic inflammatory response (SIRS) in patients with moderate and severe trauma. We conducted a prospective study with 71 individuals of whom 13 (18.3 %) were healthy controls and 58 (81.7 %) were traumatized orthopaedic patients who were categorized into two groups: 31 (43.6 %) with moderate injuries and 27 (38.1 %) patients with severe orthopaedic trauma. Thirty cc of heparinized blood were drawn from each individual within a few hours after the injury. Serum levels of pro-inflammatory, regulatory and anti-inflammatory cytokines were measured in each individual participant. High levels of pro-inflammatory cytokines IL-1β,-6,-8,-12, tumour necrosis factor alpha and interferon gamma were found in all injured patients compared to healthy controls. Only IL-6 and IL-8 were significantly higher in the injured patients. Levels of the regulatory cytokines, transformed growth factor beta (TGF-β) and IL-10 were higher in the injured patients, but significant only for TGF-β. Levels of IL-4 were significantly lower in the injured groups as compared to the controls. Secretion of large amounts of pro-inflammatory cytokines and decreased level of anti-inflammatory cytokines during the acute phase of trauma may lead to the development of systemic inflammatory response syndrome (SIRS) in unstable polytraumatized patients. SIRS may result in life threatening conditions as acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF). High levels of IL-6, IL-8, TGFβ and low levels of IL-4 were found to be reliable markers for the existence of immune reactivity in trauma patients. More research is needed to study pattern of cytokine levels along the acute period of injury, after surgical interventions and during recovery.

Acute and Perioperative Care of the Burn-Injured Patient

PubMed Central

Bittner, Edward A.; Shank, Erik; Woodson, Lee; Martyn, J.A. Jeevendra

2016-01-01

Care of burn-injured patients requires knowledge of the pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Massive airway and/or lung edema can occur rapidly and unpredictably after burn and/or inhalation injury. Hemodynamics in the early phase of severe burn injury are characterized by a reduction in cardiac output, increased systemic and pulmonary vascular resistance. Approximately 2–5 days after major burn injury, a hyperdynamic and hypermetabolic state develops. Electrical burns result in morbidity much higher than expected based on burn size alone. Formulae for fluid resuscitation should serve only as guideline; fluids should be titrated to physiologic end points. Burn injury is associated basal and procedural pain requiring higher than normal opioid and sedative doses. Operating room concerns for the burn-injured patient include airway abnormalities, impaired lung function, vascular access, deceptively large and rapid blood loss, hypothermia and altered pharmacology. PMID:25485468

Associated injuries, management, and outcomes of blunt abdominal aortic injury.

PubMed

de Mestral, Charles; Dueck, Andrew D; Gomez, David; Haas, Barbara; Nathens, Avery B

2012-09-01

Blunt abdominal aortic injury (BAAI) is very rare, and current literature is limited to case series of single-center experience. Through an analysis of the National Trauma Data Bank, the largest aggregation of United States trauma registry data, our aim was to characterize the associated injury pattern, contemporary management, and in-hospital outcomes of patients with BAAI. We used a nested case-control design. The overall cohort consisted of adult patients (age ≥ 16 years) severely injured (Injury Severity Score ≥ 16) after blunt trauma who were treated at a level 1 or 2 trauma center in years 2007 to 2009. Cases were patients with BAAI and were frequency-matched by age group and mechanism to randomly selected controls at a one-to-five ratio. Multivariable matched analysis (conditional logistic regression) was used to derive adjusted measures of association between BAAI and adjacent arterial, intra-abdominal, and bony injuries. We identified 436 patients with BAAI from 180 centers. The mean Injury Severity Score was 35 ± 14, and most patients were injured in motor vehicle crashes (84%). Multivariable analysis showed injury to the thoracic aorta, renal and iliac artery, small bowel, colon, liver, pancreas, and kidney, as well as lumbar spine fractures were independently associated with BAAI. A total of 394 patients (90%) were managed nonoperatively, and 42 (10%) underwent repair. Of these 42 patients, 29 (69%) underwent endovascular repair, with 11 patients undergoing open aortic repair and two extra-anatomic bypasses. Median time from admission to repair was 1 day (interquartile range, 1-2 days). Overall mortality was 29%. A total of 271 (69%) patients managed nonoperatively survived to hospital discharge. The index of suspicion for BAAI should be raised in severely injured patients by the presence of injuries to the lumbar spine, bowel, retroperitoneal organs, and adjacent major arteries. Although endovascular repair is the most common intervention, most patients are managed nonoperatively and survive to hospital discharge. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Trending Fibrinolytic Dysregulation: Fibrinolysis Shutdown in the Days After Injury Is Associated With Poor Outcome in Severely Injured Children.

PubMed

Leeper, Christine M; Neal, Matthew D; McKenna, Christine J; Gaines, Barbara A

2017-09-01

To trend fibrinolysis after injury and determine the influence of traumatic brain injury (TBI) and massive transfusion on fibrinolysis status. Admission fibrinolytic derangement is common in injured children and adults, and is associated with poor outcome. No studies examine fibrinolysis days after injury. Prospective study of severely injured children at a level 1 pediatric trauma center. Rapid thromboelastography was obtained on admission and daily for up to 7 days. Standard definitions of hyperfibrinolysis (HF; LY30 ≥3), fibrinolysis shutdown (SD; LY30 ≤0.8), and normal (LY30 = 0.9-2.9) were applied. Antifibrinolytic use was documented. Outcomes were death, disability, and thromboembolic complications. Wilcoxon rank-sum and Fisher exact tests were performed. Exploratory subgroups included massively transfused and severe TBI patients. In all, 83 patients were analyzed with median (interquartile ranges) age 8 (4-12) and Injury Severity Score 22 (13-34), 73.5% blunt mechanism, 47% severe TBI, 20.5% massively transfused. Outcomes were 14.5% mortality, 43.7% disability, and 9.8% deep vein thrombosis. Remaining in or trending to SD was associated with death (P = 0.007), disability (P = 0.012), and deep vein thrombosis (P = 0.048). Median LY30 was lower on post-trauma day (PTD)1 to PTD4 in patients with poor compared with good outcome; median LY30 was lower on PTD1 to PTD3 in TBI patients compared with non-TBI patients. HF without associated shutdown was not related to poor outcome, but extreme HF (LY30 >30%, n = 3) was lethal. Also, 50% of massively transfused patients in hemorrhagic shock demonstrated SD physiology on admission. All with HF (fc31.2%) corrected after hemostatic resuscitation without tranexamic acid. Fibrinolysis shutdown is common postinjury and predicts poor outcomes. Severe TBI is associated with sustained shutdown. Empiric antifibrinolytics for children should be questioned; thromboelastography-directed selective use should be considered for documented HF.

A recommended early goal-directed management guideline for the prevention of hypothermia-related transfusion, morbidity, and mortality in severely injured trauma patients.

PubMed

Perlman, Ryan; Callum, Jeannie; Laflamme, Claude; Tien, Homer; Nascimento, Barto; Beckett, Andrew; Alam, Asim

2016-04-20

Hypothermia is present in up to two-thirds of patients with severe injury, although it is often disregarded during the initial resuscitation. Studies have revealed that hypothermia is associated with mortality in a large percentage of trauma cases when the patient's temperature is below 32 °C. Risk factors include the severity of injury, wet clothing, low transport unit temperature, use of anesthesia, and prolonged surgery. Fortunately, associated coagulation disorders have been shown to completely resolve with aggressive warming. Selected passive and active warming techniques can be applied in damage control resuscitation. While treatment guidelines exist for acidosis and bleeding, there is no evidence-based approach to managing hypothermia in trauma patients. We synthesized a goal-directed algorithm for warming the severely injured patient that can be directly incorporated into current Advanced Trauma Life Support guidelines. This involves the early use of warming blankets and removal of wet clothing in the prehospital phase followed by aggressive rewarming on arrival at the hospital if the patient's injuries require damage control therapy. Future research in hypothermia management should concentrate on applying this treatment algorithm and should evaluate its influence on patient outcomes. This treatment strategy may help to reduce blood loss and improve morbidity and mortality in this population of patients.

Pulse wave velocity in patients with severe head injury a pilot study.

PubMed

Shahsavari, S; McKelvey, T; Rydenhag, B; Ritzén, C Eriksson

2010-01-01

The study aimed to determine the potential of pulse wave velocity measurements to reflect changes in compliant cerebral arteries/arterioles in head injured patients. The approach utilizes the electrocardiogram and intracranial pressure signals to measure the wave transit time between heart and cranial cavity. Thirty five clinical records of nineteen head injured patients, with different levels of cerebrovascular pressure-reactivity response, were investigated through the study. Results were compared with magnitude of normalized transfer function at the fundamental cardiac frequency. In patients with intact cerebrovascular pressure-reactivity, magnitude of normalized transfer function at the fundamental cardiac component was found to be highly correlated with pulse wave transit time.

[Polytrauma in children and adolescents. Choice of the primary care clinic and importance of pediatric traumatology competence centers].

PubMed

Debus, F; Lefering, R; Frink, M; Kühne, C; Mand, C; Ruchholtz, S

2015-05-01

The number of (seriously) injured children increased again for the first time in 2011. The aim of this study was to analyse differences compared to multiple injured adults and to show the reality of daily treatment. All cases of the DGU Trauma Registry from the years 1997 to 2010 were examined. The documented cases were divided into different the age groups. The study investigated, e.g. the mechanism of accident, injury pattern, the number of hospital and ICU days, and lethality. At 38.8% the largest percentage of severely injured children and adolescents belongs to the group of 16-17 year olds. The group of 0-5 year olds (15.9%) has the lowest percentage. The most common accident cause was traffic accidents (58.5%). The mechanism of accident and the injury patterns changes with age. Younger patients are often treated in supraregional trauma centers (0-5 year olds: 78.2% vs. 16-17 year olds: 73.1% vs. > 65 years: 63.2%). The average lethality rate was 14.8% (16.3% RISC). The percentage of severely injured children in the overall population is only 7.4%. Because the majority of patients are primarily treated in supraregional trauma centers, trauma centers with specialisation in paediatric traumatology are mandatory.

[The challenge of adequate reimbursement for the seriously injured patient in the German DRG system].

PubMed

Franz, D; Lefering, R; Siebert, H; Windolf, J; Roeder, N; Mahlke, L

2013-02-01

Critically injured patients are a very heterogeneous group, medically and economically. Their treatment is a major challenge for both the medical care and the appropriate financial reimbursement. Systematic underfunding can have a significant impact on the quality of patient care. In 2009 the German Trauma Society and the DRG-Research Group of the University Hospital Muenster initialised a DRG evaluation project to analyse the validity of case allocation of critically injured patients within the German DRG system versions 2008 and 2011 with additional consideration of clinical data from the trauma registry of the German Trauma Society. Severe deficits within the G-DRG structure were identified and specific solutions were designed and realised. A retrospective analysis was undertaken of standardised G-DRG data (§ 21 KHEntgG) including case-related cost data from 3 362 critically injured patients in the periods 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals. For 1 241 cases of the sample, complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of critically injured patients within the G-DRG system. Analyses of coding and grouping, performance of case allocation, and the homogeneity of costs in the G-DRG versions 2008 and 2011 were done. The following situations were found: (i) systematic underfunding of trauma patients in the G-DRG-Version 2008, especially trauma patients with acute paraplegia; (ii) participation in the official G-DRG development for 2011 with 13 proposals which were largely realised; (ii) the majority of cases with cost-covering in the G-DRG version 2011; (iv) significant improvements in the quality of statistical criteria; (v) overfunded trauma patients with high intensive care costs; (vi) underfunding for clinically relevant critically injured patients not identified in the G-DRG system. The quality of the G-DRG system is measured by the ability to obtain adequate case allocations for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation of critically injured patients. Additional consideration of the ISS clinical data must be further evaluated. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process. © Georg Thieme Verlag KG Stuttgart · New York.

Overuse of helicopter transport in the minimally injured: A health care system problem that should be corrected.

PubMed

Vercruysse, Gary A; Friese, Randall S; Khalil, Mazhar; Ibrahim-Zada, Irada; Zangbar, Bardiya; Hashmi, Ammar; Tang, Andrew; O'Keeffe, Terrence; Kulvatunyou, Narong; Green, Donald J; Gries, Lynn; Joseph, Bellal; Rhee, Peter M

2015-03-01

Mortality benefit has been demonstrated for trauma patients transported via helicopter but at great cost. This study identified patients who did not benefit from helicopter transport to our facility and demonstrates potential cost savings when transported instead by ground. We performed a 6-year (2007-2013) retrospective analysis of all trauma patients presenting to our center. Patients with a known mode of transfer were included in the study. Patients with missing data and those who were dead on arrival were excluded from the study. Patients were then dichotomized into helicopter transfer and ground transfer groups. A subanalysis was performed between minimally injured patients (ISS < 5) in both the groups after propensity score matching for demographics, injury severity parameters, and admission vital parameters. Groups were then compared for hospital and emergency department length of stay, early discharge, and mortality. Of 5,202 transferred patients, 18.9% (981) were transferred via helicopter and 76.7% (3,992) were transferred via ground transport. Helicopter-transferred patients had longer hospital (p = 0.001) and intensive care unit (p = 0.001) stays. There was no difference in mortality between the groups (p = 0.6).On subanalysis of minimally injured patients there was no difference in hospital length of stay (p = 0.1) and early discharge (p = 0.6) between the helicopter transfer and ground transfer group. Average helicopter transfer cost at our center was $18,000, totaling $4,860,000 for 270 minimally injured helicopter-transferred patients. Nearly one third of patients transported by helicopter were minimally injured. Policies to identify patients who do not benefit from helicopter transport should be developed. Significant reduction in transport cost can be made by judicious selection of patients. Education to physicians calling for transport and identification of alternate means of transportation would be both safe and financially beneficial to our system. Epidemiologic study, level III. Therapeutic study, level IV.

Signatures of inflammation and impending multiple organ dysfunction in the hyperacute phase of trauma: A prospective cohort study

PubMed Central

Longhi, M. Paula; Hoti, Mimoza; Patel, Minal B.; O’Dwyer, Michael; Nourshargh, Sussan; Barnes, Michael R.; Brohi, Karim

2017-01-01

Background Severe trauma induces a widespread response of the immune system. This “genomic storm” can lead to poor outcomes, including Multiple Organ Dysfunction Syndrome (MODS). MODS carries a high mortality and morbidity rate and adversely affects long-term health outcomes. Contemporary management of MODS is entirely supportive, and no specific therapeutics have been shown to be effective in reducing incidence or severity. The pathogenesis of MODS remains unclear, and several models are proposed, such as excessive inflammation, a second-hit insult, or an imbalance between pro- and anti-inflammatory pathways. We postulated that the hyperacute window after trauma may hold the key to understanding how the genomic storm is initiated and may lead to a new understanding of the pathogenesis of MODS. Methods and findings We performed whole blood transcriptome and flow cytometry analyses on a total of 70 critically injured patients (Injury Severity Score [ISS] ≥ 25) at The Royal London Hospital in the hyperacute time period within 2 hours of injury. We compared transcriptome findings in 36 critically injured patients with those of 6 patients with minor injuries (ISS ≤ 4). We then performed flow cytometry analyses in 34 critically injured patients and compared findings with those of 9 healthy volunteers. Immediately after injury, only 1,239 gene transcripts (4%) were differentially expressed in critically injured patients. By 24 hours after injury, 6,294 transcripts (21%) were differentially expressed compared to the hyperacute window. Only 202 (16%) genes differentially expressed in the hyperacute window were still expressed in the same direction at 24 hours postinjury. Pathway analysis showed principally up-regulation of pattern recognition and innate inflammatory pathways, with down-regulation of adaptive responses. Immune deconvolution, flow cytometry, and modular analysis suggested a central role for neutrophils and Natural Killer (NK) cells, with underexpression of T- and B cell responses. In the transcriptome cohort, 20 critically injured patients later developed MODS. Compared with the 16 patients who did not develop MODS (NoMODS), maximal differential expression was seen within the hyperacute window. In MODS versus NoMODS, 363 genes were differentially expressed on admission, compared to only 33 at 24 hours postinjury. MODS transcripts differentially expressed in the hyperacute window showed enrichment among diseases and biological functions associated with cell survival and organismal death rather than inflammatory pathways. There was differential up-regulation of NK cell signalling pathways and markers in patients who would later develop MODS, with down-regulation of neutrophil deconvolution markers. This study is limited by its sample size, precluding more detailed analyses of drivers of the hyperacute response and different MODS phenotypes, and requires validation in other critically injured cohorts. Conclusions In this study, we showed how the hyperacute postinjury time window contained a focused, specific signature of the response to critical injury that led to widespread genomic activation. A transcriptomic signature for later development of MODS was present in this hyperacute window; it showed a strong signal for cell death and survival pathways and implicated NK cells and neutrophil populations in this differential response. PMID:28715416

EMS versus civilian transportation of severely injured patients

DOT National Transportation Integrated Search

1999-08-26

A previous report of 5782 trauma patients demonstrated higher mortality among those transported by EMS than among their non-EMS transported counterparts. This study was performed to test the hypothesis that the two groups differed in the injury-to-ho...

Posttraumatic growth within the first three months after accidental injury in China: the role of self-disclosure, cognitive processing, and psychosocial resources.

PubMed

Dong, Chaoqun; Gong, Shumei; Jiang, Liping; Deng, Guanghui; Liu, Xiaohong

2015-01-01

The primary goals of this study, were to identify the posttraumatic growth (PTG) level of accidentally injured Chinese patients shortly after an accident occurred and to determine whether cognitive processing, self-disclosure, and psychosocial resources predicted PTG. A total of 232 patients were recruited from two public hospitals in Shanghai within the first three months of an accidental injury. Patients completed self-report questionnaires to assess severity of injury, cognitive processing, self-disclosure, psychosocial resources, and PTG. Patients reported a mid-low level of PTG (M = 50.38, SD = 18.12) in the short length of time post-injury. Hierarchical regression analysis indicated that subjective accident severity, deliberate rumination, perceived social support, and attitude towards disclosure were strong predictors of PTG. A moderating role of self-disclosure between intrusive rumination and PTG was identified. These findings support an interaction effect of rumination and self-disclosure on PTG and have implications for early intervention of accidentally injured patients.

Functional survival after acute care for severe head injury at a designated trauma center in Hong Kong.

PubMed

Taw, Benedict B T; Lam, Alan C S; Ho, Faith L Y; Hung, K N; Lui, W M; Leung, Gilberto K K

2012-07-01

Severe head injury is known to be a major cause of early mortalities and morbidities. Patients' long-term outcome after acute care, however, has not been widely studied. We aim to review the outcome of severely head-injured patients after discharge from acute care at a designated trauma center in Hong Kong. This is a retrospective study of prospectively collected data of patients admitted with severe head injuries between 2004 and 2008. Patients' functional status post-discharge was assessed using the Extended Glasgow Outcome Score (GOSE). Of a total of 1565 trauma patients, 116 had severe head injuries and 41 of them survived acute hospital care. Upon the last follow-up, 23 (56.1%) of the acute-care survivors had improvements in their GOSE, six (11.8%) experienced deteriorations, and 12 (23.5%) did not exhibit any change. The greatest improvement was observed in patients with GOSE of 5 and 6 upon discharge, but two of the 16 patients with GOSE 2 or 3 also had a good recovery. On logistic regression analysis, old age and prolonged acute hospital stay were found to be independent predictors of poor functional outcome after a mean follow-up duration of 42 months. Multidisciplinary neurorehabilitation service is an important component of comprehensive trauma care. Despite significant early mortalities, a proportion of severely head-injured patients who survive acute care may achieve good long-term functional recovery. Copyright © 2012, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.

Sleep in disorders of consciousness

PubMed Central

Cologan, Victor; Schabus, Manvel; Ledoux, Didier; Moonen, Gustave; Maquet, Pierre; Laureys, Steven

2010-01-01

SUMMARY From a behavioral as well as neurobiological point of view, sleep and consciousness are intimately connected. A better understanding of sleep cycles and sleep architecture of patients suffering from disorders of consciousness (DOC) might therefore improve the clinical care for these patients as well as our understanding of the neural correlations of consciousness. Defining sleep in severely brain-injured patients is however problematic as both their electrophysiological and sleep patterns differ in many ways from healthy individuals. This paper discusses the concepts involved in the study of sleep of patients suffering from DOC and critically assesses the applicability of standard sleep criteria in these patients. The available literature on comatose and vegetative states as well as that on locked-in and related states following traumatic or non-traumatic severe brain injury will be reviewed. A wide spectrum of sleep disturbances ranging from almost normal patterns to severe loss and architecture disorganization are reported in cases of DOC and some patterns correlate with diagnosis and prognosis. At the present time the interactions of sleep and consciousness in brain-injured patients are a little studied subject but, the authors suggest, a potentially very interesting field of research. PMID:19524464

Clinical classes of injured workers with chronic low back pain: a latent class analysis with relationship to working status.

PubMed

Carlesso, Lisa C; Raja Rampersaud, Y; Davis, Aileen M

2018-01-01

To determine (a) clinical classes of injured workers with chronic low back pain (CLBP), (b) predictors of class membership and (c) associations of classes with baseline work status. Patients with CLBP from a tertiary care outpatient clinic in Toronto, Canada were sampled. Latent class analysis was applied to determine class structure using physical, psychological and coping indicators. Classes were interpreted by class-specific means and analyzed for predictors of membership. Lastly, association of the classes with being off work was modeled. A 3-class model was chosen based on fit criteria, theoretical and clinical knowledge of this population. The resultant 3 classes represented low, moderate and high levels of clinical severity. Predictors of being in the high severity group compared to the low severity group were < high school education [odds ratio (OR) 3.06, 95% CI (1.47, 6.37)] and comorbidity total [OR 1.28, 95% CI (1.03, 1.59)]. High severity class membership was associated with four times increased risk of being off work at baseline compared to those in the low severity group [OR 3.98, 95% CI (1.61, 6.34)]. In a cohort of injured workers with CLBP, 3 clinical classes were identified with distinct psychological and physical profiles. These profiles are useful in aiding clinicians to identify patients of high clinical severity who may be potentially at risk for problematic return to work.

Helicopter versus ground emergency medical services for the transportation of traumatically injured children.

PubMed

Stewart, Camille L; Metzger, Ryan R; Pyle, Laura; Darmofal, Joe; Scaife, Eric; Moulton, Steven L

2015-02-01

Helicopter emergency medical services (HEMS) are a common mode of transportation for pediatric trauma patients. We hypothesized that HEMS improve outcomes for traumatically injured children compared to ground emergency medical services (GEMS). We queried trauma registries of two level 1 pediatric trauma centers for children 0-17 years, treated from 2003 to 2013, transported by HEMS or GEMS, with known transport starting location and outcome. A geocoding service estimated travel distance and time. Multivariate regression analyses were performed to adjust for injury severity variables and travel distance/time. We identified 14,405 traumatically injured children; 3870 (26.9%) transported by HEMS and 10,535 (73.1%) transported by GEMS. Transport type was not significantly associated with survival, ICU length of stay, or discharge disposition. Transport by GEMS was associated with a 68.6%-53.1% decrease in hospital length of stay, depending on adjustment for distance/time. Results were similar for children with severe injuries, and with propensity score matched cohorts. Of note, 862/3850 (22.3%) of HEMS transports had an ISS<10 and hospitalization<1 day. HEMS do not independently improve outcomes for traumatically injured children, and 22.3% of children transported by HEMS are not significantly injured. These factors should be considered when requesting HEMS for transport of traumatically injured children. Copyright © 2015 Elsevier Inc. All rights reserved.

[Severe parachuting accident. Analysis of 122 cases].

PubMed

Krauss, U; Mischkowsky, T

1993-06-01

Based on a population of 122 severely injured patients the causes of paragliding accidents and the patterns of injury are analyzed. A questionnaire is used to establish a sport-specific profile for the paragliding pilot. The lower limbs (55.7%) and the lower parts of the spine (45.9%) are the most frequently injured parts of the body. There is a high risk of multiple injuries after a single accident because of the tremendous axial power. The standard of equipment is good in over 90% of the cases. Insufficient training and failure to take account of geographical and meteorological conditions are the main determinants of accidents sustained by paragliders, most of whom are young. Nevertheless, 80% of our patients want to continue paragliding. Finally some advice is given on how to prevent paragliding accidents and injuries.

Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems

PubMed Central

Newgard, Craig D.; Mann, N. Clay; Hsia, Renee Y.; Bulger, Eileen M.; Ma, O. John; Staudenmayer, Kristan; Haukoos, Jason S.; Sahni, Ritu; Kuppermann, Nathan

2013-01-01

Objectives Reasons for under-triage (transporting seriously injured patients to non-trauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis. Methods This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and non-trauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department (ED) data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included: closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. “Serious injury” was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings. Results A total of 176,981 injured patients were evaluated and transported by EMS over the three-year period, of whom 5,752 (3.3%) had ISS ≥ 16, and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21 to 30 year olds to 75.8% among those older than 90 years. This trend paralleled under-triage rates, and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols. Conclusions Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age, and involves inherent differences in patient prognosis. PMID:24050797

Patient choice in the selection of hospitals by 9-1-1 emergency medical services providers in trauma systems.

PubMed

Newgard, Craig D; Mann, N Clay; Hsia, Renee Y; Bulger, Eileen M; Ma, O John; Staudenmayer, Kristan; Haukoos, Jason S; Sahni, Ritu; Kuppermann, Nathan

2013-09-01

Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis. This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. "Serious injury" was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings. A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90 years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols. Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis. © 2013 by the Society for Academic Emergency Medicine.

Benchmarking Outcomes in the Critically Injured Trauma Patient and the Effect of Implementing Standard Operating Procedures

PubMed Central

Cuschieri, Joseph; Johnson, Jeffrey L.; Sperry, Jason; West, Michael A.; Moore, Ernest E.; Minei, Joseph P.; Bankey, Paul E.; Nathens, Avery B.; Cuenca, Alex G.; Efron, Philip A.; Hennessy, Laura; Xiao, Wenzhong; Mindrinos, Michael N.; McDonald-Smith, Grace P.; Mason, Philip H.; Billiar, Timothy R.; Schoenfeld, David A.; Warren, H. Shaw; Cobb, J. Perren; Moldawer, Lyle L.; Davis, Ronald W.; Maier, Ronald V.; Tompkins, Ronald G.

2012-01-01

Objective To determine and compare outcomes with accepted benchmarks in trauma care at seven academic Level I trauma centers in which patients were treated based on a series of standard operating procedures (SOPs). Background Injury remains the leading cause of death for those under 45 years of age. We describe the baseline patient characteristics and well-defined outcomes of persons hospitalized in the United States for severe blunt trauma. Methods We followed 1,637 trauma patients from 2003–2009 up to 28 hospital days using SOPs developed at the onset of the study. An extensive database on patient and injury characteristics, clinical treatment, and outcomes was created. These data were compared with existing trauma benchmarks. Results The study patients were critically injured and in shock. SOP compliance improved 10–40% during the study period. Multiple organ failure and mortality rates were 34.8% and 16.7% respectively. Time to recovery, defined as the time until the patient was free of organ failure for at least two consecutive days, was developed as a new outcome measure. There was a reduction in mortality rate in the cohort during the study that cannot be explained by changes in the patient population. Conclusions This study provides the current benchmark and the overall positive effect of implementing SOPs for severely injured patients. Over the course of the study, there were improvements in morbidity and mortality and increasing compliance with SOPs. Mortality was surprisingly low, given the degree of injury, and improved over the duration of the study, which correlated with improved SOP compliance. PMID:22470077

Benchmarking outcomes in the critically injured trauma patient and the effect of implementing standard operating procedures.

PubMed

Cuschieri, Joseph; Johnson, Jeffrey L; Sperry, Jason; West, Michael A; Moore, Ernest E; Minei, Joseph P; Bankey, Paul E; Nathens, Avery B; Cuenca, Alex G; Efron, Philip A; Hennessy, Laura; Xiao, Wenzhong; Mindrinos, Michael N; McDonald-Smith, Grace P; Mason, Philip H; Billiar, Timothy R; Schoenfeld, David A; Warren, H Shaw; Cobb, J Perren; Moldawer, Lyle L; Davis, Ronald W; Maier, Ronald V; Tompkins, Ronald G

2012-05-01

To determine and compare outcomes with accepted benchmarks in trauma care at 7 academic level I trauma centers in which patients were treated on the basis of a series of standard operating procedures (SOPs). Injury remains the leading cause of death for those younger than 45 years. This study describes the baseline patient characteristics and well-defined outcomes of persons hospitalized in the United States for severe blunt trauma. We followed 1637 trauma patients from 2003 to 2009 up to 28 hospital days using SOPs developed at the onset of the study. An extensive database on patient and injury characteristics, clinical treatment, and outcomes was created. These data were compared with existing trauma benchmarks. The study patients were critically injured and were in shock. SOP compliance improved 10% to 40% during the study period. Multiple organ failure and mortality rates were 34.8% and 16.7%, respectively. Time to recovery, defined as the time until the patient was free of organ failure for at least 2 consecutive days, was developed as a new outcome measure. There was a reduction in mortality rate in the cohort during the study that cannot be explained by changes in the patient population. This study provides the current benchmark and the overall positive effect of implementing SOPs for severely injured patients. Over the course of the study, there were improvements in morbidity and mortality rates and increasing compliance with SOPs. Mortality was surprisingly low, given the degree of injury, and improved over the duration of the study, which correlated with improved SOP compliance.

Provider perspectives on rehabilitation of patients with polytrauma.

PubMed

Friedemann-Sánchez, Greta; Sayer, Nina A; Pickett, Treven

2008-01-01

To describe, from the perspective of U.S. Department of Veterans Affairs (VA) polytrauma rehabilitation providers, (1) patients with combat-related polytrauma and their rehabilitation, (2) polytrauma patient family member involvement in rehabilitation, and (3) the impact on providers of providing polytrauma rehabilitation. Qualitative study based on rapid assessment process methodology, which included semistructured interviews, observation, and use of a field liaison. The 4 VA polytrauma rehabilitation centers (PRCs). Fifty-six purposefully selected PRC providers and providers from consulting services. Not applicable. Provider self-report of polytrauma patient characteristics, polytrauma patient family member involvement in rehabilitation, and the impact of polytrauma rehabilitation on providers themselves. According to PRC providers, polytrauma patients are younger than VA rehabilitation patients. Strong military identities affect rehabilitation needs and reactions to severe injury. The public and the media have particular interest in war-injured patients. Patients with blast-related polytrauma have unique constellations of visible (including amputations, craniectomies, and burns) and invisible (including traumatic brain injury, pain, and posttraumatic stress disorder) injuries. Providers have adjusted treatment strategies and involved services outside of rehabilitation because of this clinical complexity. Family members are intensely involved in rehabilitation and have service needs that may surpass those of families of rehabilitation patients without polytrauma. Sources of provider stress include new responsibilities, media attention, increased oversight, and emotional costs associated with treating severely injured young patients and their families. Providers also described the work as deeply rewarding. The VA should prioritize the identification or development and implementation of strategies to address family member needs and to monitor and ensure that PRC providers have access to appropriate resources. Future research should determine whether findings generalize to patients injured in other wars and to people who sustain polytraumatic injuries outside of a war zone, including victims of terrorist attacks.

Clinical relevance of IL-6 gene polymorphism in severely injured patients

PubMed Central

Jeremić, Vasilije; Alempijević, Tamara; Mijatović, Srđan; Šijački, Ana; Dragašević, Sanja; Pavlović, Sonja; Miličić, Biljana; Krstić, Slobodan

2014-01-01

In polytrauma, injuries that may be surgically treated under regular circumstances due to a systemic inflammatory response become life-threatening. The inflammatory response involves a complex pattern of humoral and cellular responses and the expression of related factors is thought to be governed by genetic variations. This aim of this paper is to examine the influence of interleukin (IL) 6 single nucleotide polymorphism (SNP) -174C/G and -596G/A on the treatment outcome in severely injured patients. Forty-seven severely injured patients were included in this study. Patients were assigned an Injury Severity Score. Blood samples were drawn within 24 h after admission (designated day 1) and on subsequent days (24, 48, 72 hours and 7days) of hospitalization. The IL-6 levels were determined through ELISA technique. Polymorphisms were analyzed by a method of Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR). Among subjects with different outcomes, no statistically relevant difference was found with regards to the gene IL-6 SNP-174G/C polymorphism. More than a half of subjects who died had the SNP-174G/C polymorphism, while this polymorphism was represented in a slightly lower number in survivors. The incidence of subjects without polymorphism and those with heterozygous and homozygous gene IL-6 SNP-596G/A polymorphism did not present statistically significant variations between survivors and those who died. The levels of IL-6 over the observation period did not present any statistically relevant difference among subjects without the IL-6 SNP-174 or IL-6 SNP -596 gene polymorphism and those who had either a heterozygous or a homozygous polymorphism. PMID:24856384

Assessing the Validity of Using Serious Game Technology to Analyze Physician Decision Making

PubMed Central

Mohan, Deepika; Angus, Derek C.; Ricketts, Daniel; Farris, Coreen; Fischhoff, Baruch; Rosengart, Matthew R.; Yealy, Donald M.; Barnato, Amber E.

2014-01-01

Background Physician non-compliance with clinical practice guidelines remains a critical barrier to high quality care. Serious games (using gaming technology for serious purposes) have emerged as a method of studying physician decision making. However, little is known about their validity. Methods We created a serious game and evaluated its construct validity. We used the decision context of trauma triage in the Emergency Department of non-trauma centers, given widely accepted guidelines that recommend the transfer of severely injured patients to trauma centers. We designed cases with the premise that the representativeness heuristic influences triage (i.e. physicians make transfer decisions based on archetypes of severely injured patients rather than guidelines). We randomized a convenience sample of emergency medicine physicians to a control or cognitive load arm, and compared performance (disposition decisions, number of orders entered, time spent per case). We hypothesized that cognitive load would increase the use of heuristics, increasing the transfer of representative cases and decreasing the transfer of non-representative cases. Findings We recruited 209 physicians, of whom 168 (79%) began and 142 (68%) completed the task. Physicians transferred 31% of severely injured patients during the game, consistent with rates of transfer for severely injured patients in practice. They entered the same average number of orders in both arms (control (C): 10.9 [SD 4.8] vs. cognitive load (CL):10.7 [SD 5.6], p = 0.74), despite spending less time per case in the control arm (C: 9.7 [SD 7.1] vs. CL: 11.7 [SD 6.7] minutes, p<0.01). Physicians were equally likely to transfer representative cases in the two arms (C: 45% vs. CL: 34%, p = 0.20), but were more likely to transfer non-representative cases in the control arm (C: 38% vs. CL: 26%, p = 0.03). Conclusions We found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory. PMID:25153149

Pretrauma Center Red Blood Cell Transfusion Is Associated With Reduced Mortality and Coagulopathy in Severely Injured Patients With Blunt Trauma

PubMed Central

Brown, Joshua B.; Cohen, Mitchell J.; Minei, Joseph P.; Maier, Ronald V.; West, Michaela A.; Billiar, Timothy R.; Peitzman, Andrew B.; Moore, Ernest E.; Cuschieri, Joseph; Sperry, Jason L.; Inflammation, The

2014-01-01

Objective To evaluate the association of pretrauma center (PTC) red blood cell (RBC) transfusion with outcomes in severely injured patients. Background Hemorrhage remains a major driver of mortality. Little evidence exists supporting PTC interventions to mitigate this. Methods Blunt injured patients in shock arriving at a trauma center within 2 hours of injury were included from the Glue Grant database. Subjects were dichotomized by PTC RBC transfusion. Outcomes included 24-hour mortality, 30-day mortality, and trauma-induced coagulopathy [(TIC), admission international normalized ratio >1.5]. Cox regression and logistic regression determined the association of PTC RBC transfusion with outcomes. To address baseline differences, propensity score matching was used. Results Of 1415 subjects, 50 received PTC RBC transfusion. Demographics and injury severity score were similar. The PTC RBC group received 1.3 units of RBCs (median), and 52% were scene transports. PTC RBC transfusion was associated with a 95% reduction in odds of 24-hour mortality [odds ratio (OR) = 0.05; 95% confidence interval (CI), 0.01–0.48; P < 0.01], 64% reduction in the risk of 30-day mortality [hazard ratio = 0.36; 95% CI, 0.15–0.83; P = 0.02], and 88% reduction in odds of TIC (OR = 0.12; 95% CI, 0.02–0.79; P = 0.03). The matched cohort included 113 subjects (31% PTC RBC group). Baseline characteristics were similar. PTC RBC transfusion was associated with a 98% reduction in odds of 24-hour mortality (OR = 0.02; 95% CI, 0.01–0.69; P = 0.04), 88% reduction in the risk of 30-day mortality (hazard ratio = 0.12; 95% CI, 0.03–0.61; P = 0.01), and 99% reduction in odds of TIC (OR = 0.01; 95% CI, 0.01–0.95; P = 0.05). Conclusions PTC RBC administration was associated with a lower risk of 24-hour mortality, 30-day mortality, and TIC in severely injured patients with blunt trauma, warranting further prospective study. PMID:24670858

Epidemiology and risk factors of multiple-organ failure after multiple trauma: an analysis of 31,154 patients from the TraumaRegister DGU.

PubMed

Fröhlich, Matthias; Lefering, Rolf; Probst, Christian; Paffrath, Thomas; Schneider, Marco M; Maegele, Marc; Sakka, Samir G; Bouillon, Bertil; Wafaisade, Arasch

2014-04-01

In the severely injured who survive the early posttraumatic phase, multiple-organ failure (MOF) is the main cause of morbidity and mortality. An enhanced prediction of MOF might influence individual monitoring and therapy of severely injured patients. We performed a retrospective analysis of a nationwide prospective database, the TraumaRegister DGU of the German Trauma Society. Patients with complete data sets (2002-2011) and a relevant trauma load (Injury Severity Score [ISS] ≥ 16), who were admitted to an intensive care unit, were included. Of a total of 31,154 patients enclosed in this study, 10,201 (32.7%) developed an MOF according to the Sequential Organ Failure Assessment score. During the study period, mortality of all patients decreased from 18.1% in 2002 to 15.3% in 2011 (p < 0.001). Meanwhile, MOF occurred significantly more often (24.6% in 2002 vs. 31.5% in 2011, p < 0.001), but mortality of MOF patients decreased (42.6% vs. 33.3%, p < 0.001). MOF patients who died survived 2 days less (11 days in 2002 vs. 8.9 days in 2011, p < 0.001). Independent risk factors for the development of MOF following severe trauma were age, ISS, head Abbreviated Injury Scale (AIS) score of 3 or higher, thoracic AIS score of 3 or higher, male sex, Glasgow Coma Scale (GCS) score of 8 or less, mass transfusion, base excess of less than -3, systolic blood pressure less than 90 mm Hg at admission, and coagulopathy. Over one decade, we observed an ongoing decrease of mortality after multiple trauma, accompanied by decreasing mortality in the subgroup with MOF. However, incidence of MOF in the severely injured increased significantly. Thus, MOF after multiple trauma remains a challenge in intensive care. The risk factors from multivariate analysis could be instrumental in anticipating the early development of MOF. Furthermore, a reliable prediction model might be supportive for patient enrolment in trauma studies, in which MOF marks the primary end point. Epidemiologic study, level III.

Insurance status and admission to hospital for head injuries: are we part of a two-tiered medical system?

PubMed

Svenson, J E; Spurlock, C W

2001-01-01

Previous studies have shown an association between insurance status and use of resources for inpatient care. We sought to assess whether insurance status influences decisions regarding the evaluation and treatment of head injured patients in the emergency department (ED). Head injured patients were identified from ED data from 4 hospitals reporting to the Kentucky Emergency Medical Services Information System. Multiple regression analysis using admission, ED length of stay, and ED charges as outcome variables was then performed. From 216,137 ED visits there were 8,591 (4%) head injured patients identified from the database. Eliminating those with revisits, transfers to another hospital in the database, and isolated facial lacerations, there were 3,821 cases. Controlling for age, hospital, race, primary diagnosis, and indicators of severity of the injury, insurance status was significantly associated with hospital admission. Those uninsured were the least likely to be admitted (OR 0.41; 95% CI (0.31, 0.50), whereas those with public insurance had an intermediate probability (OR 0.50 95% CI (0.37, 0.68) as compared with those with private insurance. Similarly, ED charges were lower for Medicaid patients than insured patients ($880) and tended to be slightly lower for uninsured patients ($1,043) than insured patients ($1,141) (P =.001). Length of stay in the ED was shorter for publicly insured patients (179 minutes) than uninsured (186 minutes) and privately insured patients (192 minutes) (P =.001). The extent of evaluation and admission for head injured patients is associated with insurance status. This creates a dual standard of care for patients. Practitioners should work to standardize the evaluation of patients independent of paying status.

Predictors of sepsis in moderately severely injured patients: an analysis of the National Trauma Data Bank.

PubMed

Kisat, Mehreen; Villegas, Cassandra V; Onguti, Sharon; Zafar, Syed Nabeel; Latif, Asad; Efron, David T; Haut, Elliott R; Schneider, Eric B; Lipsett, Pamela A; Zafar, Hasnain; Haider, Adil H

2013-02-01

Post-traumatic sepsis is a significant cause of in-hospital death. However, socio-demographic and clinical characteristics that may predict sepsis in injured patients are not well known. The objective of this study was to identify risk factors that may be associated with post-traumatic sepsis. Retrospective analysis of patients in the National Trauma Data Bank for 2007-2008. Patients older than 16 years of age with an Injury Severity Score (ISS) ≥ 9 points were included. Multivariable logistic regression was used to determine association of sepsis with patient (age, gender, ethnicity, and insurance status), injury (mechanism, ISS, injury type, hypotension), and clinical (major surgical procedure, intensive care unit admission) characteristics. Of a total of 1.3 million patients, 373,370 met the study criteria, and 1.4% developed sepsis, with an associated mortality rate of approximately 20%. Age, male gender, African-American race, hypotension on emergency department presentation, and motor vehicle crash as the injury mechanism were independently associated with post-traumatic sepsis. Socio-demographic and injury factors, such as age, race, hypotension on admission, and severity and mechanism of injury predict post-traumatic sepsis significantly. Further exploration to explain why these patient groups are at increased risk is warranted in order to understand better and potentially prevent this life-threatening complication.

Defining hypotension in moderate to severely injured trauma patients: raising the bar for the elderly.

PubMed

Edwards, Meghan; Ley, Eric; Mirocha, James; Hadjibashi, Anoushiravan Amini; Margulies, Daniel R; Salim, Ali

2010-10-01

Hypotension, defined as systolic blood pressure less than 90 mm Hg, is recognized as a sign of hemorrhagic shock and is a validated prognostic indicator. The definition of hypotension, particularly in the elderly population, deserves attention. We hypothesized that the systolic blood pressure associated with increased mortality resulting from hemorrhagic shock increases with increasing age. The Los Angeles County Trauma Database was queried for all moderate to severely injured patients without major head injuries admitted between 1998 and 2005. Several fit statistic analyses were performed for each systolic blood pressure from 50 to 180 mm Hg to identify the model that most accurately defined hypotension for three age groups. The optimal definition of hypotension for each group was determined from the best fit model. A total of 24,438 patients were analyzed. The optimal definition of hypotension was systolic blood pressure of 100 mm Hg for patients 20 to 49 years, 120 mm Hg for patients 50 to 69 years, and 140 mm Hg for patients 70 years and older. The optimal systolic blood pressure for improved mortality in hemorrhagic shock increases significantly with increasing age. Elderly trauma patients without major head injuries should be considered hypotensive for systolic blood pressure less than 140 mm Hg.

Skateboarding injuries of today

PubMed Central

Forsman, L; Eriksson, A

2001-01-01

Background—Skateboarding injuries have increased with the rise in popularity of the sport, and the injury pattern can be expected to have changed with the development of both skateboard tricks and the materials used for skateboard construction. Objective—To describe the injury pattern of today. Methods—The pattern of injuries, circumstances, and severity were investigated in a study of all 139 people injured in skateboarding accidents during the period 1995–1998 inclusive and admitted to the University Hospital of Umeå. This is the only hospital in the area, serving a population of 135 000. Results—Three of the 139 injured were pedestrians hit by a skateboard rider; the rest were riders. The age range was 7–47 years (mean 16). The severity of the injuries was minor (AIS 1) to moderate (AIS 2); fractures were classified as moderate. The annual number of injuries increased during the study period. Fractures were found in 29% of the casualties, and four children had concussion. The most common fractures were of the ankle and wrist. Older patients had less severe injuries, mainly sprains and soft tissue injuries. Most children were injured while skateboarding on ramps and at arenas; only 12 (9%) were injured while skateboarding on roads. Some 37% of the injuries occurred because of a loss of balance, and 26% because of a failed trick attempt. Falls caused by surface irregularities resulted in the highest proportion of the moderate injuries. Conclusions—Skateboarding should be restricted to supervised skateboard parks, and skateboarders should be required to wear protective gear. These measures would reduce the number of skateboarders injured in motor vehicle collisions, reduce the personal injuries among skateboarders, and reduce the number of pedestrians injured in collisions with skateboarders. Key Words: skateboard; injury; prevention PMID:11579065

Retrospective review of injury severity, interventions and outcomes among helicopter and nonhelicopter transport patients at a Level 1 urban trauma centre

PubMed Central

Hannay, R. Scott; Wyrzykowski, Amy D.; Ball, Chad G.; Laupland, Kevin; Feliciano, David V.

2014-01-01

Background Air ambulance transport for injured patients is vitally important given increasing patient volumes, the limited number of trauma centres and inadequate subspecialty coverage in nontrauma hospitals. Air ambulance services have been shown to improve patient outcomes compared with ground transport in select circumstances. Our primary goal was to compare injuries, interventions and outcomes in patients transported by helicopter versus nonhelicopter transport. Methods We performed a retrospective 10-year review of 14 440 patients transported to an urban Level 1 trauma centre by helicopter or by other means. We compared injury severity, interventions and mortality between the groups. Results Patients transported by helicopter had higher median injury severity scores (ISS), regardless of penetrating or blunt injury, and were more likely to have Glasgow Coma Scale scores less than 8, require airway control, receive blood transfusions and require admission to the intensive care unit or operating room than patients transported by other means. Helicopter transport was associated with reduced overall mortality (odds ratio 0.41, 95% confidence interval 0.33–0.39). Patients transported by other methods were more likely to die in the emergency department. The mean ISS, regardless of transport method, rose from 12.3 to 15.1 (p = 0.011) during our study period. Conclusion Patients transported by helicopter to an urban trauma centre were more severely injured, required more interventions and had improved survival than those arriving by other means of transport. PMID:24461227

Retrospective review of injury severity, interventions and outcomes among helicopter and nonhelicopter transport patients at a Level 1 urban trauma centre.

PubMed

Hannay, R Scott; Wyrzykowski, Amy D; Ball, Chad G; Laupland, Kevin; Feliciano, David V

2014-02-01

Air ambulance transport for injured patients is vitally important given increasing patient volumes, the limited number of trauma centres and inadequate subspecialty coverage in nontrauma hospitals. Air ambulance services have been shown to improve patient outcomes compared with ground transport in select circumstances. Our primary goal was to compare injuries, interventions and outcomes in patients transported by helicopter versus nonhelicopter transport. We performed a retrospective 10-year review of 14 440 patients transported to an urban Level 1 trauma centre by helicopter or by other means. We compared injury severity, interventions and mortality between the groups. Patients transported by helicopter had higher median injury severity scores (ISS), regardless of penetrating or blunt injury, and were more likely to have Glasgow Coma Scale scores less than 8, require airway control, receive blood transfusions and require admission to the intensive care unit or operating room than patients transported by other means. Helicopter transport was associated with reduced overall mortality (odds ratio 0.41, 95% confidence interval 0.33-0.39). Patients transported by other methods were more likely to die in the emergency department. The mean ISS, regardless of transport method, rose from 12.3 to 15.1 (p = 0.011) during our study period. Patients transported by helicopter to an urban trauma centre were more severely injured, required more interventions and had improved survival than those arriving by other means of transport.

Association between the initial anatomical severity and opportunity of return to work in occupational hand injured patients.

PubMed

Lee, Yung-Yi; Chang, Jer-Hao; Shieh, Shyh-Jou; Lee, Yao-Chou; Kuo, Li-Chieh; Lee, Yungling L

2010-12-01

The severity of the injury is the most important factor to return to work (RTW) when it comes to hand injuries. The purpose of our study is to examine the relationship between the initial anatomic severity, evaluated by the Hand Injury Severity Scoring (HISS) system, and probability of RTW in occupational hand injured patients. In this retrospective cohort study, 140 patients hospitalized for surgery due to occupational hand injuries between 2004 and 2008 were recruited. Participants were interviewed for occupational history and RTW status. The probability of RTW was compared with the initial HISS scores by multiple logistic regression models. In workers' compensation group, there was a significant relationship between HISS severity and the probability of RTW. Compensated patients with moderate injuries (odds ratio [OR] = 0.15; 95% confidence interval [CI], 0.03-0.70) and severe injuries (OR = 0.13; 95% CI, 0.02-0.75) were significantly less likely to RTW than those with minor injuries, and those with major injuries were the least likely to RTW (OR = 0.07; 95% CI, 0.01-0.36). However, no association was found between HISS severity and the probability of RTW for patients without workers' compensation. With regard to the HISS components, patients with motor or neural component deficits had a significantly lower opportunity of RTW, with the neural deficits being the most influential. HISS is a useful instrument to predict the opportunity of RTW while restricted to the compensated patients. We also verified that the relationship between HISS severity and the probability of RTW existed for groups but not for individual patients.

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2)

PubMed Central

2012-01-01

Background Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. Methods/design The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. Discussion The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group. Trial Registration ClinicalTrials.gov: (NCT01523626). PMID:22458247

Employment among spinal cord injured patients living in Turkey: a cross-sectional study.

PubMed

Gunduz, Berrin; Erhan, Belgin; Bardak, Ayse Nur

2010-09-01

The aim of this study was to determine the rate of employment and to establish the factors affecting vocational status in spinal cord injured patients living in Turkey. One hundred and fifty-two traumatic spinal cord injured patients older than 18 years with injury duration of at least 1 year and living in the community were included in the study; homemakers were not taken into consideration. The demographic and clinical data were retrieved from the medical records. The patients were interviewed with a structured questionnaire about the employment status at the time of the injury and after the injury, seeking a job after the injury, possible causes for unemployment, educational activities after the injury, and being a member of a social association. Descriptive statistics, Mann-Whitney U test and Pearson's χ test were used to analyze the results. The rate of employment was 21% among this group of spinal cord injured patients. Female sex, young age at the time of the injury, longer time since injury, higher educational level, being educated after injury, and being a member of a social association have positive effects on vocational outcome; age at the time of the study and severity and level of the lesion did not affect employment. According to the results of this study, the employment rates after spinal cord injury are low in Turkey. There is a need to maximize the employment capacity. Social and educational activities after injury should be encouraged during rehabilitation.

Alcohol consumption decreases lactate clearance in acutely injured patients☆

PubMed Central

Dezman, Zachary D.W.; Comer, Angela C.; Narayan, Mayur; Scalea, Thomas M.; Hirshon, Jon Mark; Smith, Gordon S.

2017-01-01

Introduction Alcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of resuscitation in injured patients. We investigated whether acutely injured patients with positive blood alcohol content (+BAC) had less lactate clearance than sober patients. Methods We conducted a retrospective cohort study of acutely injured patients treated at an urban Level 1 trauma centre between January 2010 and December 2012. Blood alcohol and venous lactate levels were measured on all patients at the time of arrival. Study subjects were patients transported directly from the scene of injury, who had an elevated lactate concentration on arrival (≥3.0 mmol/L) and at least one subsequent lactate measurement within 24 h after admission. Lactate clearance ([Lactate1 − Lactate2]/Lactate1) was calculated for all patients. Chi-squared tests were used to compare values from sober and intoxicated subjects. Lactate clearance was plotted against alcohol levels and stratified by age and Injury Severity Score (ISS). Results Serial lactate concentration measurements were obtained in 3910 patients; 1674 of them had +BAC. Patients with +BAC were younger (mean age: 36.6 [SD 14.7] vs 41.0 [SD 19.9] years [p = 0.0001]), were more often male (83.4% vs 75.9% [p = 0.0001]), had more minor injuries (ISS < 9) (33.8% vs 27.1% [p = 0.0001]), had a lower in-hospital mortality rate (1.4% vs 3.9% [p = 0.0001]), but also had lower average lactate clearance (37.8% vs 47.6% [p = 0.0001]). The lactate clearance of the sober patients (47.6 [SD 33.5]) was twice that of those with +BAC >400 (23.5 [SD 6.5]). Lactate clearance decreased with increasing BAC irrespective of age and ISS. Conclusions In a large group of acutely injured patients, a dose-dependent decrease in lactate clearance was seen in those with elevated BAC. This relationship will cause a falsely elevated lactate reading or prolong lactate clearance and should be taken into account when evaluating patients with +BAC. PMID:27025567

[Gastric mucosa tonometry in routine monitoring in the surgical intensive care unit].

PubMed

Pestel, G; Uhlig, T; Götschl, A; Schmucker, P; Rothhammer, A

1998-06-01

Monitoring tissue oxygenation in the splanchnic region could be helpful for critically ill patients. In this study the postoperative course of gastric mucosal CO2 (prCO2) in 40 patients is shown. Following approval of the ethics committee, 24 patients schedulded for surgery with an expected large fluid turnover and 16 multiple injured patients were monitored with a gas tonometry device in addition to standard monitoring (ECG, pulse oximetry, capnometry, CVP, arterial pressure). Normoventilated patients with prCO2 > 50 for more than 30 minutes were treated with fluid therapy, followed by catecholamine therapy, followed by transfusion (fig. 1). All patients were admitted to the SICU post-operatively. The variation of prCO2-values was greater in multiple injured patients. Their prCO2-values began in a lower range compared to patients with scheduled operation, became higher at the end of the first SICU-day and remained higher thereafter. They had a higher fluid turnover and needed more catecholamines. Multiple injured patients with an arterio-intestinal CO2-Difference (CO2-Gap) > 10 had a higher ISS-Score, were longer mechanically ventilated, had a longer SICU-stay and a higher incidence of complications in comparison to patients with aCO2-Gap < 10. Perhaps a CO2-Gap > 10 could be predictive for a more severe course in intensive care patients.

Danger on the Farm: A Comparison of Agricultural and Animal-Related Injuries.

PubMed

Weaver, Jessica L; Kimbrough, Charles W; Broughton-Miller, Kimberly; Frisbie, Michelle; Wojcik, Jodi; Pentecost, Karina; Bozeman, Matthew C; Nash, Nicholas A; Harbrecht, Brian G

2017-05-01

Animal-related injuries are common in rural areas. Agricultural workers can suffer severe injuries involving farm machinery or falls. The spectrum of injuries related to rural activities is poorly defined and characterizing these injuries will improve injury prevention efforts. Records for injured patients admitted between 2010 and 2013 were retrospectively reviewed. Patients with a mechanism of injury involving a large animal or with the injury site listed as "farm" were included. Patients with agricultural injuries (n = 85) were older with more multisystem injuries than patients injured by animals (n = 132) but the Injury Severity Score was equivalent. There was no difference in intensive care unit length of stay, ventilator days, or mortality. There was no difference in frequency of solid organ injury, pelvic fractures, rib fractures, or hemo- or pneumothorax between groups. Animal injuries had more frequent traumatic brain injuries (22.4% vs 10.5%, P = 0.03), whereas agricultural injuries had more vertebral fractures (20.5% vs 9.2%). Of toxicology screens performed, 25 per cent (22/88) were positive. No significant differences were found between occupational versus recreational animal injuries. Agricultural and animal-related injuries have different characteristics but Injury Severity Score and mortality were similar. Severe injuries from both mechanisms are common in rural communities and injury prevention activities are needed in both settings.

Reconsidering the Resources Needed for Multiple Casualty Events: Lessons Learned From the Crash of Asiana Airlines Flight 214.

PubMed

Campion, Eric M; Juillard, Catherine; Knudson, M Margaret; Dicker, Rochelle; Cohen, Mitchell J; Mackersie, Robert; Campbell, Andre R; Callcut, Rachael A

2016-06-01

To date, a substantial portion of multiple casualty incident literature has focused exclusively on prehospital and emergency department resources needed for optimal disaster response. Thus, inpatient resources required to care for individuals injured in multiple casualty events are not well described. To highlight the resources beyond initial emergency department triage needed for multiple casualty events, using one of the largest commercial aviation disasters in modern US history as a case study. Prospective case series of injured individuals treated at an urban level I trauma center following the crash of Asiana Airlines flight 214 on July 6, 2013. This analysis was conducted between June 1, 2014, and December 1, 2015. Commercial jetliner crash. Medical records, imaging data, nursing overtime, blood bank records, and trauma registry data were analyzed. Disaster logs, patient injuries, and blood product data were prospectively collected during the incident. Among 307 people aboard the flight, 192 were injured; 63 of the injured patients were initially evaluated at San Francisco General Hospital and Trauma Center (the highest number at any of the receiving medical facilities; age range, 4-74 years [23 were aged <17 years and 3 were aged >60 years]; median injury severity score of 19 admitted patients, 9 [range, 9-45]), including the highest number of critically injured patients (10 of 12). Despite the high impact of the crash, only 3 persons (<1%) died, including 1 in-hospital death. Among the 63 patients, 32 (50.8%) underwent a computed tomographic imaging study, with imaging of the abdomen and pelvis being the most common. Sixteen of the 32 patients undergoing computed tomography (50.0%) had a positive finding on at least 1 scan. Nineteen patients had major injuries and required admission, with 5 taken directly from the emergency department to the operating room. The most frequent injury was spinal fracture (13 patients). In the first 48 hours, 15 operations were performed and 117 total units of blood products were transfused. A total of 370 nursing overtime hours were required to treat the injured patients on the day of the event. Proper disaster preparedness requires attention to hospital-level needs beyond initial emergency department triage. The Asiana Airlines flight 214 crash highlights the need to plan for high use of advanced imaging, blood products, operating room availability, nursing resources, and management of inpatient hospital beds.

Ten Years of Equine-related Injuries: Severity and Implications for Emergency Physicians.

PubMed

Davidson, Scott B; Blostein, Paul A; Schrotenboer, Andrew; Sloffer, Chris A; VandenBerg, Sheri L

2015-11-01

The size, speed, and unpredictable nature of horses present a significant risk for injury in all equine-related activities. We sought to examine the mechanism, severity, frequency, body regions affected, surgical requirements, rehabilitation needs, safety equipment utilization, and outcomes of equine-related injured patients. Records of inpatients who sustained an equine-related injury from 2002-2011 with International Classification of Diseases, Ninth Revision codes E828 and E906 were retrospectively reviewed for pertinent data. Ninety patients, 70% female, age (mean ± SD) 37.3 ± 19.4 years, length of stay 3.7 ± 4.5 days, Injury Severity Score 12.9 ± 8.4. Predominant mechanism of injury was fall from horse (46.7%). The chest (23%) was most frequently injured, followed by brain/head (21.5%). Thirty patients (33%) required 57 surgical procedures. Twenty percent of patients required occupational therapy and 33.3% required physical therapy while hospitalized. Only 3% required rehabilitation, with 90% discharged directly home. Safety equipment was not used in 91.9% of patients. One patient sustained a cord injury. Six patients expired, all from extensive head injuries. The majority of equine-related injuries occur while pursuing recreational activities and are due to falls. Our patients experienced more severe injuries to the trunk and head and required more surgical intervention for pelvic, facial, and brain injuries than previously reported. Failure to use safety equipment contributes to the risk of severe injury. Education and injury prevention is essential. The need for complex surgical intervention by multiple specialties supports transfer to Level I trauma centers. Copyright © 2015 Elsevier Inc. All rights reserved.

Improving geriatric trauma outcomes: A small step toward a big problem.

PubMed

Hammer, Peter M; Storey, Annika C; Bell, Teresa; Bayt, Demetria; Hockaday, Melissa S; Zarzaur, Ben L; Feliciano, David V; Rozycki, Grace S

2016-07-01

Because of the unique physiology and comorbidities of injured geriatric patients, specific interventions are needed to improve outcomes. The purpose of this study was to assess the effect of a change in triage criteria for injured geriatric patients evaluated at an American College of Surgeons Level I trauma center. As of October 1, 2013, all injured patients 70 years or older were mandated to have the highest-level trauma activation upon emergency department (ED) arrival regardless of physiology or mechanism of injury. Patients admitted before that date were designated as PRE; those admitted after were designated as POST. The study period was from October 1, 2011, through April 30, 2015. Data collected included demographics, mechanism of injury, hypotension on admission, comorbidities, Injury Severity Score (ISS), ED length of stay (LOS), complications, and mortality. Bivariate and multivariable analyses were used to compare outcomes between the study groups (p < 0.05 was considered significant). χ or Fisher's exact test was used as appropriate for bivariate analyses of categorical variables; patients' ages were compared using the Wilcoxon rank-sum test. A total of 2,269 patients (mean, 80.63 years; mean ISS, 12.2; PRE, 1,271; POST, 933) were included in the study. On multivariable analysis, increasing age, higher ISS, and hypotension were associated with higher mortality. POST patients were more likely to have an ED LOS of 2 hours or shorter (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) after controlling for hypotension, ISS, and comorbidities. POST mortality significantly decreased (odds ratio, 0.689; 95% confidence interval, 0.484-0.979). Based on age alone, the focused intervention of a higher level of trauma activation decreased ED LOS and mortality in injured geriatric patients. Therapeutic/care management study, level IV.

Regional Health System Response to the 2007 Greensburg, Kansas, EF5 Tornado.

PubMed

Ablah, Elizabeth; Tinius, Annie M; Konda, Kurt; Synovitz, Carolyn; Subbarao, Italo

2007-11-01

On May 4, 2007 an EF5 tornado hit the rural community of Greensburg, KS, destroying 95% of the town and resulting in 12 fatalities. Data was requested from the emergency medical services units that initially responded and the regional hospitals that received people injured in the tornado within 24 hours following the tornado. Requested data included patient age and sex, and injury severity score or ICD-9 codes. Critical mortality, or the number of deaths of critically injured patients, was also calculated. The extensive damage caused by the tornado effectively destroyed the infrastructure of the community and created enormous challenges for emergency medical services responders, who were unable to record any triage data. Area hospitals treated 90 patients, who had an average injury severity score of 6.4. Age was found to be related to injury severity, but no relationship between sex and injury severity was found. Critical mortality was found to be 18% for this event. Injury severity score has seldom been used to analyze natural disasters, especially tornadoes, although such analysis is helpful for understanding the magnitude of the disaster, comparing to other disasters, and preparing for future incidents. Advanced warning and personal preparedness are important factors in reducing tornado-related injuries and deaths.

Analysis of Injury and Mortality Patterns in Deceased Patients with Road Traffic Injuries: An Autopsy Study.

PubMed

Pfeifer, Roman; Schick, Sylvia; Holzmann, Christopher; Graw, Matthias; Teuben, Michel; Pape, Hans-Christoph

2017-12-01

Despite improvements in prevention and rescue, mortality rates after severe blunt trauma continue to be a problem. The present study analyses mortality patterns in a representative blunt trauma population, specifically the influence of demographic, injury pattern, location and timing of death. Patients that died between 1 January 2004 and 31 December 2005 were subjected to a standardised autopsy. death from blunt trauma due to road traffic injuries (Injury Severity Score ≥ 16), patients from a defined geographical area and death on scene or in hospital. suicide, homicide, penetrating trauma and monotrauma including isolated head injury. Statistical analyses included Student's t test (parametric), Mann-Whitney U test (nonparametric) or Chi-square test. A total of 277 consecutive injured patients were included in this study (mean age 46.1 ± 23 years; 67.5% males), 40.5% of which had an ISS of 75. A unimodal distribution of mortality was observed in blunt trauma patients. The most frequently injured body regions with the highest severity were the head (38.6%), chest (26.7%), or both head and chest (11.0%). The cumulative analysis of mortality showed that several factors, such as injury pattern and regional location of collisions, also affected the pattern of mortality. The majority of patients died on scene from severe head and thoracic injuries. A homogenous distribution of death was observed after an initial peak of death on scene. Moreover, several factors such as injury pattern and regional location of collisions may also affect the pattern of mortality.

Psychosocial Adjustment and Life Satisfaction until 5 Years after Severe Brain Damage

ERIC Educational Resources Information Center

Sorbo, Ann K.; Blomqvist, Maritha; Emanuelsson, Ingrid M.; Rydenhag, Bertil

2009-01-01

The objectives of this study were to describe psychosocial adjustment and outcome over time for severely brain-injured patients and to find suitable outcome measures for clinical practice during the rehabilitation process and for individual rehabilitation planning after discharge from hospital. The methods include a descriptive, prospective,…

Update of the trauma risk adjustment model of the TraumaRegister DGU™: the Revised Injury Severity Classification, version II.

PubMed

Lefering, Rolf; Huber-Wagner, Stefan; Nienaber, Ulrike; Maegele, Marc; Bouillon, Bertil

2014-09-05

The TraumaRegister DGU™ (TR-DGU) has used the Revised Injury Severity Classification (RISC) score for outcome adjustment since 2003. In recent years, however, the observed mortality rate has fallen to about 2% below the prognosis, and it was felt that further prognostic factors, like pupil size and reaction, should be included as well. Finally, an increasing number of cases did not receive a RISC prognosis due to the missing values. Therefore, there was a need for an updated model for risk of death prediction in severely injured patients to be developed and validated using the most recent data. The TR-DGU has been collecting data from severely injured patients since 1993. All injuries are coded according to the Abbreviated Injury Scale (AIS, version 2008). Severely injured patients from Europe (ISS ≥ 4) documented between 2010 and 2011 were selected for developing the new score (n = 30,866), and 21,918 patients from 2012 were used for validation. Age and injury codes were required, and transferred patients were excluded. Logistic regression analysis was applied with hospital mortality as the dependent variable. Results were evaluated in terms of discrimination (area under the receiver operating characteristic curve, AUC), precision (observed versus predicted mortality), and calibration (Hosmer-Lemeshow goodness-of-fit statistic). The mean age of the development population was 47.3 years; 71.6% were males, and the average ISS was 19.3 points. Hospital mortality rate was 11.5% in this group. The new RISC II model consists of the following predictors: worst and second-worst injury (AIS severity level), head injury, age, sex, pupil reactivity and size, pre-injury health status, blood pressure, acidosis (base deficit), coagulation, haemoglobin, and cardiopulmonary resuscitation. Missing values are included as a separate category for every variable. In the development and the validation dataset, the new RISC II outperformed the original RISC score, for example AUC in the development dataset 0.953 versus 0.939. The updated RISC II prognostic score has several advantages over the previous RISC model. Discrimination, precision and calibration are improved, and patients with partial missing values could now be included. Results were confirmed in a validation dataset.

One elevated bladder pressure measurement may not be enough to diagnose abdominal compartment syndrome.

PubMed

Young, Andrew Joseph; Weber, William; Wolfe, Luke; Ivatury, Rao R; Duane, Therese Marie

2013-02-01

Bladder pressure measurements (BPMs) are considered a key component in the diagnosis of abdominal compartment syndrome (ACS). The purpose of this observational review was to determine risk factors of ACS and associated mortality with particular focus on the role of BPM. A retrospective trauma registry and chart review was performed on trauma patients from January 2003 through December 2010. Comparisons were made between patients with and without ACS. There were 3172 patients included in the study of whom 46 had ACS. Patients with ACS were younger, more severely injured, with longer lengths of stay. Logistic regression determined Injury Severity Score (ISS) and urinary catheter days as independent predictors of ACS, whereas independent predictors of mortality included age, ISS, and ACS. Subset analysis demonstrated no association between BPM 20 mmHg or greater and diagnosis of ACS versus no ACS. Logistic regression indicated independent predictors of mortality were number of BPM 20 mmHg or greater and age. Patients with ACS are more severely injured with worse outcomes. An isolated BPM 20 mmHg or greater was not associated with ACS and may be inadequate to independently diagnose ACS. These findings suggest the need for repeat measurements with early intervention if they remain elevated in an effort to decrease mortality associated with ACS.

Interpersonal violence in the United Arab Emirates.

PubMed

Osman, Ossama T; Abbas, Alaa K; Eid, Hani O; Salem, Mohamed O; Abu-Zidan, Fikri M

2014-01-01

We aimed to study the anatomical distribution, severity and outcome of hospitalised interpersonal violence-related injured patients in Al-Ain, United Arab Emirates so as to give recommendations regarding the magnitude of this problem, its causes and priorities of prevention. Data were retrieved from Al-Ain Hospital Trauma Registry, which was prospectively collected over three years. There were 75 patients (males = 85.3%) having a mean age of 30 years. Eighty-one percent had blunt trauma. The estimated annual injury hospitalisation of interpersonal violence in Al-Ain city was 6.7 per 100,000 population. Females were significantly more injured by a family member (p = 0.02), at home (p = 0.005), and had more severe injuries (p = 0.003). There was a trend for children less than 18 years old to have more penetrating trauma (p = 0.06) and to be injured by a family member (p = 0.09). There was only one case of woman sexual assault and two cases of child abuse. The mean (SD) hospital stay was 7.87 (14.1) days. Less than 3% (n = 2) were admitted to the intensive care unit with no deaths. In conclusion, the majority of patients in our study had minor injuries. Nevertheless, the psychological impact may be major. This highlights the need to develop suitable mental health services in support of victims of interpersonal violence.

KSC-2014-2779

NASA Image and Video Library

2014-04-30

CAPE CANAVERAL, Fla. -- At NASA's Kennedy Space Center in Florida, a Fire Rescue vehicle stands by in a parking area near the Vehicle Assembly Building for training with pilots in NASA Aircraft Operations. The exercise is designed to develop procedures for using agency helicopters to transport injured patients to a local hospital. The activity taking place in Kennedy's Launch Complex 39 turn-basin parking lot was only one of several drills. It was part of a new training program that was developed by Kennedy's Fire Rescue department along with NASA Aircraft Operations to sharpen the skills needed to help rescue personnel learn how to collaborate with helicopter pilots in taking injured patients to hospitals as quickly as possible. Photo credit: NASA/Dan Casper

KSC-2014-2759

NASA Image and Video Library

2014-04-29

CAPE CANAVERAL, Fla. -- At NASA's Kennedy Space Center in Florida, Fire Rescue vehicles line up in a parking area near the Vehicle Assembly Building for training with pilots in NASA Aircraft Operations. The exercise is designed to develop procedures for using agency helicopters to transport injured patients to a local hospital. The activity taking place in Kennedy's Launch Complex 39 turn-basin parking lot was only one of several drills. It was part of a new training program that was developed by Kennedy's Fire Rescue department along with NASA Aircraft Operations to sharpen the skills needed to help rescue personnel learn how to collaborate with helicopter pilots in taking injured patients to hospitals as quickly as possible. Photo credit: NASA/Dan Casper

Regional brain volumetry and brain function in severely brain-injured patients.

PubMed

Annen, Jitka; Frasso, Gianluca; Crone, Julia Sophia; Heine, Lizette; Di Perri, Carol; Martial, Charlotte; Cassol, Helena; Demertzi, Athena; Naccache, Lionel; Laureys, Steven

2018-04-01

The relationship between residual brain tissue in patients with disorders of consciousness (DOC) and the clinical condition is unclear. This observational study aimed to quantify gray (GM) and white matter (WM) atrophy in states of (altered) consciousness. Structural T1-weighted magnetic resonance images were processed for 102 severely brain-injured and 52 healthy subjects. Regional brain volume was quantified for 158 (sub)cortical regions using Freesurfer. The relationship between regional brain volume and clinical characteristics of patients with DOC and conscious brain-injured patients was assessed using a linear mixed-effects model. Classification of patients with unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS) using regional volumetric information was performed and compared to classification using cerebral glucose uptake from fluorodeoxyglucose positron emission tomography. For validation, the T1-based classifier was tested on independent datasets. Patients were characterized by smaller regional brain volumes than healthy subjects. Atrophy occurred faster in UWS compared to MCS (GM) and conscious (GM and WM) patients. Classification was successful (misclassification with leave-one-out cross-validation between 2% and 13%) and generalized to the independent data set with an area under the receiver operator curve of 79% (95% confidence interval [CI; 67-91.5]) for GM and 70% (95% CI [55.6-85.4]) for WM. Brain volumetry at the single-subject level reveals that regions in the default mode network and subcortical gray matter regions, as well as white matter regions involved in long range connectivity, are most important to distinguish levels of consciousness. Our findings suggest that changes of brain structure provide information in addition to the assessment of functional neuroimaging and thus should be evaluated as well. Ann Neurol 2018;83:842-853. © 2018 American Neurological Association.

Analysis of Shahid Rajaee hospital administrative data on injuries resulting from car accidents in Shiraz, Iran: 2011-2014 data.

PubMed

Yadollahi, Mahnaz; Ghiassee, Aida; Anvar, Mehrdad; Ghaem, Hale; Farahmand, Mohammad

2017-02-01

The administrative data from trauma centers could serve as potential sources of invaluable information while studying epidemiologic features of car accidents. In this cross-sectional analysis of Shahid Rajaee hospital administrative data, we aimed to evaluate patients injured in car accidents in terms of age, gender, injury severity, injured body regions and hospitalization outcome in the recent four years (2011-2014). The hospital registry was accessed at Shiraz Trauma Research Center (Shiraz, Iran) and the admission's unit data were merged with the information gathered upon discharge. A total number of 27,222 car accident patients aged over 15 years with International Classification of Diseases 10th revision (ICD-10) external causes of injury codes (V40.9-V49.9) were analyzed. Injury severity score and injured body regions were determined based on converting ICD-10 injury codes to Abbreviated Injury Scale (AIS-98) severity codes using a domestically developed electronic algorithm. A binary logistic regression model was applied to the data to examine the contribution of all independent variables to in-hospital mortality. Men accounted for 68.9% of the injuries and the male to female ratio was 2.2:1. The age of the studied population was (34 ± 15) years, with more than 77.2% of the population located in the 15-45 years old age group. Head and neck was the most commonly injured body region (39.0%) followed by extremities (27.2%). Injury severity score (ISS) was calculated for 13,152 (48.3%) patients, of whom, 80.9% had severity scores less than 9. There were 332 patients (1.2%) admitted to the intensive care units and 422 in-hospital fatalities (1.5%) were recorded during the study period. Age above 65 years [OR = 7.4, 95% CI (5.0-10.9)], ISS above 16 [OR = 9.1, 95% CI (5.5-14.9)], sustaining a thoracic injury [OR = 7.4, 95% CI (4.6-11.9)] and head injury [OR = 4.9, 95% CI (3.1-7.6)] were the most important independent predictors of death following car accidents. Hospital administrative databases of this hospital could be used as reliable sources of information in providing epidemiologic reports of car accidents in terms of severity and outcomes. Improving the quality of recordings at hospital databases is an important initial step towards more comprehensive injury surveillance in Fars, Iran. Copyright © 2017. Production and hosting by Elsevier B.V.

Impact of aphasia on consciousness assessment: a cross-sectional study.

PubMed

Schnakers, Caroline; Bessou, Helene; Rubi-Fessen, Ilona; Hartmann, Alexander; Fink, Gereon R; Meister, Ingo; Giacino, Joseph T; Laureys, Steven; Majerus, Steve

2015-01-01

Previous findings suggest that language disorders may occur in severely brain-injured patients and could interfere with behavioral assessments of consciousness. However, no study investigated to what extent language impairment could affect patients' behavioral responses. Objective. To estimate the impact of receptive and/or productive language impairments on consciousness assessment. Twenty-four acute and subacute stroke patients with different types of aphasia (global, n = 11; Broca, n = 4; Wernicke, n = 3; anomic, n = 4; mixed, n = 2) were recruited in neurology and neurosurgery units as well as in rehabilitation centers. The Coma Recovery Scale-Revised (CRS-R) was administered. We observed that 25% (6 out of 24) of stroke patients with a diagnosis of aphasia and 54% (6 out of 11) of patients with a diagnosis of global aphasia did not reach the maximal CRS-R total score of 23. An underestimation of the consciousness level was observed in 3 patients with global aphasia who could have been misdiagnosed as being in a minimally conscious state, even in the absence of any documented period of coma. More precisely, lower subscores were observed on the communication, motor, oromotor, and arousal subscales. Consciousness assessment may be complicated by the co-occurrence of severe language deficits. This stresses the importance of developing new tools or identifying items in existing scales, which may allow the detection of language impairment in severely brain-injured patients. © The Author(s) 2014.

Snowblower injuries to the hand.

PubMed

Jardin, E; Uhring, J; Rey, P-B; Ferrier, M; Obert, L

2014-09-01

The aim of this study was to describe the nature and incidence of hand injuries caused by snowblowers, as well as the accident conditions and accident prevention. We conducted a retrospective evaluation over ten consecutive winters. Nine patients were included. All were men with an average age of 49.7 years (17-71). The accidents occurred at home in seven out of nine patients. The machine was running in 50% of the injury events. In most cases, the injuries occurred when the patient tried to unclog snow from the lateral discharge chute. Only four out of the nine patients had read the instructions or received instructions from the salesperson. The dominant hand was injured in 7 out of 9 patients. An average of 2.7 fingers were injured. The longest fingers were most commonly injured: 8 middle fingers, 7 ring fingers, 4 little fingers, 2 indexes and 1 thumb. All the fractures were open. Three patients were operated on several times. In 7 out of 9 cases, the patients had sequelae such as amputation. The mean time off work was 11.4 weeks (3-24). All the patients were experienced snowblower users (9 years and 57th use on average). Snowblower accidents are very mutilating. Prevention must include protected access to blades and better verbal and written safety warnings. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Relation between cognition and neural connection from injured cingulum to brainstem cholinergic nuclei in chronic patients with traumatic brain injury.

PubMed

Yoo, Jin-Sun; Kim, Oh Lyong; Kim, Seong Ho; Kim, Min Su; Jang, Sung Ho

2014-01-01

This study investigated the relation between cognition and the neural connection from injured cingulum to brainstem cholinergic nuclei in patients with traumatic brain injury (TBI), using diffusion tensor tractography (DTT). Among 353 patients with TBI, 20 chronic patients who showed discontinuation of both anterior cingulums from the basal forebrain on DTT were recruited for this study. The Wechsler Intelligence Scale and the Memory Assessment Scale (MAS; short-term, verbal, visual and total memory) were used for assessment of cognition. Patients were divided into two groups according to the presence of a neural connection between injured cingulum and brainstem cholinergic nuclei. Eight patients who had a neural connection between injured cingulum and brainstem cholinergic nuclei showed better short-term memory on MAS than 12 patients who did not (p < 0.05). However, other results of neuropsychological testing showed no significant difference (p > 0.05). Better short-term memory in patients who had the neural connection between injured cingulum and brainstem cholinergic nuclei appears to have been attributed to the presence of cholinergic innervation to the cerebral cortex through the neural connection instead of the injured anterior cingulum. The neural connection appears to compensate for the injured anterior cingulum in obtaining cholinergic innervation.

Woodworking injuries: a comparative study of work-related and hobby-related accidents.

PubMed

Loisel, F; Bonin, S; Jeunet, L; Pauchot, J; Tropet, Y; Obert, L

2014-10-01

The primary objective of this study was to describe the injury characteristics and demographics of patients injured during woodworking activities, upon their arrival to the emergency department in a regional of France where this industry is prevalent. The secondary objective was to compare patient and injury characteristics for work-related and hobby-related accidents. A cohort of 87 patients who had suffered a woodworking accident over a two-year period was evaluated; 79 were available for follow-up. The context and circumstances of the accident, nature and location of the injuries and patient demographics were recorded. Hobby-related accidents accounted for two-thirds of the accidents (51/79). Most of the injured workers were either loggers (35%) or carpenters (46%). The hand was injured in 53 cases (67%). Work-related accidents resulted in significantly more serious consequences in terms of hospital stay, work stoppage, resumption of work or retraining than hobby-related accidents. For the workplace accidents, 86% occurred on new machines; more than 25% of the machines involved in accidents at home were over 15 years. Sixty-eight per cent of workers were wearing their safety gear, while only 31% of those injured during recreational woodworking wore the appropriate gear. Several elements of prevention should be improved: information about the need to maintain the equipment, protect the worker with suitable clothing, and learn which maneuvers are considered hazardous. Safety gear should be regularly inspected in the workplace. Copyright © 2014. Published by Elsevier SAS.

Speedboat Propeller Injuries

PubMed Central

Sleight, M. W.

1974-01-01

Six patients are reported who were severely injured by high-speed boat propellers. With reasonable precautions such accidents need never occur, and people should be more aware of these and ensure that safety measures are enforced. ImagesFIG. 1FIG. 2 PMID:4835301

[Penetrating injury of the lungs and multiple injuries of lower extremities caused by aircraft bombs splinters].

PubMed

Golubović, Zoran; Stanić, Vojkan; Trenkić, Srbobran; Stojiljković, Predrag; Stevanović, Goran; Lesić, Aleksandar; Golubović, Ivan; Milić, Dragan; Visnjić, Aleksandar; Najman, Stevo

2010-08-01

Injuries caused by aircraft bombs cause severe damages to the human body. They are characterized by massive destruction of injured tissues and organs, primary contamination by polymorph bacterial flora and modified reactivity of the body. Upon being wounded by aircraft bombs projectiles a victim simultaneously sustains severe damages of many organs and organ systems due to the fact that a large number of projectiles at the same time injure the chest, stomach, head and extremities. We presented a patient, 41 years of age, injured by aircraft bomb with hemo-pneumothorax and destruction of the bone and soft tissue structures of the foot, as well as the treatment result of such heavy injuries. After receiving thoracocentesis and short reanimation, the patient underwent surgical procedure. The team performed thoracotomy, primary treatment of the wound and atypical resection of the left lung. Thoracic drains were placed. The wounds on the lower leg and feet were treated primarily. Due to massive destruction of bone tissue of the right foot by cluster bomb splinters, and impossibility of reconstruction of the foot, guillotine amputation of the right lower leg was performed. Twelve days after the wounding caused by cluster bomb splinters, soft tissue of the left lower leg was covered by Tirsch free transplant and the defect in the area of the left foot was covered by dorsalis pedis flap. The transplant and flap were accepted and the donor sites were epithelized. Twenty-six days following the wounding reamputation was performed and amputation stump of the right lower leg was closed. The patient was given a lower leg prosthesis with which he could move. Upon being wounded by aircraft bomb splinters, the injured person sustains severe wounds of multiple organs and organ systems due to simultaneous injuries caused by a large number of projectiles. It is necessary to take care of the vital organs first because they directly threaten the life of the wounded patient. Despite adequate surgical treatment of war wounds of the feet, because of massive defect of bone and soft tissue, amputation may be the only rational solution of the treatment. The resection of the lung may be succesfull method for the severe destruction of the lung.

Prevalence and Impact of Admission Acute Traumatic Coagulopathy on Treatment Intensity, Resource Use, and Mortality: An Evaluation of 956 Severely Injured Children and Adolescents.

PubMed

Liras, Ioannis N; Caplan, Henry W; Stensballe, Jakob; Wade, Charles E; Cox, Charles S; Cotton, Bryan A

2017-04-01

Acute coagulopathy of trauma in children is of potential importance to clinical outcomes, but knowledge is limited and has only been investigated using conventional coagulation testing. The purpose of this study was to assess the prevalence and impact of arrival coagulopathy, determined by viscoelastic hemostatic testing, in severely injured children. Pediatric patients (younger than 17 years of age) who were admitted January 2010 to May 2016 and met highest-level trauma activation were included. Patients were divided into 2 groups (coagulopathy and controls) based on arrival rapid thrombelastography values. Coagulopathy was defined as the presence of any of the following on rapid thrombelastography: activated clotting time ≥128 seconds, α-angle ≤65 degrees, maximum amplitude ≤55 mm, and lysis at 30 minutes from 20-mm amplitude ≥3%. Logistic regression was used to adjust for age, sex, blood pressure, mechanism, and injury severity. Nine hundred and fifty-six patients met inclusion; 507 (57%) were coagulopathic and 449 (43%) were not (noncoagulopathic and control cohort). Coagulopathic patients were younger (median 14 vs 15 years) and more likely to be male (68% vs 60%) and Hispanic (38% vs 31%) (all p < 0.05). Coagulopathic patients received more RBC and plasma transfusions and had fewer ICU and ventilator-free days and higher mortality (12% vs 3%; all p < 0.05). Of these 956, 197 (21%) sustained severe brain injury-123 (62%) were coagulopathic and 74 (38%) were noncoagulopathic. The mortality difference was even greater for coagulopathic head injuries (31% vs 10%; p = 0.002). Adjusting for confounders, admission coagulopathy was an independent predictor of death, with an odds ratio of 3.67 (95% CI 1.768 to 7.632; p < 0.001). Almost 60% of severely injured children and adolescents arrive with evidence of acute traumatic coagulopathy. The presence of admission coagulopathy is associated with high mortality in children, especially among those with head injuries. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Recovery of injured Broca's portion of arcuate fasciculus in the dominant hemisphere in a patient with traumatic brain injury.

PubMed

Jang, Sung Ho; Ha, Ji Wan; Kim, Hyun Young; Seo, You Sung

2017-12-01

Recovery of injured AF in patients with traumatic brain injury (TBI) has not been reported. In this study, we report on a patient with TBI who recovered from an injury to Broca's portion of AF in the dominant hemisphere, diagnosed by diffusion tensor tractography (DTT). A 28-year-old right-handed male patient suffered head trauma resulting from sliding while riding a motorcycle. He was diagnosed with a traumatic contusional hemorrhage in the left frontal lobe, subarachnoid hemorrhage, and subdural hemorrhage in the left fronto-temporal lobe. He underwent craniectomy on the left fronto-temporal area, and hematoma removal for the subdural hemorrhage in the neurosurgery department of a university hospital. Two weeks after the injury, he was transferred to the rehabilitation department of another university hospital. He showed severe aphasia and brain MRI showed leukomalactic lesion in the left frontal lobe. The result WAB for the patient showed severe aphasia, with an aphasia quotient of 45.3 percentile. However, his aphasia improved rapidly by 9 months with an aphasia quotient at the 100.0 percentile. 2-week DTT detected discontinuity in the subcortical white matter at the branch to Broca's area of left AF. By contrast, on 9-month DTT, the discontinued portion of left AF was elongated to the left Broca's area. Recovery of injured Broca's portion of AF in the dominant hemisphere along with excellent improvement of aphasia was demonstrated in a patient with TBI. This study has important implications in brain rehabilitation because the mechanism of recovery from aphasia following TBI has not been elucidated. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Treatment of candidosis in severely injured adults with short-course, low-dose amphotericin B.

PubMed

Rosemurgy, A S; Drost, T F; Murphy, C G; Kearney, R E; Albrink, M H

1990-12-01

Thirty-three (0.7%) of 4,818 trauma patients admitted between January 1, 1987, and July 1, 1989, developed invasive candidosis requiring IV antifungal therapy. All patients were seriously traumatized. Before developing candidosis, all patients had documented bacterial infections. These infections were generally polymicrobial and were treated with multiple broad-spectrum antibiotics (an average of 5.4 antibiotics for 17.2 days). Twenty-eight (85%) of 33 patients received enteral feedings for an average of 11 days +/- 1.5 (SEM) before developing candidosis and 24 (73%) received NG/oral nystatin for an average of 7.6 days +/- 0.9 before developing candidosis. All patients with candidosis were treated with intravenous amphotericin B: cumulative dose of 157.3 mg +/- 31.3 mg given over 10 days +/- 1.1. One patient developed recurrent candidosis despite NG/oral prophylaxis and enteral feedings. Six patients (18%) died due to sepsis and multiple organ failure. The patients who died did not objectively differ from the survivors. Candidosis is an infrequent infection in severely injured patients. Candidosis was invariably preceded by treatment with multiple broad-spectrum antibiotics for a variety of polymicrobial bacterial infections. NG/oral nystatin and enteral feedings did not prevent candidosis, in contrast to widely accepted beliefs. Amphotericin B therapy was safe. Recurrent candidosis was unusual. Candida infections had a high mortality rate associated with multiple blood transfusions and prolonged hospitalization. Candidosis represents a sign of severe injury and illness but can be amenable to prompt, aggressive treatment.

TraumaNetzwerk DGU(®): optimizing patient flow and management.

PubMed

Ruchholtz, Steffen; Lewan, Ulrike; Debus, Florian; Mand, Carsten; Siebert, Hartmut; Kühne, Christian A

2014-10-01

Caring for severely injured trauma patients is challenging for all medical professionals involved both in the preclinical and in the clinical course of treatment. While the overall quality of care in Germany is high there still are significant regional differences remaining. Reasons are geographical and infrastructural differences as well as variations in personnel and equipment of the hospitals. To improve state-wide trauma care the German Trauma Society (DGU) initiated the TraumaNetzwerk DGU(®) (TNW) project. The TNW is based on five major components: (a) Whitebook for the treatment of severely injured patients; (b) evidence-based guidelines for the medical care of severe injury; (c) local auditing of participating hospitals; (d) contract of interhospital cooperation; (d) TraumaRegister DGU(®) documentation. By the end of 2013, 644 German Trauma Centres (TC) had successfully passed the audit. To that date 44 regional TNWs with a mean of 13.5 TCs had been established and certified. The TNWs cover approximately 90% of the country's surface. Of those hospitals, 2.3 were acknowledged as Supraregional TC, 5.4 as Regional TC and 6.7 as Lokal TC. Moreover, cross border TNW in cooperation with hospitals in The Netherlands, Luxembourg, Switzerland and Austria have been established. Preparing for the audit 66% of the hospitals implemented organizational changes (e.g. TraumaRegister DGU(®) documentation and interdisciplinary guidelines), while 60% introduced personnel and 21% structural (e.g. X-ray in the ER) changes. The TraumaNetzwerk DGU(®) project combines the control of common defined standards of care for all participating hospitals (top down) and the possibility of integrating regional cooperation by forming a regional TNW (bottom up). Based on the joint approach of healthcare professionals, it is possible to structure and influence the care of severely injured patients within a nationwide trauma system. Copyright © 2014 Elsevier Ltd. All rights reserved.

Cellular microparticle and thrombogram phenotypes in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study: correlation with coagulopathy

PubMed Central

Matijevic, Nena; Wang, Yao-Wei W.; Wade, Charles E.; Holcomb, John B.; Cotton, Bryan A.; Schreiber, Martin A.; Muskat, Peter; Fox, Erin E.; del Junco, Deborah J.; Cardenas, Jessica C.; Rahbar, Mohammad H.; Cohen, Mitchell Jay

2014-01-01

Background Trauma-induced coagulopathy following severe injury is associated with increased bleeding and mortality. Injury may result in alteration of cellular phenotypes and release of cell-derived microparticles (MP). Circulating MPs are procoagulant and support thrombin generation (TG) and clotting. We evaluated MP and TG phenotypes in severely injured patients at admission, in relation to coagulopathy and bleeding. Methods As part of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, research blood samples were obtained from 180 trauma patients requiring transfusions at 5 participating centers. Twenty five healthy controls and 40 minimally injured patients were analyzed for comparisons. Laboratory criteria for coagulopathy was activated partial thromboplastin time (APTT) ≥35 sec. Samples were analyzed by Calibrated Automated Thrombogram to assess TG, and by flow cytometry for MP phenotypes [platelet (PMP), erythrocyte (RMP), leukocyte (LMP), endothelial (EMP), tissue factor (TFMP), and Annexin V positive (AVMP)]. Results 21.7% of patients were coagulopathic with the median (IQR) APTT of 44 sec (37, 53), and an Injury Severity Score of 26 (17, 35). Compared to controls, patients had elevated EMP, RMP, LMP, and TFMP (all p<0.001), and enhanced TG (p<0.0001). However, coagulopathic PROMMTT patients had significantly lower PMP, TFMP, and TG, higher substantial bleeding, and higher mortality compared to non-coagulopathic patients (all p<0.001). Conclusions Cellular activation and enhanced TG are predominant after trauma and independent of injury severity. Coagulopathy was associated with lower thrombin peak and rate compared to non-coagulopathic patients, while lower levels of TF-bearing PMPs were associated with substantial bleeding. PMID:25086657

Characteristics of the injuries of Syrian refugees sustained during the civil war.

PubMed

Kocamer Şimşek, Betül; Dokur, Mehmet; Uysal, Erdal; Çalıker, Necdet; Gökçe, Oruç Numan; Deniz, İbrahim Kürşat; Uğur, Murat; Geyik, Murat; Kaya, Mehmet; Dağlı, Güner

2017-05-01

During a war, many civilians are severely injured by firearms, bombs, and shrapnel. The triage of war injuries involves difficult and complicated processes requiring surgical procedures and patient monitoring in the Intensive Care Unit (ICU) of hospitals. In this study, we examine the demographic, traumatic, and critical care characteristics of cases injured during the civil war in Syria and requiring emergency surgery. Electronic data of the traumatic, surgical, and ICU monitoring features of 707 patients admitted to Kilis Public Hospital between March 2012 and January 2013 were analyzed retrospectively RESULTS: Most of the patients reported having been injured due to firearms (83.75%). Of the 707 cases studied in this work, 93.2% was male. Male patients reported a mean age of 26.1±12.1 years, while pediatric cases reported a mean age of 11.7±3.41 years. The most frequently injured region of the body was the head-neck region (52.7%). The New Injury Severity Score (NISS) of the cases was 42.5±11.2 and their American Society of Anesthesiologists (ASA) score was 3.2±0.7. The number of cases with intraoperative exitus was 7, while the number of cases who had undergone damage control surgery was 204. The number of cases hospitalized in the ICU during the postoperative period was 233, and the average hospitalization duration in the ICU was 4.67±1.32 days. Among survivor patients, the first 24-hour invasive measurements (i.e., pH, hemoglobin, body temperature, and mean arterial blood pressure) and international normalized ratio were found to be high. The number of blood products used for surviving patients was fewer relative to that used for non-surviving patients, and these NISS of these patients was 29.7±10.1. The mortality rate of all patients followed up in the ICU after emergency surgery was 45%, and neurosurgical cases showed the lowest level of survival (24.1%). The results of this study indicated that head-neck, chest-abdomen, and multiple body injuries are the most widely seen among civilians brought to Turkey because of gunshot injuries sustained during the Civil War in Syria. The number of emergency operations performed in the study sample was high, and critical care follow-up durations were long. In addition, the NISS and ASA scores of mortal cases were fairly high.

The critically ill injured patient.

PubMed

Cereda, Maurizio; Weiss, Yoram G; Deutschman, Clifford S

2007-03-01

Patients admitted to the ICU after severe trauma require frequent procedures in the operating room, particularly in cases where a damage control strategy is used. The ventilatory management of these patients in the operating room can be particularly challenging. These patients often have severely impaired respiratory mechanics because of acute lung injury and abdominal compartment syndrome. Consequently, the pressure and flow generation capabilities of standard anesthesia ventilators may be inadequate to support ventilation and gas exchange. This article presents the problems that may be encountered in patients who have severe abdominal and lung injuries, and the current management concepts used in caring for these patients in the critical care setting, to provide guidelines for the anesthetist faced with these patients in the operating room.

Numerical simulation of hemorrhage in human injury

NASA Astrophysics Data System (ADS)

Chong, Kwitae; Jiang, Chenfanfu; Santhanam, Anand; Benharash, Peyman; Teran, Joseph; Eldredge, Jeff

2015-11-01

Smoothed Particle Hydrodynamics (SPH) is adapted to simulate hemorrhage in the injured human body. As a Lagrangian fluid simulation, SPH uses fluid particles as computational elements and thus mass conservation is trivially satisfied. In order to ensure anatomical fidelity, a three-dimensional reconstruction of a portion of the human body -here, demonstrated on the lower leg- is sampled as skin, bone and internal tissue particles from the CT scan image of an actual patient. The injured geometry is then generated by simulation of ballistic projectiles passing through the anatomical model with the Material Point Method (MPM) and injured vessel segments are identified. From each such injured segment, SPH is used to simulate bleeding, with inflow boundary condition obtained from a coupled 1-d vascular tree model. Blood particles interact with impermeable bone and skin particles through the Navier-Stokes equations and with permeable internal tissue particles through the Brinkman equations. The SPH results are rendered in post-processing for improved visual fidelity. The overall simulation strategy is demonstrated on several injury scenarios in the lower leg.

A Sex Disparity Among Earthquake Victims.

PubMed

Ardagh, Michael; Standring, Sarah; Deely, Joanne M; Johnston, David; Robinson, Viki; Gulliver, Pauline; Richardson, Sandra; Dierckx, Alieke; Than, Martin

2016-02-01

Understanding who is most vulnerable during an earthquake will help health care responders prepare for future disasters. We analyzed the demography of casualties from the Christchurch earthquake in New Zealand. The demography of the total deceased, injured, and hospitalized casualties of the Christchurch earthquake was compared with that of the greater Christchurch population, the Christchurch central business district working population, and patients who presented to the single acute emergency department on the same month and day over the prior 10 years. Sex data were compared to scene of injury, context of injury, clinical characteristics of injury, and injury severity scores. Significantly more females than males were injured or killed in the entire population of casualties (P20% were injured at commercial or service localities (444/2032 males [22%]; 1105/4627 females [24%]). Adults aged between 20 and 69 years (1639/2032 males [81%]; 3717/4627 females [80%]) were most frequently injured. Where people were and what they were doing at the time of the earthquake influenced their risk of injury.

The prevalence and impact of prescription controlled substance use among injured patients at a Level I trauma center.

PubMed

Cannon, Robert; Bozeman, Matthew; Miller, Keith Roy; Smith, Jason Wayne; Harbrecht, Brian; Franklin, Glen; Benns, Matthew

2014-01-01

There has been increasing attention focused on the epidemic of prescription drug use in the United States, but little is known about its effects in trauma. The purpose of this study was to define the prevalence of prescription controlled substance use among trauma patients and determine its effects on outcome. A retrospective review of all patients admitted to a Level 1 trauma center from January 1, 2011, to December 31, 2011, was performed. Patients dying within 24 hours or without home medication reconciliations were excluded. Data review included preexisting benzodiazepine or narcotic use, sex, age, mechanism of injury, Injury Severity Scores (ISSs), intensive care unit (ICU) and overall length of stay, ventilator days, and overall cost. SAS version 9.3 was used for the analysis, and p ≤ 0.05 was considered significant. A total of 1,700 patients met inclusion criteria. Of these, 340 (20.0%) were on prescription narcotics and/or benzodiazepines at the time of admission. Patients in the narcotic/benzodiazepine group were significantly older (48 years vs. 43 years) and more likely to be women (43.7% vs. 28.9%). There was no difference in mechanism, ISS, or the presence of head injury between groups. Both ICU length of stay (3.3 days vs. 2.1 days) and total length of stay (7.8 days vs. 6.1 days) were significantly longer in patients on outpatient narcotics and/or benzodiazepines. Excluding severely injured patients, the need for mechanical ventilation was also increased among outpatient controlled substance users (15.8% vs. 11.0%). There is a substantial prevalence of preexisting controlled substance use (20%) among patients at our Level 1 trauma center. Preexisting controlled substance use is associated with longer total hospital and ICU stays. Among mildly to moderately injured patients, preinjury controlled substance is also associated with the need for mechanical ventilation. Prognostic study, level III.

Family and home in cognitive rehabilitation after brain injury: The importance of family oriented interventions.

PubMed

Wulf-Andersen, Camilla; Mogensen, Jesper

2017-01-01

Acquired brain injury (ABI) severely affects both the injured patient and her/his family. This fact alone calls for a therapeutic approach addressing not only the individual victim of ABI but also her/his family. Additionally, the optimal outcome of posttraumatic cognitive rehabilitation may be best obtained by supplementing the institution-based cognitive training with home-based training. Moving cognitive training and other therapeutic interventions into the home environment does, however, constitute an additional challenge to the family structure and psychological wellbeing of all family members. We presently argue in favour of an increased utilization of family-based intervention programs for the families of brain injured patients - in general and especially in case of utilization of home-based rehabilitative training.

Tissue engineering applications of therapeutic cloning.

PubMed

Atala, Anthony; Koh, Chester J

2004-01-01

Few treatment options are available for patients suffering from diseased and injured organs because of a severe shortage of donor organs available for transplantation. Therapeutic cloning, where the nucleus from a donor cell is transferred into an enucleated oocyte in order to extract pluripotent embryonic stem cells, offers a potentially limitless source of cells for replacement therapy. Scientists in the field of tissue engineering apply the principles of cell transplantation, material science, and engineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. The present chapter reviews recent advances that have occurred in therapeutic cloning and tissue engineering and describes applications of these new technologies that may offer novel therapies for patients with end-stage organ failure.

Therapeutic cloning and tissue engineering.

PubMed

Koh, Chester J; Atala, Anthony

2004-01-01

A severe shortage of donor organs available for transplantation in the United States leaves patients suffering from diseased and injured organs with few treatment options. Scientists in the field of tissue engineering apply the principles of cell transplantation, material science, and engineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Therapeutic cloning, where the nucleus from a donor cell is transferred into an enucleated oocyte in order to extract pluripotent embryonic stem cells, offers a potentially limitless source of cells for tissue engineering applications. The present chapter reviews recent advances that have occurred in therapeutic cloning and tissue engineering and describes applications of these new technologies that may offer novel therapies for patients with end-stage organ failure.

Diagnosis of unsuspected facial fractures on routine head computerized tomographic scans in the unconscious multiply injured patient.

PubMed

Rehm, C G; Ross, S E

1995-05-01

This article assessed the value of routine head computerized axial tomographic (CT) scans for diagnosis of unsuspected facial fractures and its clinical implications in the multiply injured patient who is intubated, unconscious, or sedated at the time of initial assessment and requires a head CT scan to assess for brain injury. At a level I trauma center from June 1, 1992 to June 1, 1993 all intubated blunt trauma patients who required routine CT scan evaluation at initial assessment were studied prospectively. Routine scanning started at the foramen magnum and included the maxilla. Patients who died within the first 24 hours were excluded. The study population included 116 patients (85 male, 21 female) aged 12 to 85 years (mean, 28 years) with injury severity scores ranging from 1 to 50 (mean, 23). The mechanism of injury was: motor vehicle accidents (n = 74), motorcycling (n = 5), pedestrians accidents (n = 13), falls (n = 10), bicycling (n = 5), assaults (n = 8), and boating accident (n = 1). There were 19 suspected facial fractures; 18 required surgical repair. There were 27 unsuspected facial fractures; 13 required surgical care. Three suspected fractures were ruled out. Routine head CT scans to assess for brain injury in the multiply injured patient are also very useful in the diagnosis of unsuspected facial fractures, almost half of which will require surgical intervention.

Self-Esteem and Anger in Borderline Patients With Self-Injury Behavior.

PubMed

Almeida, Carla Maria; Horta, Maria Purificação

2018-04-01

Anger and low self-esteem characterize borderline individuals, yet little is known about their role and impact in the presence or absence of self-injury behavior. The present study aimed to investigate the impact of anger and self-esteem in borderline patients and whether these variables distinguish these patients with and without self-injury. Patients were recruited from a psychiatric service and were evaluated for self-esteem and anger. Additionally, impulsivity and symptoms were assessed. Two groups were compared, one with self-injurious behavior (n = 18) and another one without it (n = 23). Those who injure themselves seem to have a lower self-esteem (p < 0.001), yet the strengthening of self-esteem seems to have different outcomes, according to the presence or absence of self-injury. Anger and self-esteem seem to influence the severity of diagnosis, but only in patients who self-injure. Anger and self-esteem may influence borderline patients differently according to the presence or absence of self-injury.

The role of whole-body computed tomography in the diagnosis of thoracic injuries in severely injured patients - a retrospective multi-centre study based on the trauma registry of the German trauma society (TraumaRegister DGU®).

PubMed

Lang, Patricia; Kulla, Martin; Kerwagen, Fabian; Lefering, Rolf; Friemert, Benedikt; Palm, Hans-Georg

2017-08-15

Thoracic injuries are a leading cause of death in polytrauma patients. Early diagnosis and treatment are of paramount importance. Whole-body computed tomography (WBCT) has largely replaced traditional imaging techniques such as conventional radiographs and focused computed tomography (CT) as diagnostic tools in severely injured patients. It is still unclear whether WBCT has led to higher rates of diagnosis of thoracic injuries and thus to a change in outcomes. In a retrospective study based on the trauma registry of the German Trauma Society (TraumaRegister DGU ® ), we analysed data from 16,545 patients who underwent treatment in 59 hospitals between 2002 and 2012 (ISS ≥ 9). The 3 years preceding and the 3 years following the introduction of WBCT as a standard imaging modality for the investigation of severely injured patients were assessed for every hospital. Accordingly, patients were assigned to either the pre-WBCT or the WBCT group. We compared the numbers of thoracic injuries and the outcomes of patients before and after the routine use of WBCT. A total of 13,564 patients (pre-WBCT: n = 5005, WBCT: n = 8559) were included. Relevant thoracic injuries were detected in 47.8%. There were no major differences between the patient groups in injury severity (pre-WBCT: median ISS 21; WBCT: median ISS 22), injury patterns and demographics. After the introduction of WBCT, only minor changes were observed regarding the rates of most thoracic injuries. Clinically relevant injuries were pulmonary contusions (pre-WBCT: 18.5%; WBCT: 28.7%), injuries to the lung parenchyma (pre-WBCT: 12.6%; WBCT: 5.9%), multiple rib fractures (pre-WBCT: 10.6%; WBCT: 21.6%), and pneumothoraces (pre-WBCT: 17.3%; WBCT: 21.6%). The length of stay in the intensive care unit (pre-WBCT: 10.8 days; WBCT: 9.7 days) and in hospital (pre-WBCT: 26.2 days; WBCT: 23.3 days) decreased. There was no difference in overall mortality (pre-WBCT: 15.5%; WBCT: 15.6%). The routine use of WBCT in the trauma room setting has led to changes in patient management that are not reflected in the rates of diagnosis of severe thoracic injuries (e.g. tension pneumothoraces, cardiac injuries, arterial injuries). By contrast, there was a relevant increase in the rates of diagnosis of minor thoracic injuries, which, however, did not result in an improvement in survival prognosis.

Hospital trauma level's association with outcomes for injured pregnant women and their neonates in Washington state, 1995–2012

PubMed Central

Distelhorst, John Thomas; Soltis, Michele A.; Krishnamoorthy, Vijay; Schiff, Melissa A.

2017-01-01

Background: Trauma occurs in 8% of all pregnancies. To date, no studies have evaluated the effect of the hospital's trauma designation level as it relates to birth outcomes for injured pregnant women. Methods: This population-based, retrospective cohort study evaluated the association between trauma designation levels and injured pregnancy birth outcomes. We linked Washington State Birth and Fetal Death Certificate data and the Washington State Comprehensive Hospital Abstract Recording System. Injury was identified using the International Classification of Diseases, Ninth Revision injury diagnosis and external causation codes. The association was analyzed using logistic regression to estimate odds ratios and 95% confidence intervals (CIs). Results: We identified 2492 injured pregnant women. Most birth outcomes studied, including placental abruption, induction of labor, premature rupture of membranes, cesarean delivery, maternal death, gestational age <37 weeks, fetal distress, fetal death, neonatal respiratory distress, and neonatal death, showed no association with trauma hospital level designation. Patients at trauma Level 1–2 hospitals had a 43% increased odds of preterm labor (95% CI: 1.15–1.79) and a 66% increased odds of meconium at delivery (95% CI: 1.05–2.61) compared to those treated at Level 3–4 hospitals. Patients with an injury severity score >9, treated at trauma Level 1–2 hospitals, had an aOR of low birth weight, <2500 g, of 2.52 (95% CI: 1.12–5.64). Conclusions: The majority of birth outcomes for injured patients had no association with hospitalization at a Level 1–2 compared to a Level 3–4 trauma center. PMID:28971027

Cerebral Glucose Metabolism and Sedation in Brain-injured Patients: A Microdialysis Study.

PubMed

Hertle, Daniel N; Santos, Edgar; Hagenston, Anna M; Jungk, Christine; Haux, Daniel; Unterberg, Andreas W; Sakowitz, Oliver W

2015-07-01

Disturbed brain metabolism is a signature of primary damage and/or precipitates secondary injury processes after severe brain injury. Sedatives and analgesics target electrophysiological functioning and are as such well-known modulators of brain energy metabolism. Still unclear, however, is how sedatives impact glucose metabolism and whether they differentially influence brain metabolism in normally active, healthy brain and critically impaired, injured brain. We therefore examined and compared the effects of anesthetic drugs under both critical (<1 mmol/L) and noncritical (>1 mmol/L) extracellular brain glucose levels. We performed an explorative, retrospective analysis of anesthetic drug administration and brain glucose concentrations, obtained by bedside microdialysis, in 19 brain-injured patients. Our investigations revealed an inverse linear correlation between brain glucose and both the concentration of extracellular glutamate (Pearson r=-0.58, P=0.01) and the lactate/glucose ratio (Pearson r=-0.55, P=0.01). For noncritical brain glucose levels, we observed a positive linear correlation between midazolam dose and brain glucose (P<0.05). For critical brain glucose levels, extracellular brain glucose was unaffected by any type of sedative. These findings suggest that the use of anesthetic drugs may be of limited value in attempts to influence brain glucose metabolism in injured brain tissue.

Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients

PubMed Central

2012-01-01

Introduction Daily interruption of sedation (IS) has been implemented in 30 to 40% of intensive care units worldwide and may improve outcome in medical intensive care patients. Little is known about the benefit of IS in acutely brain-injured patients. Methods This prospective observational study was performed in a neuroscience intensive care unit in a tertiary-care academic center. Twenty consecutive severely brain-injured patients with multimodal neuromonitoring were analyzed for levels of brain lactate, pyruvate and glucose, intracranial pressure (ICP), cerebral perfusion pressure (CPP) and brain tissue oxygen tension (PbtO2) during IS trials. Results Of the 82 trial days, 54 IS-trials were performed as interruption of sedation and analgesics were not considered safe on 28 days (34%). An increase in the FOUR Score (Full Outline of UnResponsiveness score) was observed in 50% of IS-trials by a median of three (two to four) points. Detection of a new neurologic deficit occurred in one trial (2%), and in one-third of IS-trials the trial had to be stopped due to an ICP-crisis (> 20 mmHg), agitation or systemic desaturation. In IS-trials that had to be aborted, a significant increase in ICP and decrease in PbtO2 (P < 0.05), including 67% with critical values of PbtO2 < 20 mmHg, a tendency to brain metabolic distress (P < 0.07) was observed. Conclusions Interruption of sedation revealed new relevant clinical information in only one trial and a large number of trials could not be performed or had to be stopped due to safety issues. Weighing pros and cons of IS-trials in patients with acute brain injury seems important as related side effects may overcome the clinical benefit. PMID:23186037

Deciphering the use and predictive value of "emergency medical services provider judgment" in out-of-hospital trauma triage: a multisite, mixed methods assessment.

PubMed

Newgard, Craig D; Kampp, Michael; Nelson, Maria; Holmes, James F; Zive, Dana; Rea, Thomas; Bulger, Eileen M; Liao, Michael; Sherck, John; Hsia, Renee Y; Wang, N Ewen; Fleischman, Ross J; Barton, Erik D; Daya, Mohamud; Heineman, John; Kuppermann, Nathan

2012-05-01

"Emergency medical services (EMS) provider judgment" was recently added as a field triage criterion to the national guidelines, yet its predictive value and real world application remain unclear. We examine the use and independent predictive value of EMS provider judgment in identifying seriously injured persons. We analyzed a population-based retrospective cohort, supplemented by qualitative analysis, of injured children and adults evaluated and transported by 47 EMS agencies to 94 hospitals in five regions across the Western United States from 2006 to 2008. We used logistic regression models to evaluate the independent predictive value of EMS provider judgment for Injury Severity Score ≥ 16. EMS narratives were analyzed using qualitative methods to assess and compare common themes for each step in the triage algorithm, plus EMS provider judgment. 213,869 injured patients were evaluated and transported by EMS over the 3-year period, of whom 41,191 (19.3%) met at least one of the field triage criteria. EMS provider judgment was the most commonly used triage criterion (40.0% of all triage-positive patients; sole criterion in 21.4%). After accounting for other triage criteria and confounders, the adjusted odds ratio of Injury Severity Score ≥ 16 for EMS provider judgment was 1.23 (95% confidence interval, 1.03-1.47), although there was variability in predictive value across sites. Patients meeting EMS provider judgment had concerning clinical presentations qualitatively similar to those meeting mechanistic and other special considerations criteria. Among this multisite cohort of trauma patients, EMS provider judgment was the most commonly used field trauma triage criterion, independently associated with serious injury, and useful in identifying high-risk patients missed by other criteria. However, there was variability in predictive value between sites.

An Experience in the Management of the Open Abdomen in Severely Injured Burn Patients

DTIC Science & Technology

2012-07-01

laparotomy was ACS in 31 patients (82%), abdominal trauma in 6 patients (16%), and a perforated gastric ulcer in 1 patient (3%). The abdominal...and other primary intra-abdominal pathology resulting in an abdominal catastrophe. Decompres- sive laparotomy for the treatment of ACS has been...presence of burns involving abdominal skin. • Treatment characteristics: method of temporary abdominal closure, number of days to closure, and number

Traffic-related pedestrian injuries amongst expatriate workers in Qatar: a need for cross-cultural injury prevention programme.

PubMed

Latifi, Rifat; El-Menyar, Ayman; Al-Thani, Hassan; Zarour, Ahmad; Parchani, Ashok; Abdulrahman, Husham; Asim, Mohammad; Peralta, Ruben; Consunji, Rafael

2015-01-01

Qatar is a rapidly developing country in which expatriate workers constitute the majority of population. Also, Qatar is an example of right-sided road driving convention (RDC) country. The aim of our study is to analyse the traffic-related pedestrian injuries (TRPI) amongst expatriates in relation to RDC. A retrospective analysis of prospectively collected data of TRPI patients who were admitted to the only Level I trauma centre in Qatar between 2009 and 2011 was performed. Demographics, country of origin, time of injury, injury severity score (ISS), RDC, morbidity and mortality were analysed. Of the 4997 injured patients, 601 (12%) were pedestrians. Of these, 92% were expatriates. The mean age was 31.8 ± 17 and 64% of them were 18-45 years old. Mean ISS was higher in those who were injured on weekends (15.4 ± 10) in comparison to working days (13.5 ± 10) (p = 0.04). The overall mortality was 15%. Sixty-seven percent of those who died were from left RDC countries. Expatriate workers, originally from left RDC countries are disproportionately affected by TRPI. This group of injured patients requires focused injury prevention programmes that are culture and language appropriate.

The effect of expedited rotator cuff surgery in injured workers: a case-control study.

PubMed

Razmjou, Helen; Lincoln, Sandra; Boljanovic, Dragana; Gallay, Stephen; Henry, Patrick; Richards, Robin R; Holtby, Richard

2017-07-01

Expediting rotator cuff surgery is expected to facilitate recovery and return to work in injured workers. This case-control study examined the effect of expedited rotator cuff surgery on recovery and work status in injured workers. Injured workers who had undergone an expedited rotator cuff surgery funded by parallel-pay insurance (study group) were compared with workers who had used the public health insurance (control group) while adjusting for sex, age, severity of pathology, and follow-up period. Disability was measured by the American Shoulder and Elbow Surgeons (ASES) Standardized Assessment Form score. The percentage of patients who exceeded the minimal clinically important difference of 17 points in the ASES was calculated. The study group waited less time to have surgery than the control group (P < .0001), reported less disability after surgery, and had a higher number of patients whose improvement exceeded the minimal clinically important difference (119 vs. 65, P < .0001). The study group was more likely to be working at the time of the final follow-up (P < .0001). The final multivariable regressions, which adjusted for unmatched variables, such as dominant side involvement, mechanism of injury, and associated operations that were different between groups, were consistent with univariable analyses indicating superior results in the study group. Injured workers who underwent expedited rotator cuff surgery reported less disability and had a more successful return to work after surgery than injured workers who waited longer for specialist assessment and surgery within the public health system. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Lawn mower injuries to children in Pennsylvania, 1989 to 1993.

PubMed

Bernardo, L M; Gardner, M J

1996-01-01

Lawn mowers pose a significant risk of morbidity and mortality to children. The purpose of this study was to identify the characteristics of children injured by lawn mowers admitted to accredited trauma centers in Pennsylvania from 1989 to 1993. Data were available on 177 children who sustained 504 injuries. The majority of children were less than 5 years old, male, injured by a power mower, during the summer, at home, and with an injury to an extremity. Four cases that represent patients with a low injury Severity Score but a long hospitalization are discussed.

Analysis of clinical risk factors associated with the prognosis of severe multiple-trauma patients with acute lung injury.

PubMed

Wu, Junsong; Sheng, Lei; Wang, Shenhua; Li, Qiang; Zhang, Mao; Xu, Shaowen; Gan, Jianxin

2012-09-01

Several clinical risk factors have been reported to be associated with the prognosis of acute lung injury (ALI). However, these studies have included a general trauma patient population, without singling out the severely injured multiple-trauma patient population. To identify the potential risk factors that could affect the prognosis of ALI in multiple-trauma patients and investigate the prognostic effects of certain risk factors among different patient subpopulations. In this retrospective cohort study, severely injured multiple-trauma patients with early onset of ALI from several trauma centers were studied. Potential risk factors affecting the prognosis of ALI were examined by univariate and multivariate logistic analyses. There were 609 multiple-trauma patients with ALI admitted to the emergency department and emergency intensive care unit during the study period. The nine risk factors that affected prognosis, as indicated by the unadjusted odds ratios with 95% confidence intervals, were the APACHE II (Acute Physiology and Chronic Health Evaluation II) score, duration of trauma, age, gastrointestinal hemorrhage, pulmonary contusion, disseminated intravascular coagulation (DIC), multiple blood transfusions in 6 h, Injury Severity Score (ISS), and aspiration of gastric contents. Specific risk factors also affected different patient subpopulations in different ways. Patients older than 65 years and with multiple (> 10 units) blood transfusions in the early stage after multiple trauma were found to be independent risk factors associated with deterioration of ALI. The other factors studied, including pulmonary contusion, APACHE II score ≥ 20, ISS ≥ 16, gastrointestinal hemorrhage, and aspiration of gastric contents, may predict the unfavorable prognosis of ALI in the early stage of trauma, with their effects attenuating in the later stage. Duration of trauma ≥ 1 h and the presence of DIC may also indicate unfavorable prognosis during the entire treatment period. Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.

Recovery of cortical effective connectivity and recovery of consciousness in vegetative patients

PubMed Central

Rosanova, Mario; Gosseries, Olivia; Casarotto, Silvia; Boly, Mélanie; Casali, Adenauer G.; Bruno, Marie-Aurélie; Mariotti, Maurizio; Boveroux, Pierre; Tononi, Giulio; Laureys, Steven

2012-01-01

Patients surviving severe brain injury may regain consciousness without recovering their ability to understand, move and communicate. Recently, electrophysiological and neuroimaging approaches, employing simple sensory stimulations or verbal commands, have proven useful in detecting higher order processing and, in some cases, in establishing some degree of communication in brain-injured subjects with severe impairment of motor function. To complement these approaches, it would be useful to develop methods to detect recovery of consciousness in ways that do not depend on the integrity of sensory pathways or on the subject's ability to comprehend or carry out instructions. As suggested by theoretical and experimental work, a key requirement for consciousness is that multiple, specialized cortical areas can engage in rapid causal interactions (effective connectivity). Here, we employ transcranial magnetic stimulation together with high-density electroencephalography to evaluate effective connectivity at the bedside of severely brain injured, non-communicating subjects. In patients in a vegetative state, who were open-eyed, behaviourally awake but unresponsive, transcranial magnetic stimulation triggered a simple, local response indicating a breakdown of effective connectivity, similar to the one previously observed in unconscious sleeping or anaesthetized subjects. In contrast, in minimally conscious patients, who showed fluctuating signs of non-reflexive behaviour, transcranial magnetic stimulation invariably triggered complex activations that sequentially involved distant cortical areas ipsi- and contralateral to the site of stimulation, similar to activations we recorded in locked-in, conscious patients. Longitudinal measurements performed in patients who gradually recovered consciousness revealed that this clear-cut change in effective connectivity could occur at an early stage, before reliable communication was established with the subject and before the spontaneous electroencephalogram showed significant modifications. Measurements of effective connectivity by means of transcranial magnetic stimulation combined with electroencephalography can be performed at the bedside while by-passing subcortical afferent and efferent pathways, and without requiring active participation of subjects or language comprehension; hence, they offer an effective way to detect and track recovery of consciousness in brain-injured patients who are unable to exchange information with the external environment. PMID:22226806

[Process indicators: tools for monitoring the management of severe trauma cases in Catalonia].

PubMed

Prat, Salvi; Muñoz-Ortiz, Laura; Navarro, Salvador; Koo, Maylin; Jiménez-Fábrega, Xavier; Martínez-Cruz, Olga; Espallargues, Mireia

2016-10-01

Process indicators have been widely used to monitor the way trauma care is provided. We aimed to analyze whether data from a hospital's severe trauma register could facilitate the evaluation of aspects of the initial management of severe injuries. Observational, retrospective population-based study. A working group of experts selected a set of trauma care process indicators relevant to some aspects of initial care, diagnosis, and treatment of severely injured patients. Four of the indicators referred to prehospital care and 5 to hospital care. We calculated the observed and expected compliance rates for all the indicators. A total of 1526 cases (44.4%) were analyzed for 2013; 1908 (55.6%) were analyzed for 2014. We were able to evaluate 3 of the 4 prehospital process indicators: endotracheal intubation in patients with a score of 8 on the Glasgow coma scale (GCS) (84% compliance), venous access established before hospital arrival (83.4%), and placement of a neck collar to immobilize the cervical spine (72.7%). Compliance for the hospital-phase indicators were as follows: performance of a computed tomography scan of the head within 60 minutes in cases with a GCS of 13 (5.3% compliance, craniotomy in candidate patients within 2 hours of diagnosis (65%), diagnostic examination for abdominal injuries within 60 minutes in patients with systolic blood pressure 90 mm Hg (89.3%), and therapeutic laparotomy or angiography within 4 hours of abdominal injury in candidate patients with systolic blood pressure 90 mm Hg (51.7%). Compliance was 69.9% for the last process indicator: surgical treatment of open fractures within 8 hours of an accident. Our findings show that a hospital trauma register provides data about care process indicators that can allow us to monitor the quality of care of severely injured patients.

An epidemiological approach to mass casualty incidents in the Principality of Asturias (Spain).

PubMed

Castro Delgado, Rafael; Naves Gómez, Cecilia; Cuartas Álvarez, Tatiana; Arcos González, Pedro

2016-02-24

Mass Casualty Incidents (MCI) have been rarely studied from epidemiological approaches. The objective of this study is to establish the epidemiological profile of MCI in the autonomous region of the Principality of Asturias (Spain) and analyse ambulance deployment and severity of patients. This is a population-based prospective study run in 2014. Inclusion criteria for MCI is "every incident with four or more people affected that requires ambulance mobilisation". Thirty-nine MCI have been identified in Asturias in 2014. Thirty-one (79%) were road traffic accidents, three (7.5%) fires and five (12.8%) other types. Twenty-one incidents (56.7%) had four patients, and only three of them (8%) had seven or more patients. An average of 2.41 ambulances per incident were deployed (standard error = 0.18). Most of the patients per incident were minor injured patients (mean = 4; standard error = 0.2), and 0,26 were severe patients (standard error = 0.08). There was a positive significant correlation (p < 0.01) between the total number of patients and the total number of ambulances deployed and between the total number of patients and Advanced Life Support (ALS) ambulances deployed (p < 0.001). The total number of non-ALS ambulances was not related with the total number of patients. Population based research in MCI is essential to define MCI profile. Quantitative definition of MCI, adapted to resources, avoid selection bias and present a more accurate profile of MCI. As espected, road traffic accidents are the most frequent MCI in our region. This aspect is essential to plan training and response to MCI. Analysis of total response to MCI shows that for almost an hour, we should plan extra resources for daily emergencies. This data is an important issue to bear in mind when planning MCI response. The fact that most patients are classified as minor injured and more advanced life support units than needed are deployed shows that analysis of resources deployment and patient severity helps us to better plan future MCI response. Road traffic accidents with minor injured patients are the most frequent MCI in our region. More advanced life support units than needed have been initially deployed, which might compromise response to daily emergencies during an MCI.

Military surgery in the 21st century.

PubMed

Mellor, S G

2006-01-01

The battlefield has changed. UK and US Forces in Iraq and Afghanistan are engaged in asymmetric, three bloc warfare. Three bloc warfare indicates that what is effectively war-fighting occurs in parallel with peace-keeping and humanitarian operations. Casualties are numerically lower than in previous conflicts but many survivors are horrifically mutilated as body armour prevents the fatal injury in this severely injured group. Rapid evacuation of severely injured from the point of injury, usually by helicopter, provides extreme challenges for surgical teams. Damage control surgery requires support in the form of environmental control, adequate diagnostics (including computerised tomography) and effective intensive care facilities if the patient is to survive. Teams need to be highly trained and to have experience of complex surgery and trauma. They must be adequately resourced if lives are to be saved.

The process of confrontation with disability in patients with spinal cord injury

PubMed Central

Ahmadzadeh, Gholamhossein; Kouchaki, Anahita; Malekian, Azadeh; Aminorro’aya, Mahin; Boroujeni, Ali Zargham

2010-01-01

BACKGROUND: Spinal injury can establish severe psychological outcomes for the patient and his/her family which requires high adjustment. Health system staff would be able to play their roles well in caring these patients provided with knowing what steps spinal injured people should pass to handle their disability and also what assistance they need in what stages from what sources. This study aimed to explain the process of confrontation with disability in spinal cord injured patients. METHODS: This was a qualitative study with grounded theory approach which was performed in Strauss and Corbin proposed method on twenty people with spinal cord injury who had past at least three months from their spinal injury. Sampling was done in purposive and theoretical method, and analysis of the results was also performed during constant comparative process. RESULTS: Central concept in the data was support which was associated with other concepts and affected them. The patients, with the help of internal and external support could overcome their main problem that was disability feeling and dependency on others and find a new definition for the self, and ultimately achieve the sense of independence and autonomy. CONCLUSIONS: Knowing the process of confrontation with disability along with better understanding of spinal cord injured people would help health system staff to actualize and support their potentials much better through strengthening internal resources and providing appropriate supportive services of each individual. PMID:22069411

Patient Characteristics and Temporal Trends in Police Transport of Blunt Trauma Patients: A Multicenter Retrospective Cohort Study.

PubMed

Kaufman, Elinore J; Jacoby, Sara F; Sharoky, Catherine E; Carr, Brendan G; Delgado, M Kit; Reilly, Patrick M; Holena, Daniel N

2017-01-01

Police transport (PT) of penetrating trauma patients has the potential to decrease prehospital times for patients with life-threatening hemorrhage and is part of official policy in Philadelphia, Pennsylvania. We hypothesized that rates of PT of bluntly injured patients have increased over the past decade. We used Pennsylvania Trauma Outcomes Study registry data from 2006-15 to identify bluntly injured adult patients transported to all 8 trauma centers in Philadelphia. PT was compared to ambulance transport, excluding transfers, burn patients, and private transport. We compared demographics, mechanism, and injury outcomes between PT and ambulance transport patients and used multivariable logistic regression to identify independent predictors of PT. We also identified physiological indicators and injury patterns that might have benefitted from prehospital intervention by EMS. Of 28 897 bluntly injured patients, 339 (1.2%) were transported by police and 28 558 (98.8%) by ambulance. Blunt trauma accounted for 11% of PT and penetrating trauma for 89%. PT patients were younger, more likely to be male, and more likely to be African American or Asian and were more often injured by assault or motor vehicle crash. There were no significant differences presenting physiology between PT and EMS patients. In multivariable logistic regression analysis, male sex (OR 1.89, 95%CI 1.40-2.55), African American race (OR 1.71 95%CI 1.34-2.18), and Asian race (OR 2.25, 95%CI 1.22-4.14) were independently associated with PT. Controlling for injury severity and physiology, there was no significant difference in mortality between PT and EMS. Overall, 64% of PT patients had a condition that might have benefited from prehospital intervention such as supplemental oxygen for brain injury or spine stabilization for vertebral fractures. PT affects a small minority of blunt trauma patients, and did not appear associated with higher mortality. However, PT patients included many who might have benefited from proven, prehospital intervention. Clinicians, EMS providers, and law enforcement should collaborate to optimize use of PT within the trauma system.

Imaging features of blast injuries: experience from 2015 Ankara bombing in Turkey.

PubMed

Yazgan, Cisel; Aksu, Nalan M

2016-06-01

To present the radiological features of blast-related injuries in the victims of the 10 October 2015 Ankara bombing and emphasize the importance of imaging. This retrospective descriptive study included a total of 28 patients who underwent CT scan or radiographic imaging within 6 h after the bombing on 10 October 2015. CT scans and plain radiographs were evaluated regarding mechanisms of injuries. Injuries were categorized as primary, secondary, tertiary and quaternary. The number of shrapnel and distribution of injuries were noted. Injury Severity Score (ISS) was used to rank the severity of the injury. Primary blast injuries consisted of only tympanic membrane rupture. A high rate of patients (21/28 patients) in the study group suffered from secondary blast injuries. Tertiary injuries were detected in only three patients. Of the severely injured patients, five had abdominal injuries, three had thoracic injuries and six had extremity injuries. ISS was significantly higher in patients with thoracic and abdominal injuries. Our results after the suicide bomb attacks showed that the most common injury pattern was secondary blast injury. The torso was the most commonly injured body region, followed by the extremities. This specific injury pattern requires the use of immense radiological imaging. Hence, radiologists should be aware of the mechanisms and spectrums of blast-related injuries. Both the unique injury pattern and the following chaos make blast-related injuries a challenge in terms of triage, diagnosis and management. Radiologists should be familiar with the wide spectrum of these unique injuries.

Musculoskeletal disorders and associated healthcare costs among family members of injured workers.

PubMed

Asfaw, Abay; Pana-Cryan, Regina; Bushnell, Tim; Sauter, Steven

2015-11-01

Research has infrequently looked beyond the injured worker when gauging the burden of occupational injury. We explored the relationship between occupational injury and musculoskeletal disorders (MSDs) among family members of injured workers. We used 2005 and 2006 Truven Health Analytics databases, which contain information on workers' compensation and family healthcare claims. We used descriptive analyses, and negative binomial and two-part models. Family members of severely injured workers had a 15% increase in the total number of MSD outpatient claims and a 34% increase in the mean cost of MSD claims compared to family members of non-severely injured workers within 3 months after injury. Extrapolating cost results to the national level implies that severe occupational injury would be associated with between $29 and $33 million additional cost of family member outpatient MSD claims. Occupational injury can impose a formerly unrecognized health burden on family members of injured workers. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Pneumonia in multiple injured patients: a prospective controlled trial on early prediction using clinical and immunological parameters.

PubMed

Andermahr, J; Greb, A; Hensler, T; Helling, H J; Bouillon, B; Sauerland, S; Rehm, K E; Neugebauer, E

2002-05-01

In a prospective trial 266 multiple injured patients were included to evaluate clinical risk factors and immune parameters related to pneumonia. Clinical and humoral parameters were assessed and multivariate analysis performed. The multivariate analysis (odds ratio with 95% confidence interval (CI)) revealed male gender (3.65), traumatic brain injury (TBI) (2.52), thorax trauma (AIS(thorax) > or = 3) (2.05), antibiotic prophylaxis (1.30), injury severity score (ISS) (1.03 per ISS point) and the age (1.02 per year) as risk factors for pneumonia. The main pathogens were Acinetobacter Baumannii (40%) and Staphylococcus aureus (25%). A tendency towards higher Procalcitonin (PCT) and Interleukin (IL)-6 levels two days after trauma was observed for pneumonia patients. The immune parameters (PCT, IL-6, IL-10, soluble tumor necrosis factor p-55 and p-75) could not confirm the diagnosis of pneumonia earlier than the clinical parameters.

[The Brain-Injured Relationship: Neuropsychological Rehabilitation Counselling and Therapy of Couples and Families].

PubMed

Müller, T

2016-12-01

A brain-injured patient's system of relationships is severely disbalanced, and seeks a new equilibrium very much like a kinetic mobile sculpture responding to an impulse. Thus, it is not only the deficits in the patients and their environment and resources that define the success of participation in the process of rehabilitation. Fundamentally, it relies on stable and adjustable relationships as well as trustful communication in the patients' social systems. Negotiating participation is a concerted, interactive adjustment process for everyone involved in dealing with a disruptive life event. Dysfunction in relationships and communication, which frequently is a direct or indirect consequence of brain injuries, puts at risk the sustainability of progress reached during rehabilitation. In this system of relationships often heavily burdened, neuropsychological rehabilitation counseling is needed to secure the long-term success of rehabilitation. © Georg Thieme Verlag KG Stuttgart · New York.

Therapeutic cloning applications for organ transplantation.

PubMed

Koh, Chester J; Atala, Anthony

2004-04-01

A severe shortage of donor organs available for transplantation in the United States leaves patients suffering from diseased and injured organs with few treatment options. Scientists in the field of tissue engineering apply the principles of cell transplantation, material science, and engineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Therapeutic cloning, where the nucleus from a donor cell is transferred into an enucleated oocyte in order to extract pluripotent embryonic stem cells, offers a potentially limitless source of cells for tissue engineering applications. The present chapter reviews recent advances that have occurred in therapeutic cloning and tissue engineering and describes applications of these new technologies that may offer novel therapies for patients with end-stage organ failure. Copyright 2004 Elsevier B.V.

Reducing the Indication for Ventilatory Support in the Severely Burned Patient: Results of a New Protocol Approach at a Regional Burn Center.

PubMed

Gille, Jochen; Bauer, Nicole; Malcharek, Michael J; Dragu, Adrian; Sablotzki, Armin; Taha, Hischam; Czeslick, Elke

2016-01-01

Initial management of the severely injured routinely includes sedation and mechanical ventilatory support. However, nonjudiciously applied mechanical ventilatory support can itself lead to poorer patient outcomes. In an attempt to reduce this iatrogenic risk, a standardized, in-house, five-point protocol providing clinical guidance on the use and duration of ventilation was introduced and analyzed, and the impact on patient outcomes was assessed. In 2007, a protocol for early spontaneous breathing was introduced and established in clinical practice. This protocol included: 1) early extubation (≤6 hours after admission) in the absence of absolute ventilatory indication; 2) avoidance of "routine intubation" in spontaneously breathing patients; 3) early postoperative extubation, including patients requiring multiple surgical interventions; 4) intensive chest and respiratory physiotherapy with routine application of expectorants; and 5) early active mobilization. A retrospective clinical study compared patients (group A) over a 2-year period admitted under the new protocol with a historical patient group (group B). Patients in group A (n = 38) had fewer ventilator days over the time-course of treatment (3 [1; 5.8] vs 18.5 days [0.5; 20.5]; P = .0001) with a lower rate of tracheostomies (15.8 vs 54%; P = .0003). Patients on ventilation at admission in group A had shorter ventilation periods after admission (4.75 [4; 22.25] vs 378 hours [8.5; 681.5]; P = .0003), and 66.7% of these patients were extubated within 6 hours of admission (vs 9.1% in group B). No patients fulfilling the inclusion criteria required re- or emergency intubation. In the first 5 days of treatment, significantly lower Sequential Organ Failure Assessment scores were recorded in group A. There was also a trend for lower mortality rates (0 [0%] vs 6 [14%]), sepsis rates (24 [63.2%] vs 37 [88.1%]), and cumulative fluid balance on days 3 and 7 in group A. In contrast, group A demonstrated an elevated rate of pneumonia (15 [39.5%] vs 8 [19%]). These trends, however, lacked statistical significance. Our five-point protocol was safe and easily translated into clinical practice. In the authors experience, this protocol significantly reduced the ventilatory period in severely injured. Furthermore, this study suggests that many injured may be over-treated with routine ventilation, which carries accompanying risks.

Type, severity, management and outcome of ocular and adnexal firework-related injuries: the Rotterdam experience.

PubMed

Frimmel, Sonja; de Faber, J Tjeerd; Wubbels, Rene J; Kniestedt, Christoph; Paridaens, Dion

2018-03-13

To study the type, severity, management and outcome of firework-related adnexal and ocular injuries during New Year's Eve festivities. A retrospective analysis of 123 injured patients (143 eyes) treated at the Rotterdam Eye Hospital between 2009 and 2013. All ages were included and analysed according to age, gender, active participant or bystander, laterality, location, dimension and severity of injury. Outcome parameter was the final best-corrected visual acuity. The mean age was 22 ± 13 years with 87% males and 53% bystanders. 52% were ≤18 years. There was a higher number of female than male bystanders (63% versus 51%, p = 0.30). 50% of the eyes sustained mild, 13% moderate and 37% severe trauma. Adults suffered more from severe injuries compared to children (42% versus 31%). The most frequent intervention was gunpowder removal (20%), followed by traumatic cataract surgery (12%) and amniotic membrane grafting (8%). 76% of patients were followed over 1 year. At the end of follow-up, 88 (61.5%) eyes had recovered fully, while 55 (38.5%) eyes suffered from persistent complications with reduced vision ≤0.8 in 30% of injured eyes. 15 patients (12%, 10 adults, five children) were considered legally blind (vision ≤0.1). Three (2%) eyes were subject to evisceration. Every year, around New Year's Eve 30-45 victims were referred to the Rotterdam Eye Hospital; 50% sustained moderate-to-severe trauma. In severe firework injuries, patients required multiple treatments that may not prevent permanent blindness and/or functional/cosmetic disfigurement. The majority was bystander and younger than 18 years. © 2018 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Employment among Spinal Cord Injured Patients Living in Turkey: A Cross-Sectional Study

ERIC Educational Resources Information Center

Gunduz, Berrin; Erhan, Belgin; Bardak, Ayse Nur

2010-01-01

The aim of this study was to determine the rate of employment and to establish the factors affecting vocational status in spinal cord injured patients living in Turkey. One hundred and fifty-two traumatic spinal cord injured patients older than 18 years with injury duration of at least 1 year and living in the community were included in the study;…

Fireworks type, injury pattern, and permanent impairment following severe fireworks-related injuries.

PubMed

Sandvall, Brinkley K; Jacobson, Lauren; Miller, Erin A; Dodge, Ryan E; Alex Quistberg, D; Rowhani-Rahbar, Ali; Vavilala, Monica S; Friedrich, Jeffrey B; Keys, Kari A

2017-10-01

There is a paucity of clinical data on severe fireworks-related injuries, and the relationship between firework types, injury patterns, and magnitude of impairment is not well understood. Our objective was to describe the relationship between fireworks type, injury patterns, and impairment. Retrospective case series (2005-2015) of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or an operation at a Level 1 Trauma/Burn Center. Fireworks types, injury patterns (body region, injury type), operation, and permanent impairment were examined. Data from 294 patients 1 to 61years of age (mean 24years) were examined. The majority (90%) were male. 119 (40%) patients were admitted who did not undergo surgery, 163 (55%) patients required both admission and surgery, and 12 (5%) patients underwent outpatient surgery. The greatest proportion of injuries was related to shells/mortars (39%). There were proportionally more rocket injuries in children (44%), more homemade firework injuries in teens (34%), and more shell/mortar injuries in adults (86%). Brain, face, and hand injuries were disproportionately represented in the shells/mortars group. Seventy percent of globe-injured patients experienced partial or complete permanent vision loss. Thirty-seven percent of hand-injured patients required at least one partial or whole finger/hand amputation. The greatest proportion of eye and hand injuries resulting in permanent impairment was in the shells/mortars group, followed by homemade fireworks. Two patients died. Severe fireworks-related injuries from homemade fireworks and shells/mortars have specific injury patterns. Shells/mortars disproportionately cause permanent impairment from eye and hand injury. Published by Elsevier Inc.

The safety of early fresh, whole blood transfusion among severely battle injured at US Marine Corps forward surgical care facilities in Afghanistan.

PubMed

Auten, Jonathan D; Lunceford, Nicole L; Horton, Jaime L; Galarneau, Mike R; Galindo, Roger M; Shepps, Craig D; Zieber, Tara J; Dewing, Chris B

2015-11-01

In Afghanistan, care of the acutely injured trauma patient commonly occurred in facilities with limited blood banking capabilities. Apheresis platelets were often not available. Component therapy consisted of 1:1 packed red blood cells and fresh frozen plasma. Fresh, whole blood transfusion often augmented therapy in the severely injured patient. This study analyzed the safety of fresh, whole blood use in a resource-limited setting. A retrospective analysis was performed on a prospectively collected data set of US battle injuries presenting to three US Marine Corps (USMC) expeditionary surgical care facilities in Helmand Province, Afghanistan, between January 2010 and July 2012. Included in the review were patients with Injury Severity Scores (ISSs) of 15 or higher receiving blood transfusions. Univariate analyses were performed, followed by multivariable logistic regression to describe the relationship between the treatment group and posttreatment complications such as trauma-induced coagulopathy, infection, mortality, venous thromboembolism, and transfusion reaction. Propensity scores were calculated and included in multivariable models to adjust for potential bias in treatment selection. A total of 61 patients were identified; all were male marines with a mean (SD) age of 23.5 (3.6) years. The group receiving fresh, whole blood was noted to have higher ISSs and lower blood pressure, pH, and base deficits on arrival. Traumatic coagulopathy was significantly less common in the group receiving fresh, whole blood (odds ratio, 0.01; 95% confidence interval, 0.00-0.18). Multivariable models found no other significant differences between the treatment groups. The early use of fresh, whole blood in a resource-limited setting seems to confer a benefit in reducing traumatic coagulopathy. This study's small sample size precludes further statement on the overall safety of fresh, whole blood use. Therapy study, level IV.

An Analysis of Distance from Collision Site to Pedestrian Residence in Pedestrian versus Automobile Collisions Presenting to a Level 1 Trauma Center.

PubMed

Anderson, Craig L; Dominguez, Kathlynn M; Hoang, Teresa V; Rowther, Armaan Ahmed; Carroll, M Christy; Lotfipour, Shahram; Hoonpongsimanont, Wirachin; Chakravarthy, Bharath

2012-01-01

This study tests the hypothesis that most pedestrian collisions occur near victims' homes. Patients involved in automobile versus pedestrian collisions who presented to the emergency department at a Level I trauma center between January 2000 and December 2009 were included in the study. Patient demographics were obtained from the trauma registry. Home address was determined from hospital records, collision site was determined from the paramedic run sheet, and the shortest walking distance between the collision site and pedestrian residence was determined using Google Maps. We summarized distances for groups with the median and compared groups using the Kruskal-Wallis rank test. We identified 1917 pedestrian injury cases and identified both residence address and collision location for 1213 cases (63%). Forty-eight percent of the collisions were near home (within 1.1 km, 95% CI 45-51%). Median distance from residence to collision site was 1.4 km (interquartile range 0.3-7.4 km). For ages 0-17, the median distance 0.7 km, and 59% (95% CI 54-63%) of collisions occurred near home. For ages 65 and older, the median distance was 0.6 km and 65% (95% CI 55-73%) were injured near home. Distance did not differ by sex, race, ethnicity, or blood alcohol level. More severe injuries (Injury Severity Score ≥ 16) occurred further from home than less severe injuries (median 1.9 km vs. 1.3 km, p=.01). Patients with a hospital stay of 3 days or less were injured closer to home (median 1.3 km) than patients with a hospital stay of 4 days or more (median 1.8 km, p=.001). Twenty-two percent were injured within the same census tract as their home, 22% on the boundary of their home census tract, and 55% in a different census tract.

[Morbimortality in patients with hepatic trauma].

PubMed

Fonseca-Neto, Olival Cirilo Lucena da; Ehrhardt, Rogério; Miranda, Antonio Lopes de

2013-06-01

The liver is the intra-abdominal organ more injured in patient victims of trauma. The injury occurs more frequently in the penetrating trauma. The incidence of mortality for injuries of the liver is 10%. To evaluate the mortality of the patients with hepatic trauma, the treatment applied and its evolution. Were analyzed, retrospectively, the charts of all patients with hepatic trauma and surgical indication. Were analyzed: gender, age, ISS (injury severity score), classification of the abdominal trauma type (open or closed), causing instrument of the open traumas, degree of the injury, hepatic segments involved, presence of associated injuries, type of surgical treatment: not-therapeutic laparotomy and therapeutic laparotomy, reoperations, complications, time of hospitalization in days and mortality. One hundred and thirty-seven patients participated. Of these, 124 were men (90.5%). The majority (56.2%) had 20-29 years old. Closed abdominal trauma was most prevalent (67.9%). Of the penetrating traumas, the originated with firearms were in 24.8%. One hundred and three patients had only one injured hepatic segment (75.2%) and 34 (24.8%) two. Grade II injuries were in 66.4%. Of the 137 patients with laparotomy, 89 had been not-therapeutic, while in 48 it was necessary to repair associated injuries. Spleen and diaphragm had been the more frequently injured structures, 30% and 26%, respectively. The ISS varied of eight to 72, being the ISS > 50 (eight patients) associate with fatal evolution (five patients). Biliary fistula and hepatic abscess had been the main complications. Seven deaths had occurred. Concomitant injuries, hepatic and other organs, associated with ISS > 50 presented higher possibility of complications and death.

Single Versus Multiple Solid Organ Injuries Following Blunt Abdominal Trauma.

PubMed

El-Menyar, Ayman; Abdelrahman, Husham; Al-Hassani, Ammar; Peralta, Ruben; AbdelAziz, Hiba; Latifi, Rifat; Al-Thani, Hassan

2017-11-01

We aimed to describe the pattern of solid organ injuries (SOIs) and analyze the characteristics, management and outcomes based on the multiplicity of SOIs. A retrospective study in a Level 1 trauma center was conducted and included patients admitted with blunt abdominal trauma between 2011 and 2014. Data were analyzed and compared for patients with single versus multiple SOIs. A total of 504 patients with SOIs were identified with a mean age of 28 ± 13 years. The most frequently injured organ was liver (45%) followed by spleen (30%) and kidney (18%). One-fifth of patients had multiple SOIs, of that 87% had two injured organs. Patients with multiple SOIs had higher frequency of head injury and injury severity scores (p < 0.05). The majority of SOIs were treated nonoperatively, whereas operative management was required in a quarter of patients, mostly in patients with multiple SOIs (p = 0.01). Blood transfusion, sepsis and hospital stay were greater in multiple than single SOIs (p < 0.05). The overall mortality was 11% which was comparable between the two groups. In patients with single SOIs, the mortality was significantly higher in those who had pancreatic (28.6%) or hepatic injuries (13%) than the other SOIs. SOIs represent one-tenth of trauma admissions in Qatar. Although liver was the most frequently injured organ, the rate of mortality was higher in pancreatic injury. Patients with multiple SOIs had higher morbidity which required frequent operative management. Further prospective studies are needed to develop management algorithm based on the multiplicity of SOIs.

Impact of 2015 earthquakes on a local hospital in Nepal: A prospective hospital-based study.

PubMed

Giri, Samita; Risnes, Kari; Uleberg, Oddvar; Rogne, Tormod; Shrestha, Sanu Krishna; Nygaard, Øystein Petter; Koju, Rajendra; Solligård, Erik

2018-01-01

Natural disasters pose a great challenge to the health systems and individual health facilities. In low-resource settings, disaster preparedness systems are often limited and not been well described. Two devastating earthquakes hit Nepal within a 17-days period in 2015. This study aims to describe the burden and distribution of emergency cases to a local hospital. This is a prospective observational study of patients presenting to a local hospital for a period of 21 days following the earthquake on April 25, 2015. Demographic and clinical information was prospectively registered for all patients in the systematic emergency registry. Systematic telephone interviews were conducted in a random sample of the patients 90 days after admission to the hospital. A total of 2,003 emergency patients were registered during the period. The average daily number of emergency patients during the first five days was almost five times higher (n = 150) than the pre-incident daily average (n = 35). The majority of injuries were fractures (58%), 348 (56%) in the lower extremities. A total of 345 surgical procedures were performed and the hospital treated 111 patients with severe injuries related to the earthquake (compartment syndrome, crush injury, and internal injury). Among those with follow-up interviews, over 90% reported that they had been severely affected by the earthquakes; complete house damage, living in temporary shelter, or loss of close family member. The hospital experienced a very high caseload during the first days, and the majority of patients needed orthopaedic services. The proportion of severely injured and in-hospital deaths were relatively low, probably indicating that the most severely injured did not reach the hospital in time. The experiences underline the need for robust and easily available local health services that can respond to disasters.

20 years of trauma documentation in Germany--actual trends and developments.

PubMed

2014-10-01

The TraumaRegister DGU(®) has been founded 20 years ago. Although initially supported by larger hospitals and universities, it has recently become a representative registry for the care of severely injured patients in Germany. Based on the registry data some important trends and developments of the recent decades are presented. German trauma patients with an Injury Severity Score (ISS)≥ 16 were eligible if primary admitted from the scene. All cases documented between 1993 and 2012 (20 years) were eligible. For selected variables, an average change per years was calculated using linear regression analysis. A total of 49,801 patients was analysed. The mean age was 46.3 years, and 72% were males. The following relevant trends could be observed: The average age increased dramatically from 38 to 50 years. Pre-hospital intubation rate was halfed in patients with Glasgow Coma Scale (GCS)>8 but remained constant in unconscious patients (GCS ≤ 8; 90% intubation rate). Pre-hospital volume administration decreased as well, which led to less blood transfusions (from 45% to 16%). The use of helicopters for transportation into a trauma centre decreased as well but today still 27% of all cases are transported by air. Whole-body CT was performed in about 80% of patients; this value is stable in the last four years. Hospital mortality could be reduced and was 2-3% lower than expected in recent years. The Revised Injury Severity Classification (RISC) score used as a reference here was based on TR-DGU data from the 1990s. Standardised prospective registration of severely injured patients over 20years allows to empirically monitor trends and developments in acute trauma care. Copyright © 2014 Elsevier Ltd. All rights reserved.

Thoracic injuries sustained by severely injured front-seat passengers and drivers: injury patterns and their relationship to crash characteristics.

PubMed

Stübig, Timo; Brand, Stephan; Zeckey, Christian; Beltran, Michael J; Otte, Dietmar; Krettek, Christian; Haasper, Carl

2013-01-01

Thoracic injuries are common in vehicle crashes, but only a few studies thus far have analysed the relationship between injury characteristics and collision details and discussed the possible implications for future vehicle design and prevention. In this study, the crash details were prospectively collected at the scene of injury between 2004 and 2009 for severely injured patients. The collected data included the type of collision, angle of impact and change of velocity on impact as well as injury characteristics and patient demographics, including abbreviated injury scale (AIS) and injury severity score (ISS).There were 5998 accidents involving 8830 patients over this five-year period; 31 met the inclusion criteria (23 males and eight females). The mean ISS was 37 ± 12.68, the mean AIS Thorax was 4.0. Lung contusions were found in 90% of the patients, pneumothoraces in 58% and rib fractures in 81%. There was a significant relationship between accident deceleration speed (ΔV), AIS Thorax (p = 0.02) and the incidence of pneumothoraces (p = 0.046). The analysis showed a high overall incidence of thoracic injuries in car passengers. Future improvements in automobile safety and design should seek to reduce the incidence of thoracic injuries by uniform vehicle deformation and further implementation of side airbags.

Fate of combat nerve injury.

PubMed

Beltran, Michael J; Burns, Travis C; Eckel, Tobin T; Potter, Benjamin K; Wenke, Joseph C; Hsu, Joseph R

2012-11-01

Assess a cohort of combat-related type III open tibia fractures with peripheral nerve injury to determine the injury mechanism and likelihood for recovery or improvement in nerve function. Retrospective study. Three military medical centers. Out of a study cohort of 213 type III open tibia fractures, 32 fractures (in 32 patients) with a total of 43 peripheral nerve injuries (peroneal or tibial) distal to the popliteal fossa met inclusion criteria and were available for follow-up at an average of 20 months (range, 2-48 months). Clinical assessment of motor and sensory nerve improvement. There was a 22% incidence of peripheral nerve injury in the study cohort. At an average follow-up of 20 months (range, 2-48 months), 89% of injured motor nerves were functional, whereas the injured sensory nerves had function in 93%. Fifty percent and 27% of motor and sensory injuries demonstrated improvement, respectively (P = 0.043). With the numbers available, there was no difference in motor or sensory improvement based on mechanism of injury, fracture severity or location, soft tissue injury, or specific nerve injured. In the subset of patients with an initially impaired sensory examination, full improvement was related to fracture location (P = 0.0164). Type III open tibia fractures sustained in combat are associated with a 22% incidence of peripheral nerve injury, and the majority are due to multiple projectile penetrating injury. Despite the severe nature of these injuries, the vast majority of patients had a functional nerve status by an average of 2-year follow-up. Based on these findings, discussions regarding limb salvage and amputation should not be overly influenced by the patient's peripheral nerve status. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Open extensor tendon injuries: an epidemiologic study.

PubMed

Patillo, Dominic; Rayan, Ghazi M

2012-01-01

To report the epidemiology, mechanism, anatomical location, distribution, and severity of open extensor tendon injuries in the digits, hand, and forearm as well as the frequency of associated injuries to surrounding bone and soft tissue. Retrospective chart review was conducted for patients who had operative repair of open digital extensor tendon injuries in all zones within an 11-year period. Data was grouped according to patient characteristics, zone of injury, mechanism of injury, and presence of associated injury. Statistical analysis was used to determine the presence of relevant associations. Eighty-six patients with 125 severed tendons and 105 injured digits were available for chart reviews. Patients were predominantly males (83%) with a mean age of 34.2 years and the dominant extremity was most often injured (60%). The thumb was the most commonly injured (25.7%), followed by middle finger (24.8), whereas small finger was least affected (10.5%). Sharp laceration was the most common mechanism of injury (60%), and most of these occurred at or proximal to the metacarpophalangeal joints. Most saw injuries occurred distal to the metacarpophalangeal joint. Zone V was the most commonly affected in the fingers (27%) while zone VT was the most commonly affected in the thumb (69%). Associated injuries to bone and soft tissue occurred in 46.7% of all injuries with saw and crush/avulsions being predictive of fractures and damage to the underlying joint capsule. The extensor mechanism is anatomically complex, and open injuries to the dorsum of the hand, wrist, and forearm, especially of crushing nature and those inflicted by saws, must be thoroughly evaluated. Associated injuries should be ruled out in order to customize surgical treatment and optimize outcome.

More than meets the eye: social, economic, and emotional impacts of work-related injury and illness.

PubMed

Lax, Michael B; Klein, Rosemary

2008-01-01

The impact of an occupational illness or injury on an injured worker can be severe. This study assessed several dimensions of the impact on a group of 50 injured workers, all patients at an Occupational Health Center. The dimensions assessed included aspects of access to health care, support from treating physicians in obtaining Workers' Compensation benefits, financial impacts, the role of attorneys and "Independent Medical Examiners," and the impact on mental health. Many reported that their treating physician did not want to become involved in Workers' Compensation, despite indicating a belief that the health condition was work-related. The financial impacts of a work-related diagnosis were particularly striking, with respondents reporting that they were burdened both with costs directly related to the medical care of their condition, and with coping with ongoing general expenses on a reduced income. Many respondents reported depleting savings, borrowing money, taking out retirement funds, and declaring bankruptcy in efforts to cope. Emotionally, respondents almost universally reported their diagnosis and related issues were associated with depression, anxiety, and loss of identity and self-worth. This study demonstrates how a work-related injury or illness can extend far beyond the physical impact for injured workers. Existing systems fail to adequately compensate or rehabilitate injured workers, leaving them to their own devices to deal with their losses, medical or otherwise.

[Changes in the characteristics and incidence of multiple-injury accidents in the Navarre community over a 10-year period].

PubMed

Gradin Purroy, Carlos; Belzunegui Otano, Tomás; Bermejo Fraile, Begoña; Teijeira, Rafael; Fortún Moral, Mariano; Reyero Díez, Diego

2015-06-01

To compare morbidity and mortality rates, the epidemiologic profile, and survival of patients with multiple injuries attended by the emergency services in the Navarre autonomous community in Spain in the periods of 2002-2003 and 2010-2012. Observational analysis of 2 cohorts of accident patients with Injury Severity Scores of 15 points or more. Logistic regression was used to identify variables related to mortality. A total of 651 patients were attended in the first period; 626 were attended in the second. The annual multiple-injury incidence rate decreased from 58.1 per 100 000 population in the first period to 33.5 per 100 000 population in the second; mortality decreased from 30.3 to 15.3 per 100 000 population. The mean (SD) age was 45 (22) years in the first cohort and 52 (23) years in the second. The gender distribution (75% male) did not change. The percentage injured in traffic accidents decreased from 44% to 24%; the percentage of elderly patients hurt in falls increased from 9% to 26%. The problem of the number of young people injured in accidents in our community has been brought under control, but the proportion of older patients injured in falls has risen. This change may slow the effort to improve mortality rates in patients with multiple injuries and it obliges us to introduce measures to prevent falls in the elderly.

[Relevance of Vascular Trauma in Trauma Care - Impact on Clinical Course and Mortality].

PubMed

Lech, L; Jerkku, T; Kanz, K-G; Wierer, M; Mutschler, W; Koeppel, T A; Lefering, R; Banafsche, R

2016-10-01

There is a lack of evidence as to the relevance of vascular trauma (VT) in patients with severe injuries. Therefore, we reviewed registry data in the present study in order to systematically objectify the effect of VT in these patients. This study aimed to provide an adequate picture of the relevance of vascular trauma and to identify adverse prognostic factors. In a retrospective analysis of records from the TraumaRegister DGU® (TR-DGU) in two subgroups with moderate and severe VT, we examined the records for differences in terms of morbidity, mortality, follow-up and prognostic parameters compared to patients without VT with the same ISS. From a total of 42,326 patients, 2,961 (7 %) had a VT, and in 2,437 cases a severe VT (AIS ≥ 3) was diagnosed (5.8 %). In addition to a higher incidence of shock and a 2 to 3-fold increase in fluid replacement and erythrocyte transfusion, patients with severe VT had a 60 % higher rate of multiple organ failure, and in-hospital mortality was twice as high (33.8 %). The massively increased early mortality (8.0 vs. 25.2 %) clearly illustrates how severely injured patients are placed at risk by the presence of a relevant VT with a comparable ISS. In our opinion, due to an unexpected poor prognosis in the TR-DGU data for vascular injuries, increased attention is required in the care of severely injured patients. Based on our comprehensive analysis of negative prognostic factors, a further adjustment to the standards of vascular medicine could be advisable. The influence of the level of care provided by the admitting hospital and the relevance of a further hospital transfer to prognosis and clinical outcome is currently being analysed. Georg Thieme Verlag KG Stuttgart · New York.

Early ICU Standardized Rehabilitation Therapy for the Critically Injured Burn Patient

DTIC Science & Technology

2014-10-01

Therapy for the Critically Injured Burn Patient PRINCIPAL INVESTIGATOR: Peter E. Morris , MD...the Critically Injured Burn Patient 5b. GRANT NUMBER 6. AUTHOR(S) Morris , James Holmes, Brad Freeman, Bruce Cairns, Michael Berry, L Doug E-Mail...and has been submitted for publication appendix). a. 6 iii. Parry SM, EI-Ansary D, Berney S, Koopman R, Cartwright MS, Morris PE, Hilton A, Sarwal A

Risk factors associated with legal interventions.

PubMed

Holloway-Beth, Alfreda; Forst, Linda; Lippert, Julia; Brandt-Rauf, Sherry; Freels, Sally; Friedman, Lee

Current research regarding injuries caused during interactions between police officers and civilians is conducted intermittently or on a very narrow sample frame which provides very little clinical information about the injuries suffered or the adverse outcomes. The aim of this study is to identify comorbid risk factors and describe acute outcomes of medically treated traumatic injuries occurring as a result of contact with law enforcement personnel. For this retrospective study, patients injured as a result of contact with law enforcement personnel were identified using ICD-9 external cause of injury codes from medical record databases of patients treated in all hospitals and trauma units in Illinois between 2000 and 2009. A total of 836 cases injured as a result of contact with law enforcement personnel were identified. These patients were more likely to suffer from substance abuse, depression, schizophrenia, and paralytic disorders compared to the reference cases. Persons injured as a result of contact with law enforcement personnel were predominately injured from being man-handled, unarmed blows, firearms or being struck by a blunt object. Although the injury severity did not differ from the comparison group, these patients had longer lengths of hospitalization, a greater proportion of injuries to the back and spine, and a greater proportion required extended care in an intermediate care facility (not a jail) following discharge. Although medical record data do not explain the detailed circumstances of the face-to-face encounters between law enforcement personnel and civilians, the data provide valuable information regarding who may be at risk of injury and the clinical features of injuries that are suffered following a legal intervention. Similar data systems should be considered to augment existing data systems.

Risk factors associated with legal interventions.

PubMed

Holloway-Beth, Alfreda; Forst, Linda; Lippert, Julia; Brandt-Rauf, Sherry; Freels, Sally; Friedman, Lee

2016-12-01

Current research regarding injuries caused during interactions between police officers and civilians is conducted intermittently or on a very narrow sample frame which provides very little clinical information about the injuries suffered or the adverse outcomes. The aim of this study is to identify comorbid risk factors and describe acute outcomes of medically treated traumatic injuries occurring as a result of contact with law enforcement personnel. For this retrospective study, patients injured as a result of contact with law enforcement personnel were identified using ICD-9 external cause of injury codes from medical record databases of patients treated in all hospitals and trauma units in Illinois between 2000 and 2009. A total of 836 cases injured as a result of contact with law enforcement personnel were identified. These patients were more likely to suffer from substance abuse, depression, schizophrenia, and paralytic disorders compared to the reference cases. Persons injured as a result of contact with law enforcement personnel were predominately injured from being man-handled, unarmed blows, firearms or being struck by a blunt object. Although the injury severity did not differ from the comparison group, these patients had longer lengths of hospitalization, a greater proportion of injuries to the back and spine, and a greater proportion required extended care in an intermediate care facility (not a jail) following discharge. Although medical record data do not explain the detailed circumstances of the face-to-face encounters between law enforcement personnel and civilians, the data provide valuable information regarding who may be at risk of injury and the clinical features of injuries that are suffered following a legal intervention. Similar data systems should be considered to augment existing data systems.

All-terrain vehicles and associated spinal injuries.

PubMed

Sanfilippo, James A; Winegar, Corbett D; Harrop, James S; Albert, Todd J; Vaccaro, Alexander R

2008-08-15

Case cohort. To illuminate factors associated with all-terrain vehicle (ATV) injuries and injury morphology. Traditionally thought of as safe, injuries associated with ATVs can be severe and life threatening. In 2005 alone, the US Consumer Product Safety Commission estimated 136,100 injuries and 767 deaths associated with ATVs use and misuse. A database of all spine related consults from one institution was reviewed and all patients with spine or spinal cord injuries associated with ATV use were identified. All pertinent demographic, clinical, and radiographic information were collected and analyzed. Thirty-six patients were identified from the spinal cord injury database. The male:female ratio was 11:1 of the ATV injured patient. This is statistically different from the general database population, with a males representing 70% of patients (P < 0.002). The average ATV injured patient was 13.7 years younger than the average database patient (P < 0.001). The incidence of an axial compression or burst type fracture morphology was significantly higher in the ATV injured patient population (50%) compared with the database population as a whole (12%). Factors predisposing patients to injury on ATVs include excessive speed, use of alcohol or controlled substances, use of machinery after dark, and inexperience. All-terrain vehicles (ATVs) are currently experiencing enormous popularity in the United States. These recreational vehicles are associated with a higher incidence of axial compression and burst-type fracture morphologies. In general, all-terrain vehicles although highly dangerous leading to death or serious injury can be fun, enjoyable, and safe if proper regulations and safety precautions are implemented and followed.

Which future for traumatology in Europe?

PubMed

Rommens, P M

2014-01-01

The last decades have been characterized by rapid changes in society, medicine and surgery. There is a distinct evolution towards specialization and super-specialization. Trauma surgery also evolves towards a specialty, focused on the care of the injured. To optimize the quality of care and meet the needs of patients and care providers, a well-structured trauma surgery training program as well as the regionalization of trauma care with the implementation of Level I trauma centers are needed. The core competence of the European trauma surgeon is the coordination of the early management of the severely injured and the treatment of muskuloskeletal trauma, which represent the most common pathologies in our countries.

Development in pain and neurologic complaints after whiplash: a 1-year prospective study.

PubMed

Kasch, Helge; Bach, Flemming W; Stengaard-Pedersen, Kristian; Jensen, Troels S

2003-03-11

To prospectively examine the course of pain and other neurologic complaints in patients with acute whiplash injury and in controls with acute ankle injury. Patients with acute whiplash (n = 141) and ankle-injured controls (n = 40) were consecutively sampled, and underwent interview and examination after 1 week and 1, 3, 6, and 12 months. Outcome measures were pain intensity, pain frequency, and associated symptoms. Initial overall pain intensity above lower extremities (pain in neck, head, shoulder-arm, and low back) was similar in patients with whiplash (median Visual Analogue Scale [VAS](0-100) of 20 [25th and 75th percentile, 4, 39]) and ankle-injured controls (median VAS(0-100) of 15 [5, 34]). Whiplash-injured patients reported median overall VAS(0-100) pain intensity above lower extremities of 23 (12, 40) after 11 days and 14 (12, 40) after 1 year. Controls reported pain intensity of 0 (0, 4) after 12 days and 0 (0, 9) after 1 year. Reported overall pain frequency above lower extremities was 96% after 11 days and 74% after 1 year in whiplash-injured patients and 33% after 12 days and 47% after 1 year in controls. Associated neurologic symptoms were two to three times more common after whiplash injury. Correlation was found between pain intensity and associated symptoms in whiplash-injured patients but not controls. Pain occurs with high frequency but low intensity after whiplash and ankle injury. Associated neurologic symptoms were not correlated to pain in ankle-injured controls, but were correlated to pain in patients with whiplash injury. Persistent symptoms in whiplash-injured patients may be caused by both specific neck injury-related factors and nonspecific post-traumatic reactions. Disability was only encountered in the whiplash group.

Optimizing cerebral perfusion pressure during fiberoptic bronchoscopy in severe head injury: effect of hyperventilation.

PubMed

Previgliano, I J; Ripoll, P I; Chiappero, G; Galíndez, F; Germani, L; González, D H; Ferrari, N; Hlavnicka, A; Purvis, C

2002-01-01

The aim of this study was to evaluate if Hyperventilation (HV) could avoid the Intracranial Pressure (ICP) peak that occurs during Fiberoptic Bronchoscopy (FB) in severely head injured patients. A Cerebral Perfusion Pressure (CPP) > 75 mmHg was maintained in 34 patients, with a subgroup randomized to receive controlled HV during FB. Measurements were done before the procedure, during maximum ICP values and 30 minutes after FB. The HV group had minor ICP values after FB, without differences in CPP and ICP peak values.

Differences in kinematics of single leg squatting between anterior cruciate ligament-injured patients and healthy controls.

PubMed

Yamazaki, J; Muneta, T; Ju, Y J; Sekiya, I

2010-01-01

Seventy to eighty percent of all anterior cruciate ligament (ACL) injuries are due to non-contact injury mechanisms. It has been reported that the majority of injuries due to single leg landing come from valgus positioning of the lower leg. Preventing valgus positioning during single leg landing is expected to help reduce the number of ACL injuries. We found that many ACL-deficient patients cannot perform stable single leg squatting. Therefore, we performed 3D motion analysis of the single-legged half squat for ACL-injured patients to evaluate its significance as a risk factor for ACL injuries. We evaluated the relative angles between the body, thigh, and lower leg using an electromagnetic device during single leg half squatting performed by 63 ACL-injured patients (32 males, 31 females) the day before ACL reconstruction and by 26 healthy control subjects with no knee problems. The uninjured leg of ACL-injured male subjects demonstrated significantly less external knee rotation than that of the dominant leg of the male control. The uninjured leg of ACL-injured female subjects demonstrated significantly more external hip rotation and knee flexion and less hip flexion than that of the dominant leg of the female control. Comparing injured and uninjured legs, the injured leg of male subjects demonstrated significantly less external knee and hip rotation, less knee flexion, and more knee varus than that of the uninjured leg of male subjects. The injured leg of female subjects demonstrated more knee varus than that of the uninjured leg of female subjects. Regarding gender differences, female subjects demonstrated significantly more external hip rotation and knee valgus than male subjects did in both the injured and uninjured legs (P < 0.05). The current kinematic study exhibited biomechanical characteristics of female ACL-injured subjects compared with that of control groups. Kinematic correction during single leg half squat would reduce ACL reinjury in female ACL-injured subjects.

Keep the brain cool--endovascular cooling in patients with severe traumatic brain injury: a case series study.

PubMed

Fischer, Marlene; Lackner, Peter; Beer, Ronny; Helbok, Raimund; Klien, Stephanie; Ulmer, Hanno; Pfausler, Bettina; Schmutzhard, Erich; Broessner, Gregor

2011-04-01

As brain temperature is reported to be extensively higher than core body temperature in traumatic brain injury (TBI) patients, posttraumatic hyperthermia is of particular relevance in the injured brain. To study the influence of prophylactic normothermia on brain temperature and the temperature gradient between brain and core body in patients with severe TBI using an intravascular cooling system and to assess the relationship between brain temperature and intracranial pressure (ICP) under endovascular temperature control. Prospective case series study conducted in the neurologic intensive care unit of a tertiary care university hospital. Seven patients with severe TBI with a Glasgow Coma Scale score of 8 or less were consecutively enrolled. Prophylactic normothermia, defined as a target temperature of 36.5°C, was maintained using an intravascular cooling system. Simultaneous measurements of brain and urinary bladder temperature and ICP were taken over a 72-hour period. The mean bladder temperature in normothermic patients was 36.3 ± 0.4°C, and the mean brain temperature was determined as 36.4 ± 0.5°C. The mean temperature difference between brain and bladder was 0.1°C. We found a significant direct correlation between brain and bladder temperature (r = 0.95). In 52.4% of all measurements, brain temperature was higher than core body temperature. The mean ICP was 18 ± 8 mm Hg. Intravascular temperature management stabilizes both brain and body core temperature; prophylactic normothermia reduces the otherwise extreme increase of intracerebral temperature in patients with severe TBI. The intravascular cooling management proved to be an efficacious and feasible method to control brain temperature and to avoid hyperthermia in the injured brain. We could not find a statistically significant correlation between brain temperature and ICP.

Validation of the FASH (Functional Assessment Scale for Acute Hamstring Injuries) questionnaire for German-speaking football players.

PubMed

Lohrer, Heinz; Nauck, Tanja; Korakakis, Vasileios; Malliaropoulos, Nikos

2016-10-24

The FASH (Functional Assessment Scale for Acute Hamstring Injuries) questionnaire has been recently developed as a disease-specific self-administered questionnaire for use in Greek, English, and German languages. Its psychometric qualities (validity and reliability) were tested only in Greek-speaking patients mainly representing track and field athletes. As hamstring injuries represent the most common football injury, we tested the validity and reliability of the FASH-G (G = German version) questionnaire in German-speaking footballers suffering from acute hamstring injuries. The FASH-G questionnaire was tested for reliability and validity, in 16 footballers with hamstring injuries (patients' group), 77 asymptomatic footballers (healthy group), and 19 field hockey players (at-risk group). Known-group validity was tested by comparing the total FASH-G scores of the injured and non-injured groups. Reliability of the FASH-G questionnaire was analysed in 18 asymptomatic footballers using the intra-class coefficient. Known-group validity was demonstrated by significant differences between injured and non-injured participants (p < 0.001). The FASH-G exhibited very good test-retest reliability (intra-class correlation coefficient = 0.982, p < 0.001). Internal consistency was excellent (α = 0.938). Compared with the results presented in the original publication, no statistical differences were found between healthy athletes (p = 0.257), but patients' groups and at-risk groups presented scoring differences (p = 0.040 and <0.001, respectively). The FASH-G is a valid and reliable instrument to assess and determine the severity of hamstring injuries in German footballers.

Severe Trauma Stress Inoculation Training for Combat Medics using High Fidelity Simulation

DTIC Science & Technology

2013-12-01

why several programs have been developed to introduce TC3 principles to military medical providers (Physician Assistants (PA), nurses , and doctors... Practitioner and senior medical Non~Commissioned Officer (NCO) a practical working knowledge of how to deal with the injured patient in a combat...environment and under simulated battlefield conditions. TCMC, on the other hand, provides the Physician Assistant, Physician, Nurse Practitioner and senior

Emerging technologies for pediatric and adult trauma care.

PubMed

Moulton, Steven L; Haley-Andrews, Stephanie; Mulligan, Jane

2010-06-01

Current Emergency Medical Service protocols rely on provider-directed care for evaluation, management and triage of injured patients from the field to a trauma center. New methods to quickly diagnose, support and coordinate the movement of trauma patients from the field to the most appropriate trauma center are in development. These methods will enhance trauma care and promote trauma system development. Recent advances in machine learning, statistical methods, device integration and wireless communication are giving rise to new methods for vital sign data analysis and a new generation of transport monitors. These monitors will collect and synchronize exponentially growing amounts of vital sign data with electronic patient care information. The application of advanced statistical methods to these complex clinical data sets has the potential to reveal many important physiological relationships and treatment effects. Several emerging technologies are converging to yield a new generation of smart sensors and tightly integrated transport monitors. These technologies will assist prehospital providers in quickly identifying and triaging the most severely injured children and adults to the most appropriate trauma centers. They will enable the development of real-time clinical support systems of increasing complexity, able to provide timelier, more cost-effective, autonomous care.

Onset of Coagulation Function Recovery Is Delayed in Severely Injured Trauma Patients with Venous Thromboembolism.

PubMed

McCully, Belinda H; Connelly, Christopher R; Fair, Kelly A; Holcomb, John B; Fox, Erin E; Wade, Charles E; Bulger, Eileen M; Schreiber, Martin A

2017-07-01

Altered coagulation function after trauma can contribute to development of venous thromboembolism (VTE). Severe trauma impairs coagulation function, but the trajectory for recovery is not known. We hypothesized that enhanced, early recovery of coagulation function increases VTE risk in severely injured trauma patients. Secondary analysis was performed on data from the Pragmatic Randomized Optimal Platelet and Plasma Ratio (PROPPR) trial, excluding patients who died within 24 hours or were on pre-injury anticoagulants. Patient characteristics, adverse outcomes, and parameters of platelet function and coagulation (thromboelastography) were compared from admission to 72 hours between VTE (n = 83) and non-VTE (n = 475) patients. A p value < 0.05 indicates significance. Despite similar patient demographics, VTE patients exhibited hypercoagulable thromboelastography parameters and enhanced platelet function at admission (p < 0.05). Both groups exhibited hypocoagulable thromboelastography parameters, platelet dysfunction, and suppressed clot lysis (low clot lysis at 30 minutes) 2 hours after admission (p < 0.05). The VTE patients exhibited delayed coagulation recovery (a significant change compared with 2 hours) of K-value (48 vs 24 hours), α-angle (no recovery), maximum amplitude (24 vs 12 hours), and clot lysis at 30 minutes (48 vs 12 hours). Platelet function recovery mediated by arachidonic acid (72 vs 4 hours), ADP (72 vs 12 hours), and collagen (48 vs 12 hours) was delayed in VTE patients. The VTE patients had lower mortality (4% vs 13%; p < 0.05), but fewer hospital-free days (0 days [interquartile range 0 to 8 days] vs 10 days [interquartile range 0 to 20 days]; p < 0.05) and higher complication rates (p < 0.05). Recovery from platelet dysfunction and coagulopathy after severe trauma were delayed in VTE patients. Suppressed clot lysis and compensatory mechanisms associated with altered coagulation that can potentiate VTE formation require additional investigation. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Performance of International Classification of Diseases-based injury severity measures used to predict in-hospital mortality and intensive care admission among traumatic brain-injured patients.

PubMed

Gagné, Mathieu; Moore, Lynne; Sirois, Marie-Josée; Simard, Marc; Beaudoin, Claudia; Kuimi, Brice Lionel Batomen

2017-02-01

The International Classification of Diseases (ICD) is the main classification system used for population-based traumatic brain injury (TBI) surveillance activities but does not contain direct information on injury severity. International Classification of Diseases-based injury severity measures can be empirically derived or mapped to the Abbreviated Injury Scale, but no single approach has been formally recommended for TBI. The aim of this study was to compare the accuracy of different ICD-based injury severity measures for predicting in-hospital mortality and intensive care unit (ICU) admission in TBI patients. We conducted a population-based retrospective cohort study. We identified all patients 16 years or older with a TBI diagnosis who received acute care between April 1, 2006, and March 31, 2013, from the Quebec Hospital Discharge Database. The accuracy of five ICD-based injury severity measures for predicting mortality and ICU admission was compared using measures of discrimination (area under the receiver operating characteristic curve [AUC]) and calibration (calibration plot and the Hosmer-Lemeshow goodness-of-fit statistic). Of 31,087 traumatic brain-injured patients in the study population, 9.0% died in hospital, and 34.4% were admitted to the ICU. Among ICD-based severity measures that were assessed, the multiplied derivative of ICD-based Injury Severity Score (ICISS-Multiplicative) demonstrated the best discriminative ability for predicting in-hospital mortality (AUC, 0.858; 95% confidence interval, 0.852-0.864) and ICU admissions (AUC, 0.813; 95% confidence interval, 0.808-0.818). Calibration assessments showed good agreement between observed and predicted in-hospital mortality for ICISS measures. All severity measures presented high agreement between observed and expected probabilities of ICU admission for all deciles of risk. The ICD-based injury severity measures can be used to accurately predict in-hospital mortality and ICU admission in TBI patients. The ICISS-Multiplicative generally outperformed other ICD-based injury severity measures and should be preferred to control for differences in baseline characteristics between TBI patients in surveillance activities or injury research when only ICD codes are available. Prognostic study, level III.

Imaging features of blast injuries: experience from 2015 Ankara bombing in Turkey

PubMed Central

Aksu, Nalan M

2016-01-01

Objective: To present the radiological features of blast-related injuries in the victims of the 10 October 2015 Ankara bombing and emphasize the importance of imaging. Methods: This retrospective descriptive study included a total of 28 patients who underwent CT scan or radiographic imaging within 6 h after the bombing on 10 October 2015. CT scans and plain radiographs were evaluated regarding mechanisms of injuries. Injuries were categorized as primary, secondary, tertiary and quaternary. The number of shrapnel and distribution of injuries were noted. Injury Severity Score (ISS) was used to rank the severity of the injury. Results: Primary blast injuries consisted of only tympanic membrane rupture. A high rate of patients (21/28 patients) in the study group suffered from secondary blast injuries. Tertiary injuries were detected in only three patients. Of the severely injured patients, five had abdominal injuries, three had thoracic injuries and six had extremity injuries. ISS was significantly higher in patients with thoracic and abdominal injuries. Conclusion: Our results after the suicide bomb attacks showed that the most common injury pattern was secondary blast injury. The torso was the most commonly injured body region, followed by the extremities. This specific injury pattern requires the use of immense radiological imaging. Hence, radiologists should be aware of the mechanisms and spectrums of blast-related injuries. Advances in knowledge: Both the unique injury pattern and the following chaos make blast-related injuries a challenge in terms of triage, diagnosis and management. Radiologists should be familiar with the wide spectrum of these unique injuries. PMID:26959613

A cross-sectional community study of post-traumatic stress disorder and social support in Lao People's Democratic Republic

PubMed Central

Southivong, Bouavanh; Nakahara, Shinji; Southivong, Chanhpheng

2013-01-01

Abstract Objective To estimate post-traumatic stress disorder (PTSD) symptoms in those injured and not injured by landmines or unexploded ordnance (UXO) in rural Lao People's Democratic Republic and to determine whether the perception of social support was associated with PTSD symptom severity. Methods A community survey was conducted among 190 people injured by landmines or UXO and 380 age-, sex- and neighbourhood-matched non-injured individuals in the Sepone district of Savannakhet Province, the part of the Lao People's Democratic Republic most heavily bombed during the Viet Nam War. Using the Harvard Trauma Questionnaire and the Medical Outcomes Study Social Support Survey, trained health-care workers conducted face-to-face interviews to assess PTSD symptoms and level of perceived social support. Multiple linear regression was performed to explore the association between social support and other factors and PTSD. Findings The prevalence of PTSD was higher among the injured (10%) than among the non-injured (4%), but the level of perceived social support was not significantly different between the two groups. A higher level of perceived social support was associated with milder symptoms of PTSD. Women, older people and those with a formal education were more often and more severely affected by PTSD. Conclusion The perception of strong social support might help to alleviate the symptoms of PTSD among people injured by landmines or UXO in rural parts of the Lao People's Democratic Republic. Psychosocial interventions should be incorporated in assistance for the injured because they have more severe and longer-lasting symptoms of PTSD than the non-injured. PMID:24115800

Use of recombinant factor VIIA for control of combat-related haemorrhage.

PubMed

Woodruff, Susan I; Dougherty, Amber L; Dye, Judy L; Mohrle, Charlene R; Galarneau, Michael R

2010-02-01

Recombinant activated human coagulation factor VII (rFVIIa), an intravascular strategy to promote clotting, is being used as an adjunct to surgical control of bleeding in combat trauma patients. To describe the initial experiences with rFVIIa administered to combat casualties at US Navy-Marine Corps medical treatment facilities in Iraq, and to compare survival outcomes of those treated with rFVIIa to controls not receiving rFVIIa. Medical encounter data from the US Navy-Marine Corps Combat Trauma Registry were retrospectively reviewed to identify all battle-injured patients documented as having received rFVIIa during the period May 2004 to January 2006 of Operation Iraqi Freedom. Available clinical and injury related data are presented to characterise the patients. To assess effects of rFVIIa on survival outcomes, rFVIIa cases were matched to controls on injury severity and age. 22 battle-injured patients from the Combat Trauma Registry received rFVIIa. Primarily young US Marines, these patients typically had penetrating injuries from improvised explosive devices and gunshot wounds. Injuries were often abdominal. The average dose used was similar to that reported in another study of civilian trauma patients, although dosing varies widely in the existing experimental and anecdotal literature. Over two-thirds (68%) of the rFVIIa patients survived-an identical outcome seen for a matched control group of 22 patients. Survival of seriously injured combat casualties was good, although identical to that of a control group. Methodological limitations of this retrospective study preclude making firm conclusions about the effectiveness of rFVIIa. Future controlled studies are needed for safety and efficacy testing of rFVIIa in combat trauma patients.

Damage Control Resuscitation: A New Paradigm for Fluid Resuscitation of Severely Injured Soldiers

DTIC Science & Technology

2006-11-01

Chughtai , 2006). Its use in treating hemorrhaging trauma patients is attractive because it offers a site-specific therapy for controlling...L., 2006: The use of fresh whole blood in massive transfusion. J Trauma, 60, S59- 69. Rizoli, S. B. and Chughtai , T., 2006: The emerging role of

Evaluation of electrical aversion therapy for inappropriate sexual behaviour after traumatic brain injury: a single case experimental design study

PubMed Central

ter Mors, Bert Jan; van Heugten, Caroline M; van Harten, Peter N

2012-01-01

Inappropriate sexual behaviour after acquired brain injury is a severe complication. Evidence for effective treatment is not available. Electrical aversion therapy (EAT) is a behavioural therapeutic option used in persons with intellectual disabilities, which might be suitable for brain-injured individuals for whom other therapies are not effective. The effect of EAT in brain injury has not been investigated previously. A single case experimental design was used. In an ABBA (baseline-treatment-treatment-withdrawal) design the frequency of the target behaviour (ie, inappropriate sexual behaviour) in a 40-year-old man was measured daily. A total of 551 measurements were recorded. A significant reduction of the target behaviour was seen after the first treatment phase (baseline 12.18 (2.59) vs 3.15 (3.19) mean target behaviours daily); this reduction remained stable over time. We conclude that EAT was effective in this patient with inappropriate sexual behaviour due to severe brain injury. EAT can therefore be considered in therapy resistant inappropriate sexual behaviour in brain-injured patients. PMID:22922913

Evaluation of electrical aversion therapy for inappropriate sexual behaviour after traumatic brain injury: a single case experimental design study.

PubMed

Ter Mors, Bert Jan; van Heugten, Caroline M; van Harten, Peter N

2012-08-24

Inappropriate sexual behaviour after acquired brain injury is a severe complication. Evidence for effective treatment is not available. Electrical aversion therapy (EAT) is a behavioural therapeutic option used in persons with intellectual disabilities, which might be suitable for brain-injured individuals for whom other therapies are not effective. The effect of EAT in brain injury has not been investigated previously. A single case experimental design was used. In an ABBA (baseline-treatment-treatment-withdrawal) design the frequency of the target behaviour (ie, inappropriate sexual behaviour) in a 40-year-old man was measured daily. A total of 551 measurements were recorded. A significant reduction of the target behaviour was seen after the first treatment phase (baseline 12.18 (2.59) vs 3.15 (3.19) mean target behaviours daily); this reduction remained stable over time. We conclude that EAT was effective in this patient with inappropriate sexual behaviour due to severe brain injury. EAT can therefore be considered in therapy resistant inappropriate sexual behaviour in brain-injured patients.

Lessons of War: Combat-related Injury Infections during the Vietnam War and Operation Iraqi and Enduring Freedom

PubMed Central

Blyth, Dana M.; Yun, Heather C.; Tribble, David R.; Murray, Clinton K.

2015-01-01

Summary In over a decade of war, numerous advancements have been made to improve overall combat-related mortality, but infectious complications remain a leading cause of both morbidity and mortality in combat-related injured personnel. Here we will attempt to compare the challenges and lessons of combat-related injuries and infections from the Vietnam War with those of OIF/OEF. Throughout the Vietnam War and OIF/OEF, there have been similar infection-related challenges faced in caring for combat-related trauma patients. Both conflicts reinforced the importance of rapid medical evacuation and definitive surgical management of war wounds. They revealed the constant evolution of infecting organisms and the challenge of increasing antimicrobial resistance. We have also seen that with decreased mortality of severely injured personnel new morbidities must be addressed. Using the foundation of fragmented research from the Vietnam War, previously successful models were assembled into joint service research institutions which have allowed these questions to be addressed. However, many questions regarding measures to reduce infectious complications in our combat-injured personnel remain unanswered. Continued research building on established knowledge is critical for continued improvements in the care of combat-related trauma patients. PMID:26406435

[Principles of management of high-energy injuries of the leg].

PubMed

Jovanović, Mladen; Janjić, Zlata; Marić, Dusan

2002-01-01

High-energy traumas are open or closed injuries caused by force (missile, traffic injuries, crush or blust injuries, falling from heights), affecting the body surface and transferring high amount of kinetic energy inducing great damage to the tissue. Management of such lower extremity injuries has evolved over past several decades, but still remains a difficult task for every surgical team. Specific anatomic and functional characteristics combined with extensive injuries demands specific treatment protocols. In a multiple injured patient the first priority is management of life-threatening trauma. Despite other injuries, surgical treatment of limb-threatening injuries must start as soon as life-threatening condition has been managed. Algorithms are especially beneficial in management of severely injured, but salvageable extremities and in making decision on amputation. Insight into mechanisms of injury, as well as systematic examination of the affected limb, should help us understand the extensiveness of trauma and make an adequate management plan. Prevention of wound infection and surgical approach to high-energy limb trauma, which includes wound extension, wound excision, skeletal stabilization and if necessary muscle compartment release, should be done in the first 6 hours after injury. Commonly used methods for soft tissue defects must provide wound coverage in less than five days following injury. Early passive and active mobilization and verticalization of patients is very important for successful treatment. Good and timely evaluation of the injured and collaboration between plastic and orthopaedic surgeons from the beginning of treatment, are crucial for final outcome.

[Use of ECMO (extracorporeal membrane oxygenation) in a traumatic brain injured patient with severe hypoxemia].

PubMed

Menut, R; Larrieu, N; Conil, J-M; Georges, B; Fourcade, O; Geeraerts, T

2013-10-01

Traumatic brain injuries are fairly sensitive to hypoxia. For patient with associated lung and brain traumas, different means used to improve oxygen blood level are poorly described. We report the use of ECMO in a refractory hypoxemia occurred to a multitrauma young patient with neurological lesions. Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

Terror management and attributions of blame to innocent victims: reconciling compassionate and defensive responses.

PubMed

Hirschberger, Gilad

2006-11-01

In this article, 4 studies test the hypothesis that reminders of personal death bias the normative attribution process and increase the motivation to blame severely injured, innocent victims. In Studies 1 and 2, primes of death led to greater attributions of blame to severely injured victims but did not significantly influence attributions of blame to either mildly injured victims or negatively portrayed others. In Study 3, primes of death led to greater attributions of blame to victims of circumstance but did not influence attributions of blame to victims who were explicitly responsible for their condition. In Study 4, innocent victims who were severely injured elicited more death-related cognitions than did victims who were responsible for their condition or who were only mildly injured. These findings indicate that the predictions of normative models of attribution may be moderated, and even overturned, when observers are reminded of their personal death such that defensive needs override rational inferential processes.

[Rehabilitation in the German statutory accident insurance. Guide to the new outpatient and inpatient structures].

PubMed

Simmel, S; Bühren, V

2015-02-01

The German statutory accident insurance (DGUV) has the statutory mandate to eliminate or to prevent an aggravation of the consequences of accidents by all appropriate means and is based on the principle of rehabilitation before pension. For this, special methods have been developed in recent decades, such as employer's mutual insurance inpatient further treatment (BGSW, Berufsgenossenschaftliche Stationäre Weiterbehandlung) and extended outpatient physiotherapy (EAP, Erweiterte Ambulante Physiotherapie). In 2012 the workplace-related musculoskeletal rehabilitation (ABMR, Arbeitsplatz-bezogene muskuloskelettale Rehabilitation) was added to these complex treatments. For complex injuries and delayed healing these methods approach their limits. The accident clinics of the Association of Clinics in Statutory Accident Insurance (KUV, Klinikverbund der gesetzlichen Unfallversicherung) provide a number of specialized rehabilitation measures in order to ensure an optimal seamless rehabilitation of the severely injured. In addition to complex inpatient rehabilitation (KSR, Komplexe Stationäre Rehabilitation) integrated special rehabilitation procedures, such as neurorehabilitation for severely traumatic brain injured patients and rehabilitation after spinal cord injury and other special rehabilitation methods, such as occupation-oriented rehabilitation (TOR, Tätigkeitsorientierte Rehabilitation) and pain rehabilitation, ensure that the German Society for Trauma Surgery (DGU) phase model of trauma rehabilitation is implemented. This provides an early start in the context of acute treatment as so-called early rehabilitation. After a specialized post-acute rehabilitation, additional therapeutic options are often required. An appropriate treatment of severely injured patients is important, for example through rehabilitation managers, which must not end with discharge from the rehabilitation hospital. The aim of all efforts is the reintegration into the working and social environment in addition to the best possible quality of life.

The Effects of Pediatric Advanced Life Support Guidelines on Pediatric Trauma Airway Management.

PubMed

Sperka, Jana; Hanson, Sheila J; Hoffmann, Raymond G; Dasgupta, Mahua; Meyer, Michael T

2016-08-01

Recent Pediatric Advanced Life Support (PALS) guidelines have deemphasized the use of advanced airways in short transport. It is unclear if guideline recommendations have altered practice. We sought to determine if a temporal change exists in the number of prehospital pediatric trauma intubations since the 2005 PALS guidelines update. This is an institutional review board-approved, retrospective, single-center study. Reviewed all pediatric trauma activations where patients younger than 19 years were intubated at the scene, en route or at the level 1 trauma center during 2006 to 2011. Specific complications collected were esophageal intubations, mainstem intubations and need for re-intubations. There were 1012 trauma activations, 1009 pediatric patients, 300 (29.7%) intubated during transport to Children's Hospital of Wisconsin Pediatric Trauma Center (PTC) or upon arrival. Mean age of 9.5 ± 5.9 years. Fifty-seven percent (n = 172) were intubated before PTC, 31.7% (n = 95) field intubations, 25.7% (n = 77) outside facility intubations. 44% (n = 132) at PTC. Age was not a significant variable. There was no difference in the proportion of injured children requiring intubation who were intubated before arrival to the PTC. Those intubated in the field versus a facility had significantly increased mortality (P = 0.0002), longer hospital days (P = 0.0004) including intensive care unit days (P = 0.0003) and ventilator days (P = 0.0003) even when adjusted for illness severity. There was no significant change in the proportion of pretrauma room intubations following the 2005 PALS guidelines even when adjusted for illness or injury severity. Children injured farther from the PTC and more severely injured children were more likely to be intubated before arrival at the PTC.

Direct medical costs of motorcycle crashes in Ontario

PubMed Central

Pincus, Daniel; Wasserstein, David; Nathens, Avery B.; Bai, Yu Qing; Redelmeier, Donald A.; Wodchis, Walter P.

2017-01-01

BACKGROUND: There is no reliable estimate of costs incurred by motorcycle crashes. Our objective was to calculate the direct costs of all publicly funded medical care provided to individuals after motorcycle crashes compared with automobile crashes. METHODS: We conducted a population-based, matched cohort study of adults in Ontario who presented to hospital because of a motorcycle or automobile crash from 2007 through 2013. For each case, we identified 1 control absent a motor vehicle crash during the study period. Direct costs for each case and control were estimated in 2013 Canadian dollars from the payer perspective using methodology that links health care use to individuals over time. We calculated costs attributable to motorcycle and automobile crashes within 2 years using a difference-in-differences approach. RESULTS: We identified 26 831 patients injured in motorcycle crashes and 281 826 injured in automobile crashes. Mean costs attributable to motorcycle and automobile crashes were $5825 and $2995, respectively (p < 0.001). The rate of injury was triple for motorcycle crashes compared with automobile crashes (2194 injured annually/100 000 registered motorcycles v. 718 injured annually/100 000 registered automobiles; incidence rate ratio [IRR] 3.1, 95% confidence interval [CI] 2.8 to 3.3, p < 0.001). Severe injuries, defined as those with an Abbreviated Injury Scale ≥ 3, were 10 times greater (125 severe injuries annually/100 000 registered motorcycles v. 12 severe injuries annually/100 000 registered automobiles; IRR 10.4, 95% CI 8.3 to 13.1, p < 0.001). INTERPRETATION: Considering both the attributable cost and higher rate of injury, we found that each registered motorcycle in Ontario costs the public health care system 6 times the amount of each registered automobile. Medical costs may provide an additional incentive to improve motorcycle safety. PMID:29158454

Acute bilateral leg amputation following combat injury in UK servicemen.

PubMed

Penn-Barwell, J G; Bennett, P M; Kay, A; Sargeant, I D

2014-07-01

This study aims to characterise the injuries and surgical management of British servicemen sustaining bilateral lower limb amputations. The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained between March 2004 and March 2010. Amputations were excluded if they occurred more than 7 days after injury or if they were at the ankle or more distal. There were 1694 UK military patients injured or killed during this six-year study period. Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All casualties were men with a mean age of 25.1 years (SD 4.3): all were injured in Afghanistan by Improvised Explosive Devices (IEDs). Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score (NISS) was 48.2 (SD 13.2): four patients had a maximum score of 75. The mean TRISS probability of survival was 60% (SD 39.4), with 18 having a survival probability of less than 50% i.e. unexpected survivors. The most common amputation pattern was bilateral trans-femoral (TF) amputations, which was seen in 25 patients (58%). Nine patients also lost an upper limb (triple amputation): no patients survived loss of all four limbs. In retained upper limbs extensive injuries to the hands and forearms were common, including loss of digits. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD 41.7). The maximum transfusion was 12 units of platelets, 94 packed red cells, 8 cryoprecipitate, 76 units of fresh frozen plasma and 3 units of fresh whole blood, a total of 193 units of blood products. Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

The trauma ecosystem: The impact and economics of new trauma centers on a mature statewide trauma system.

PubMed

Ciesla, David J; Pracht, Etienne E; Leitz, Pablo T; Spain, David A; Staudenmayer, Kristan L; Tepas, Joseph J

2017-06-01

Florida serves as a model for the study of trauma system performance. Between 2010 and 2104, 5 new trauma centers were opened alongside 20 existing centers. The purpose of this study was to explore the impact of trauma system expansion on system triage performance and trauma center patients' profiles. A statewide data set was queried for all injury-related discharges from adult acute care hospitals using International Classification of Diseases, Ninth Revision (ICD-9) codes for 2010 and 2014. The data set, inclusion criteria, and definitions of high-risk injury were chosen to match those used by the Florida Department of Health in its trauma registry. Hospitals were classified as existing Level I (E1) or Level II (E2) trauma centers and new E2 (N2) centers. Five N2 centers were established 11.6 to 85.3 miles from existing centers. Field and overall trauma system triage of high-risk patients was less accurate with increased overtriage and no change in undertriage. Annual volume at N2 centers increased but did not change at E1 and E2 centers. In 2014, Patients at E1 and E2 centers were slightly older and less severely injured, while those at N2 centers were substantially younger and more severely injured than in 2010. The injured patient-payer mix changed with a decrease in self-pay and commercial patients and an increase in government-sponsored patients at E1 and E2 centers and an increase in self-pay and commercial patients with a decrease in government-sponsored patients at N2 centers. Designation of new trauma centers in a mature system was associated with a change in established trauma center demographics and economics without an improvement in trauma system triage performance. These findings suggest that the health of an entire trauma system network must be considered in the design and implementation of a regional trauma system. Therapeutic/care management study, level IV; epidemiological, level IV.

Personality change following head injury: assessment with the NEO Five-Factor Inventory.

PubMed

Lannoo, E; de Deyne, C; Colardyn, F; de Soete, G; Jannes, C

1997-11-01

We evaluated personality change following head injury in 68 patients at 6 months postinjury using the NEO Five-Factor Inventory to assess the five personality dimensions of the Five-Factor Model of Personality. All items had to be rated twice, once for the preinjury and once for the current status. Twenty-eight trauma patients with injuries to other parts of the body than the head were used as controls. For the head-injured group, 63 relatives also completed the questionnaire. The results showed no differences between the ratings of head-injured patients and the ratings of trauma control patients. Both groups showed significant change in the personality dimensions Neuroticism, Extraversion, and Conscientiousness. Compared to their relatives, head-injured patients report a smaller change in Extraversion and Conscientiousness. Changes were not reported on the Openness and Agreeableness scales, by neither the head-injured or their relatives, nor by the trauma controls.

An independent SSVEP-based brain-computer interface in locked-in syndrome.

PubMed

Lesenfants, D; Habbal, D; Lugo, Z; Lebeau, M; Horki, P; Amico, E; Pokorny, C; Gómez, F; Soddu, A; Müller-Putz, G; Laureys, S; Noirhomme, Q

2014-06-01

Steady-state visually evoked potential (SSVEP)-based brain-computer interfaces (BCIs) allow healthy subjects to communicate. However, their dependence on gaze control prevents their use with severely disabled patients. Gaze-independent SSVEP-BCIs have been designed but have shown a drop in accuracy and have not been tested in brain-injured patients. In the present paper, we propose a novel independent SSVEP-BCI based on covert attention with an improved classification rate. We study the influence of feature extraction algorithms and the number of harmonics. Finally, we test online communication on healthy volunteers and patients with locked-in syndrome (LIS). Twenty-four healthy subjects and six LIS patients participated in this study. An independent covert two-class SSVEP paradigm was used with a newly developed portable light emitting diode-based 'interlaced squares' stimulation pattern. Mean offline and online accuracies on healthy subjects were respectively 85 ± 2% and 74 ± 13%, with eight out of twelve subjects succeeding to communicate efficiently with 80 ± 9% accuracy. Two out of six LIS patients reached an offline accuracy above the chance level, illustrating a response to a command. One out of four LIS patients could communicate online. We have demonstrated the feasibility of online communication with a covert SSVEP paradigm that is truly independent of all neuromuscular functions. The potential clinical use of the presented BCI system as a diagnostic (i.e., detecting command-following) and communication tool for severely brain-injured patients will need to be further explored.

Nerve trauma of the lower extremity: evaluation of 60,422 leg injured patients from the TraumaRegister DGU® between 2002 and 2015.

PubMed

Huckhagel, Torge; Nüchtern, Jakob; Regelsberger, Jan; Gelderblom, Mathias; Lefering, Rolf

2018-05-15

Nerve lesions are well known reasons for reduced functional capacity and diminished quality of life. By now only a few epidemiological studies focus on lower extremity trauma related nerve injuries. This study reveals frequency and characteristics of nerve damages in patients with leg trauma in the European context. Sixty thousand four hundred twenty-two significant limb trauma cases were derived from the TraumaRegister DGU® between 2002 and 2015. The TR-DGU is a multi- centre database of severely injured patients. We compared patients with additional nerve injury to those with intact neural structures for demographic data, trauma mechanisms, concomitant injuries, treatment and outcome parameters. Approximately 1,8% of patients with injured lower extremities suffer from additional nerve trauma. These patients were younger (mean age 38,1 y) and more likely of male sex (80%) compared to the patients without nerve injury (mean age 46,7 y; 68,4% male). This study suggests the peroneal nerve to be the most frequently involved neural structure (50,9%). Patients with concomitant nerve lesions generally required a longer hospital stay and exhibited a higher rate for subsequent rehabilitation. Peripheral nerve damage was mainly a consequence of motorbike (31,2%) and car accidents (30,7%), whereas leg trauma without nerve lesion most frequently resulted from car collisions (29,6%) and falls (29,8%). Despite of its low frequency nerve injury remains a main cause for reduced functional capacity and induces high socioeconomic expenditures due to prolonged rehabilitation and absenteeism of the mostly young trauma victims. Further research is necessary to get insight into management and long term outcome of peripheral nerve injuries.

The “weekend warrior”: Fact or fiction for major trauma?

PubMed Central

Roberts, Derek J.; Ouellet, Jean-Francois; McBeth, Paul B.; Kirkpatrick, Andrew W.; Dixon, Elijah; Ball, Chad G.

2014-01-01

Background The “weekend warrior” engages in demanding recreational sporting activities on weekends despite minimal physical activity during the week. We sought to identify the incidence and injury patterns of major trauma from recreational sporting activities on weekends versus weekdays. Methods We performed a retrospective cohort study using the Alberta Trauma Registry comparing all adults who were severely injured (injury severity score [ISS] ≥ 12) while engaging in physical activity on weekends versus weekdays between 1995 and 2009. Results Among the 351 identified patients (median ISS 18; median hospital stay 6 d; mortality 6.6%), significantly more were injured on the weekend than during the week (54.8% v. 45.2%, p = 0.016). Common mechanisms were motocross (23.6%), hiking or mountain/rock climbing (15.4%), skateboarding or rollerblading (12.3%), hockey/ice-skating (10.3%) and aircraft- (9.9%) and water-related (7.7%) activities. This distribution was similar regardless of the day of the week. Most patients were injured as a result of a ground-level (21.9%) or higher fall while hiking, mountain climbing or rock climbing (25.9%); motocross-related incidents (24.2%); or collision with a tree, person, man-made object or moving vehicle (14.0%). Injury patterns were similar across both groups (all p > 0.05): head (55.8%), spine (35.1%), chest (35.0%), extremities (31.1%), face (17.4%), abdomen (13.1%). Surgical intervention was required in 41% of patients: 15.1% required open reduction and internal fixation, 8.3% spinal fixation, 7.4% craniotomy, 5.1% facial repair and 4.3% laparotomy. Conclusion The weekend warrior concept may be a validated entity for major trauma. PMID:24869618

Rationale for the selective administration of tranexamic acid to inhibit fibrinolysis in the severely injured patient.

PubMed

Moore, Ernest E; Moore, Hunter B; Gonzalez, Eduardo; Sauaia, Angela; Banerjee, Anirban; Silliman, Christopher C

2016-04-01

Postinjury fibrinolysis can manifest as three distinguishable phenotypes: 1) hyperfibrinolysis, 2) physiologic, and 3) hypofibrinolysis (shutdown). Hyperfibrinolysis is associated with uncontrolled bleeding due to clot dissolution; whereas, fibrinolysis shutdown is associated with organ dysfunction due to microvascular occlusion. The incidence of fibrinolysis phenotypes at hospital arrival in severely injured patients is: 1) hyperfibrinolysis 18%, physiologic 18%, and shutdown 64%. The mechanisms responsible for dysregulated fibrinolysis following injury remain uncertain. Animal work suggests hypoperfusion promotes fibrinolysis, while tissue injury inhibits fibrinolysis. Clinical experience is consistent with these observations. The predominant mediator of postinjury hyperfibrinolysis appears to be tissue plasminogen activator (tPA) released from ischemic endothelium. The effects of tPA are accentuated by impaired hepatic clearance. Fibrinolysis shutdown, on the other hand, may occur from inhibition of circulating tPA, enhanced clot strength impairing the binding of tPA and plasminogen to fibrin, or the inhibition of plasmin. Plasminogen activator inhibitor -1 (PAI-1) binding of circulating tPA appears to be a major mechanism for postinjury shutdown. The sources of PAI-1 include endothelium, platelets, and organ parenchyma. The laboratory identification of fibrinolysis phenotype, at this moment, is best determined with viscoelastic hemostatic assays (TEG, ROTEM). While D-dimer and plasmin antiplasmin (PAP) levels corroborate fibrinolysis, they do not provide real-time assessment of the circulating blood capacity. Our clinical studies indicate that fibrinolysis is a very dynamic process and our experimental work suggests plasma first resuscitation reverses hyperfibrinolysis. Collectively, we believe recent clinical and experimental work suggest antifibrinolytic therapy should be employed selectively in the acutely injured patient, and optimally guided by TEG or ROTEM. © 2016 AABB.

Organ engineering--combining stem cells, biomaterials, and bioreactors to produce bioengineered organs for transplantation.

PubMed

Murphy, Sean Vincent; Atala, Anthony

2013-03-01

Often the only treatment available for patients suffering from diseased and injured organs is whole organ transplant. However, there is a severe shortage of donor organs for transplantation. The goal of organ engineering is to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Recent progress in stem cell biology, biomaterials, and processes such as organ decellularization and electrospinning has resulted in the generation of bioengineered blood vessels, heart valves, livers, kidneys, bladders, and airways. Future advances that may have a significant impact for the field include safe methods to reprogram a patient's own cells to directly differentiate into functional replacement cell types. The subsequent combination of these cells with natural, synthetic and/or decellularized organ materials to generate functional tissue substitutes is a real possibility. This essay reviews the current progress, developments, and challenges facing researchers in their goal to create replacement tissues and organs for patients. Copyright © 2013 WILEY Periodicals, Inc.

Medical aspects of the Iraqi missile attacks on Israel.

PubMed

Karsenty, E; Shemer, J; Alshech, I; Cojocaru, B; Moscovitz, M; Shapiro, Y; Danon, Y L

1991-01-01

During the period 18 January-28 February 1991, a total of 39 Iraqi modified Scud missiles landed in Israel, most of them in the densely populated Tel Aviv area. There were 23 missile attack alerts. These attacks caused 1,059 cases of injury; there were two deaths and 232 patients were admitted to emergency rooms for injuries directly related to the explosions, only one of which was severe. A survey among 91 of the injured showed that 46.6% of the wounds were caused by glass splinters, 31.1% were blunt contusions, and 22.2% were acute psychological reactions. No case of blast injury was reported. Inappropriate injection of atropine was reported in 230 cases. Acute anxiety was the reason for admission of 544 patients to emergency rooms. Another 40 patients sustained various traumas while rushing to the sealed room. The relatively low number of injured people is striking in view of the density of population in the areas hit. Various explanations are discussed.

Damage control surgery in the abdomen: an approach for the management of severe injured patients.

PubMed

Germanos, Stylianos; Gourgiotis, Stavros; Villias, Constantinos; Bertucci, Marco; Dimopoulos, Nikitas; Salemis, Nikolaos

2008-06-01

Damage control is well established as a potentially life-saving procedure in a few selected critically injured patients. In these patients the 'lethal triad' of hypothermia, acidosis, and coagulopathy is presented as a vicious cycle that often can not be interrupted and which marks the limit of the patient's ability to cope with the physiological consequences of injury. The principles of damage control have led to improved survival and to stopped bleeding until the physiologic derangement has been restored and the patient could undergo a prolong operation for definitive repair. Although morbidity is remaining high, it is acceptable if it comes in exchange for improved survival. There are five critical decision-making stages of damage control: I, patient selection and decision to perform damage control; II, operation and intraoperative reassessment of laparotomy; III, resuscitation in the intensive care unit; IV, definitive procedures after returning to the operating room; and V, abdominal wall reconstruction. The purpose of this article is to review the physiology of the components of the 'lethal triad', the indication and principles of abdominal damage control of trauma patients, the reoperation time, and the pathophysiology of abdominal compartment syndrome.

Non-Invasive Ultrasonic Diagnosing and Monitoring of Intracranial Pressure/Volume

DTIC Science & Technology

2001-10-01

these risks, intracranial pressure is usually monitored only in the severely head injured patients and only if there is clinical or CT or MRI ...proportion of patients for whom the computer tomography (CT) or magnetic resonance imaging ( MRI ) scan do not show the evidence of the raised pressure...thresholds and the Cushing phenomenon induced by upper brainstem ischemia. During ICH it was demonstrated that there is an increase of sympathetic

The economic impact of electric saw injuries to the hand.

PubMed

Hoxie, Samuel C; Capo, Jason A; Dennison, David G; Shin, Alexander Y

2009-01-01

Injuries from electric saws cause considerable hand trauma. This study is designed to provide information detailing the costs of these injuries. The study was performed in a tertiary referral academic medical center. The records of patients injured by electric table saws were reviewed. Information regarding demographics, injury severity, medical expense, and time lost from work was analyzed. The patients were stratified by injury severity for further analysis. The mean wage for the region was used to estimate costs of time away from work. The Consumer Protection Agency's review was used to estimate the nationwide burden of these injuries. The study group included 134 patients. Of these patients, 126 were male and 8 were female. The dominant hand was injured in 20; the nondominant, in 114. The mean age was 47.0 years. The mean time lost from work was 64 days. The mean cost of medical expenses for all patients was $22,086, with $8,668 in lost wages, for a total of $30,754 mean cost per injury. The total economic burden for the injuries in this study is $4,121,097. These injuries represent a spectrum of severity, with minor injuries incurring lower hospital fees and requiring less time off work as compared to more involved injuries. Electric saws cause a wide spectrum of injuries that result in not only tremendous physical and emotional pain but also substantial economic impact as well. Technologies that would prevent such injuries would be a socioeconomic advancement. Federal mandates to implement such technologies should be encouraged.

The consequences of high-risk behaviors: trauma during pregnancy.

PubMed

Patteson, Stephen K; Snider, Carolyn C; Meyer, David S; Enderson, Blaine L; Armstrong, Janice E; Whitaker, Gregory L; Carroll, Roger C

2007-04-01

Trauma during pregnancy places two lives at risk. Knowledge of risk factors for trauma during pregnancy may improve outcomes. We reviewed the charts of 188 such patients admitted to a Level I trauma center from 1996 to 2004. A comparison was made of injury severity and outcome from a cohort of nonpregnant female trauma patients selected with a similar temporal occurrence and age range. Motor vehicle collisions comprised 160 cases, 67 using a restraint device. Of 84 patients tested, 45 tested positive for intoxicants, 16 positive for 2 or more intoxicants. A significant trend toward less testing through the study period was observed (p = 0.0002). Injury severity was assessed by Revised Trauma Score (RTS). RTS <11 or admission to operating room or intensive care units (OR/ICU) classified patients as severely injured. The six maternal fatalities had an RTS <11 or OR/ICU disposition. Fetal outcomes included 155 live in utero, 18 live births, and 15 fatalities correlating with injury severity by either criteria (p < 0.0001). Of the fetal fatalities, 7 occurred with RTS = 12, but only 3 fatalities occurred in the 147 cases not admitted to OR/ICU. Gestational age correlated (p < 0.0001) with fetal outcomes. The 18 live births had mean gestational ages of 35 +/- 4 weeks as compared with fetal fatalities at 20 +/- 9 weeks, and fetuses alive in utero at 22 +/- 9 weeks gestation. Coagulation tests prothrombin time (PT), international normalized ratio (INR) (both p < 0.008), and partial thromboplastin time (PTT) (p < 0.0001) correlated with maternal outcome. A matched cohort of nonpregnancy trauma cases during the same time frame indicated that, despite a significantly higher percentage of severely injured patients, fewer fatalities occurred. This might reflect a greater risk for the pregnant trauma patient. This study of trauma in pregnancy cases revealed a high percentage with risk behaviors. There was a significant trend toward less intoxicant testing in recent years. Coagulation tests were the most predictive of outcomes. Lower gestational age correlated with fetal demise.

[Spinal cord injuries caused by aviation accidents].

PubMed

Heim, M; Ohry, A; Zeilig, G; Gur, S

1992-05-15

During the past 15 years fewer than 1% of those treated in the National Spinal Cord Injury Center were injured as a result of aviation accidents. In addition to 9 such patients treated at the center since 1973, another 6 were found among the many hundreds receiving ambulatory care in our clinics. 3 patients had survived a helicopter crash, 2 were injured while ejecting from combat aircraft, 3 were injured in crashes of light aircraft, 1 fell from a hand glider and 6 were injured in parachute drops. Of the 15 reviewed, 6 use wheelchairs, 3 walk assisted by orthopedic devices, while 6 ambulate freely. Although initial hospitalization was not substantially longer than in other patients with spinal cord injuries, extended ambulatory psychological intervention was necessary.

Tissue engineering, stem cells, cloning, and parthenogenesis: new paradigms for therapy

PubMed Central

Hipp, Jason; Atala, Anthony

2004-01-01

Patients suffering from diseased and injured organs may be treated with transplanted organs. However, there is a severe shortage of donor organs which is worsening yearly due to the aging population. Scientists in the field of tissue engineering apply the principles of cell transplantation, materials science, and bioengineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Both therapeutic cloning (nucleus from a donor cell is transferred into an enucleated oocyte), and parthenogenesis (oocyte is activated and stimulated to divide), permit extraction of pluripotent embryonic stem cells, and offer a potentially limitless source of cells for tissue engineering applications. The stem cell field is also advancing rapidly, opening new options for therapy. The present article reviews recent progress in tissue engineering and describes applications of these new technologies that may offer novel therapies for patients with end-stage organ failure. PMID:15588286

Tissue engineering, stem cells, cloning, and parthenogenesis: new paradigms for therapy.

PubMed

Hipp, Jason; Atala, Anthony

2004-12-08

: BACKGROUND: Patients suffering from diseased and injured organs may be treated with transplanted organs. However, there is a severe shortage of donor organs which is worsening yearly due to the aging population. Scientists in the field of tissue engineering apply the principles of cell transplantation, materials science, and bioengineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Both therapeutic cloning (nucleus from a donor cell is transferred into an enucleated oocyte), and parthenogenesis (oocyte is activated and stimulated to divide), permit extraction of pluripotent embryonic stem cells, and offer a potentially limitless source of cells for tissue engineering applications. The stem cell field is also advancing rapidly, opening new options for therapy. The present article reviews recent progress in tissue engineering and describes applications of these new technologies that may offer novel therapies for patients with end-stage organ failure.

Tissue engineering and regenerative medicine: concepts for clinical application.

PubMed

Atala, Anthony

2004-01-01

Patients suffering from diseased and injured organs may be treated with transplanted organs. However, there is a severe shortage of donor organs that is worsening yearly given the aging population. Scientists in the field of regenerative medicine and tissue engineering apply the principles of cell transplantation, material science, and bioengineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Therapeutic cloning, where the nucleus from a donor cell is transferred into an enucleated oocyte in order to extract pluripotent embryonic stem cells, offers a potentially limitless source of cells for tissue engineering applications. The stem cell field is also advancing rapidly, opening new options for therapy. This paper reviews recent advances that have occurred in regenerative medicine and describes applications of these new technologies that may offer novel therapies for patients with end-stage organ failure.

Engineering tissues, organs and cells.

PubMed

Atala, Anthony

2007-01-01

Patients suffering from diseased and injured organs may be treated with transplanted organs; however, there is a severe shortage of donor organs that is worsening yearly, given the ageing population. In the field of regenerative medicine and tissue engineering, scientists apply the principles of cell transplantation, materials science and bioengineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Therapeutic cloning, where the nucleus from a donor cell is transferred into an enucleated oocyte in order to extract pluripotent embryonic stem cells, offers a potentially limitless source of cells for tissue engineering applications. The stem cell field is also advancing rapidly, opening new options for therapy, including the use of amniotic and placental fetal stem cells. This review covers recent advances that have occurred in regenerative medicine and describes applications of these technologies using chemical compounds that may offer novel therapies for patients with end-stage organ failure. 2007 John Wiley & Sons, Ltd

A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures in multiple trauma patients: an analysis based on the trauma registry of the German Trauma Society.

PubMed

Steinhausen, Eva; Lefering, Rolf; Tjardes, Thorsten; Neugebauer, Edmund A M; Bouillon, Bertil; Rixen, Dieter

2014-05-01

Today, there is a trend toward damage-control orthopedics (DCO) in the management of multiple trauma patients with long bone fractures. However, there is no widely accepted concept. A risk-adapted approach seems to result in low acute morbidity and mortality. Multiple trauma patients with bilateral femoral shaft fractures (FSFs) are considered to be more severely injured. The objective of this study was to validate the risk-adapted approach in the management of multiple trauma patients with bilateral FSF. Data analysis is based on the trauma registry of the German Trauma Society (1993-2008, n = 42,248). Multiple trauma patients with bilateral FSF were analyzed in subgroups according to the type of primary operative strategy. Outcome parameters were mortality and major complications as (multiple) organ failure and sepsis. A total of 379 patients with bilateral FSF were divided into four groups as follows: (1) no operation (8.4%), (2) bilateral temporary external fixation (DCO) (50.9%), bilateral primary definitive osteosynthesis (early total care [ETC]) (25.1%), and primary definitive osteosynthesis of one FSF and DCO contralaterally (mixed) (15.6%). Compared with the ETC group, the DCO group was more severely injured. The incidence of (multiple) organ failure and mortality rates were higher in the DCO group but without significance. Adjusted for injury severity, there was no significant difference of mortality rates between DCO and ETC. Injury severity and mortality rates were significantly increased in the no-operation group. The mixed group was similar to the ETC group regarding injury severity and outcome. In Germany, both DCO and ETC are practiced in multiple trauma patients with bilateral FSF so far. The unstable or potentially unstable patient is reasonably treated with DCO. The clearly stable patient is reasonably treated with nailing. When in doubt, the patient is probably not totally stable, and the safest precaution may be to use DCO as a risk-adapted approach. Therapeutic study, level IV. Epidemiologic study, level III.

Same Abbreviated Injury Scale Values May Be Associated with Different Risks to Mortality in Trauma Patients: A Cross-Sectional Retrospective Study Based on the Trauma Registry System in a Level I Trauma Center.

PubMed

Rau, Cheng-Shyuan; Wu, Shao-Chun; Kuo, Pao-Jen; Chen, Yi-Chun; Chien, Peng-Chen; Hsieh, Hsiao-Yun; Hsieh, Ching-Hua

2017-12-11

The Abbreviated Injury Scale (AIS) measures injury severity of a trauma patient with a numeric method for ranking anatomy-based specific injuries. The summation of the squares of the three most severe injuries in the AIS of six predefined body regions comprises the Injury Severity Score (ISS). It assumes that the mortality of a given AIS value is similar across all body regions. However, such an assumption is less explored in the literature. In this study, we aimed to compare the mortality rates of the patients with the same AIS value in different injured body regions in a level I trauma center. Hospitalized adult trauma patients with isolated serious to critical injury (AIS of 3 to 5) between 1 January 2009, and 31 December 2016, from the Trauma Registry System in a level I trauma center were grouped according to the injured body regions (including, the head/neck, thorax, abdomen, or extremities) and were exclusively compared according to their AIS stratum. Categorical data were compared using the two-sided Fisher exact or Pearson chi-square tests. ANOVA with Games-Howell post hoc test was performed to assess the differences in continuous data of the patients with injury in different body regions. The primary outcome of the study was in-hospital mortality. The adjusted odds ratios (AORs) were estimated using a stepwise selection of a multivariable regression model adjusted by controlling the confounding variables such as sex, age, comorbidities, and ISS. Survival curves were estimated with the Kaplan-Meier approach with a corresponding log-rank test. The patients with AIS of 5 for abdomen injury and those with AIS of 3 for extremity injury had a significantly lower odds of adjusted mortality (adjusted odds ratio (AOR) 0.1, 95% confidence interval (CI) 0.01-0.39, p = 0.004 and AOR 0.3, 95% CI 0.15-0.51, p < 0.001, respectively) than that of the patients with head/neck injury. However, the patients with AIS of 4 for extremity injury demonstrated significantly higher odds of adjusted mortality (AOR 8.4, 95% CI 2.84-25.07, p < 0.001) than the patients with head/neck injury. This study found that the risks to mortality in the patients with a given AIS value of serious to critical injury in different injured body regions were not the same, even after controlling for confounding variables such as sex, age, comorbidities, and ISS.

Same Abbreviated Injury Scale Values May Be Associated with Different Risks to Mortality in Trauma Patients: A Cross-Sectional Retrospective Study Based on the Trauma Registry System in a Level I Trauma Center

PubMed Central

Rau, Cheng-Shyuan; Wu, Shao-Chun; Kuo, Pao-Jen; Chen, Yi-Chun; Chien, Peng-Chen; Hsieh, Hsiao-Yun

2017-01-01

The Abbreviated Injury Scale (AIS) measures injury severity of a trauma patient with a numeric method for ranking anatomy-based specific injuries. The summation of the squares of the three most severe injuries in the AIS of six predefined body regions comprises the Injury Severity Score (ISS). It assumes that the mortality of a given AIS value is similar across all body regions. However, such an assumption is less explored in the literature. In this study, we aimed to compare the mortality rates of the patients with the same AIS value in different injured body regions in a level I trauma center. Hospitalized adult trauma patients with isolated serious to critical injury (AIS of 3 to 5) between 1 January 2009, and 31 December 2016, from the Trauma Registry System in a level I trauma center were grouped according to the injured body regions (including, the head/neck, thorax, abdomen, or extremities) and were exclusively compared according to their AIS stratum. Categorical data were compared using the two-sided Fisher exact or Pearson chi-square tests. ANOVA with Games-Howell post hoc test was performed to assess the differences in continuous data of the patients with injury in different body regions. The primary outcome of the study was in-hospital mortality. The adjusted odds ratios (AORs) were estimated using a stepwise selection of a multivariable regression model adjusted by controlling the confounding variables such as sex, age, comorbidities, and ISS. Survival curves were estimated with the Kaplan–Meier approach with a corresponding log-rank test. The patients with AIS of 5 for abdomen injury and those with AIS of 3 for extremity injury had a significantly lower odds of adjusted mortality (adjusted odds ratio (AOR) 0.1, 95% confidence interval (CI) 0.01–0.39, p = 0.004 and AOR 0.3, 95% CI 0.15–0.51, p < 0.001, respectively) than that of the patients with head/neck injury. However, the patients with AIS of 4 for extremity injury demonstrated significantly higher odds of adjusted mortality (AOR 8.4, 95% CI 2.84–25.07, p < 0.001) than the patients with head/neck injury. This study found that the risks to mortality in the patients with a given AIS value of serious to critical injury in different injured body regions were not the same, even after controlling for confounding variables such as sex, age, comorbidities, and ISS. PMID:29232883

[Prevention, diagnosis and surgical treatment of injuries of the biliary tract during laparoscopic cholecystectomy. Treatment of papilla injuries caused by invasive endoscopy. Part 2. Surgical treatment of biliary tract injuries].

PubMed

Sváb, J; Pesková, M; Krska, Z; Gürlich, R; Kasalický, M

2005-04-01

Introduction of endoscopic invasive procedures in the 70th and 80th years leaded to decrease reoperations on biliary tree. latrogenic injury of the biliary tract have increased in incidence in the first decade with the introduction of laparoscopic cholecystectomy. Athough a number of factors have been identified with a high risk of injury (and number of technical steps have been emphasized to avoid these injury, the incidence of the bile duct injury has reached at least double the rate observed with open cholecystectomy. Most patients that sustained a bile duct injury are recognized in the weeks following laparoscopic cholecystectomy. Careful preoperative preparation should include control of sepsis by draining any bile collections or fistulas and complete cholangiography. Long-term results are best achieved in specialized hepatobiliary centers performing biliary reconstruction with a Roux-Y hepaticojejunostomy. Success rates over 90% have been reported from several centres to date with intermediate follow-up. Introduction of an invasive endoscopy. Very dangerous is injury after endoscopic papilotomy. In an article of a review of experiences of the Ist Department of Surgery of General hospital in Prague since 1971 in 1 017 reoperations on biliary tree has been carried out. There were in 311 patients 164 hepato-hepatostomies and 147 hepaticojejunostomies used (Tab. 1). By laparoscopic injuries in the last decade were hilary injuries (Bismuth IV) and hepaticojejunostomy was done in all cases. Died 6%, long-term results are acceptable by injured patients with hepatico-hepaticostomies in 70%, by hepaticojejunostomies in 90%. Reoperated were 10% patients. Remnant patients were dilated endoscopically. Postoperatively morbidity was high, above 26%. In years 1995-2003 were 8 patients with papila injury and inflammation in retroperitoneum operated as a injured duodenum (Tab. 2). Better experiences with treatment of injured biliary tree and papila are in centres interested in hepatobiliary surgery which know anatomy of hilus of the liver and can see wide hepaticojejunostomy. Transfer of drained injured patient to centre is possible.

Factors associated with non-return to work in the severely injured victims 3 years after a road accident: A prospective study.

PubMed

Pélissier, C; Fort, E; Fontana, L; Charbotel, B; Hours, M

2017-09-01

Road accidents may impact victims' physical and/or mental health and socio-occupational life, particularly the capacity to return to work. The purpose of our study is to assess modifiable medical and socio-occupational factors of non-return to work in the severely injured 3 years after a road accident. Among1,168 road accidents casualties in the Rhône administrative Département of France followed for five years, 141 of the 222 severely injured (Maximal Abbreviated Injury Scale ≥ 3) aged more than 16 years who were in work at the time of the accident, reported whether they had returned to work in the 3 years following the accident. The subgroups of those who had (n=113) and had not returned to work (n=28) were compared for socio-occupational (gender, age, educational level, marital status, socio-occupational group) accident-related medical factors (type of road user, type of journey, responsibility in the accident, initial care) and post-accident medical factors (pain intensity, post-traumatic stress disorder, physical sequelae, quality of life) by using standardized tools. Severity of initial head, face and lower-limb injury, intense persistent pain, post-traumatic stress disorder, poor self-assessed quality of life and health status at 3 years were associated with non-return to work on univariate analysis. On multivariate analysis, severity of initial head and lower-limb injury, intense persistent pain at 3 years and post-traumatic stress disorder were significantly associated with non-return to work 3 years following severe road-accident injury. Post-traumatic stress disorder and chronic pain were essential modifiable medical determinants of non-return to work in the severely injured after a road accident: early adapted management could promote return to work in the severely injured. Improve early adapted treatment of pain and PTSD in the rehabilitation team should help the severely injured return to work following a road accident. Copyright © 2017 Elsevier Ltd. All rights reserved.

Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy

PubMed Central

Gonzalez, Eduardo; Moore, Ernest E.; Moore, Hunter B.; Chapman, Michael P.; Chin, Theresa L.; Ghasabyan, Arsen; Wohlauer, Max V.; Barnett, Carlton C.; Bensard, Denis D.; Biffl, Walter L.; Burlew, Clay C.; Johnson, Jeffrey L.; Pieracci, Fredric M.; Jurkovich, Gregory J.; Banerjee, Anirban; Silliman, Christopher C.; Sauaia, Angela

2017-01-01

Background Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA). Methods This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation. Upon MTP activation, patients were randomized to be managed either by an MTP goal directed by TEG or by CCA (ie, international normalized ratio, fibrinogen, platelet count). Primary outcome was 28-day survival. Results One hundred eleven patients were included in an intent-to-treat analysis (TEG = 56, CCA = 55). Survival in the TEG group was significantly higher than the CCA group (log-rank P = 0.032, Wilcoxon P = 0.027); 20 deaths in the CCA group (36.4%) compared with 11 in the TEG group (19.6%) (P = 0.049). Most deaths occurred within the first 6 hours from arrival (21.8% CCA group vs 7.1% TEG group) (P = 0.032). CCA patients required similar number of red blood cell units as the TEG patients [CCA: 5.0 (2–11), TEG: 4.5 (2–8)] (P = 0.317), but more plasma units [CCA: 2.0 (0–4), TEG: 0.0 (0–3)] (P = 0.022), and more platelets units [CCA: 0.0 (0–1), TEG: 0.0 (0–0)] (P = 0.041) in the first 2 hours of resuscitation. Conclusions Utilization of a goal-directed, TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation. PMID:26720428

Combined Abdominal and Spine Injuries after High Energy Flexion-Distraction Trauma.

PubMed

Woltmann, Alexander; Beisse, Rudolph; Eckardt, Henrik; Potulski, Michael; Bühren, Volker

2007-10-01

Combined abdominal (AT) and spine (ST) trauma in the multiply traumatized patient (MT) requires optimal clinical management. At the Traumacenter Murnau, Germany all multiply injured patients (injury severity score ≥ 16) are registered in a large prospective database (DGU-Tramaregister). From 1 January 2002 until 31 December 2004, 731 multiply injured patients (ISS ≥ 16) were admitted to the Trauma Center Murnau. In this population, ST was diagnosed in 287 patients (39%), AT was diagnosed in 100 patients (14%), and in 35 patients (5%) a combined ST and AT was observed. The most frequent injury mechanism in patients with a combined ST and AT was high-energy flexion-distraction trauma caused by motor vehicle accident with seat belt fastened passengers, bicycle accident, and fall from great height. In the cohort group of 35 patients, 29 required either abdominal or spinal operation. In 23 patients the AT and in 18 patients the ST necessitated operation. In 14 patients both the AT and ST called for surgery. The AT was predominately treated with splenectomies, resections and suturing of the intestine. The ST resulted in 14 posterior and four postponed anterior stabilizations of the thoracolumbar and four anterior fusions of the cervical spine. Mean age of these patients was 37 years in comparison to 47 years in the control group (MT without combined AT and ST). ISS of patients with combined AT and ST was 38 points compared to 26 points in the control group, and mortality was 7% in the combined group compared to 14% in the control group. The present study documents that damage control principles applied to patients sustaining the complex combination of AT and ST can result in low mortality rates despite the severity of this injury.

Circulating AST, H-FABP, and NGAL are early and accurate biomarkers of graft injury and dysfunction in a preclinical model of kidney transplantation.

PubMed

Jochmans, Ina; Lerut, Evelyne; van Pelt, Jos; Monbaliu, Diethard; Pirenne, Jacques

2011-11-01

To investigate circulating biomarkers of initial graft injury in a porcine kidney autotransplant model. Injury endured by kidney grafts early posttransplant determines their outcome. However, creatinine (clearance) is a poor surrogate of tissue injury and urinary biomarkers are limited by graft anuria or persistent native kidney diuresis. No validated circulating biomarkers quantifying initial graft injury exist. Minimally injured porcine kidney grafts (n = 6) were cold stored (18 hours) and autotransplanted. Moderately (n = 6) and severely injured grafts (n = 7) were exposed to 30 or 60 minutes warm ischemia before storage and autotransplantation. Four biomarkers [aspartate transaminase (AST), heart-type fatty acid-binding protein (H-FABP), neutrophil gelatinase-associated lipocalin (NGAL), and N-acetyl-β-glucosaminidase (NAG)] were measured posttransplant and compared with creatinine (clearance) and histology. Diuresis was delayed in moderately [2.5 days (2-3)] and severely [4 days (4-5)] versus minimally injured grafts (P < 0.001). Creatinine peaked later than AST, H-FABP, and NGAL [4 days (3-5) vs 3 hours (3-6), 6 hours (6-24), 2 days (1-3), respectively] and only differentiated minimally from severely injured grafts. Peak AST and H-FABP distinguished all injury grades. Neutrophil gelatinase-associated lipocalin discriminated initial graft injury 2 days posttransplant. Peak AST, H-FABP, and NGAL correlated with peak creatinine [Pearson coefficients: 0.70 (P = 0.001), 0.85 (P < 0.0001), 0.80 (P < 0.0001)]. N-acetyl-β-glucosaminidase was not different. Decreased clearance accounted for a small percentage of H-FABP and NGAL increase. Histology was not different among transplanted groups. Plasma AST, H-FABP, and NGAL reflect the severity of initial kidney graft injury and predict graft dysfunction earlier and more accurately than creatinine (clearance) and histology. They represent promising tools to improve patient care after kidney transplantation.

[TraumaNetwork, Trauma Registry of the DGU®, Whitebook, S3 Guideline on Treatment of Polytrauma/Severe Injuries - An Approach for Validation by a Retrospective Analysis of 2304 Patients (2002-2011) of a Level 1 Trauma Centre].

PubMed

Schoeneberg, C; Schilling, M; Keitel, J; Kauther, M D; Burggraf, M; Hussmann, B; Lendemans, S

2017-04-01

Background: In the last decades, a reduction in mortality in severely injured patients with an ISS ≥ 16 could be observed. Some authors report a death rate of about 22 %. Moreover, there were some new insights in the last years such as the reduction in mortality by use of whole-body CT and the introduction of the S3 guideline of the German Society of Trauma Surgery "Treatment of Patients with Severe and Multiple Injuries" have supported the evidence-based treatment of severely injured patients. Methods: A retrospective analysis of 2304 patients was performed between 2002 and 2011. The data of the authors' clinic for the trauma registry of the DGU® were used. After applying the inclusion criteria, ISS ≥ 16 and primary transfer from the accident site, 968 patients remained. Results: In the study population, a mean ISS of 29.81 and a mean GCS of 9.42 were found. The average age was 46.04 years. The mortality rate was 28.7 %. A significant difference between decedents and survivors was found at the ISS, GCS, RTS, new ISS, TRISS, RISC, AIS head, AIS skin, RR pre-clinical, pre-clinical heart rate and age. To test whether the lethality was reduced by the increased use of whole-body CT, a division into a group prior to and from 2009 was performed. Results revealed a significant increase in the whole-body CT rate from 56.96 to 71.7 %. The mortality rate declined from 32.3 to 24.5 %. In the same way it was verified whether the S3 guideline had an impact on mortality. Therefore, a division into groups before and from 2011 was conducted. Here, the mortality rate decreased from 30.4 to 18.4 %. In addition, a comparison between 2010 and 2011 was performed. Overall, there were statistically significant differences in the trauma room time, the surgical time, the volume infused, the rate of multiple organ failure and the rate of whole-body CTs performed. Conclusion: In the period from 2002 to 2011 a mortality rate of 28.7 % was found. The higher rate in comparison to published data is most likely explained by the high rate of serious and severe head injuries. The increased use of whole-body CT and the introduction of the S3 guideline led to a significant decrease in mortality in the authors' patient population. This is due particularly to the accelerating of the treatment of severely injured patients, the reduction of the infused volume, shortened surgical phase within the first 24 hours and the increased use of whole-body CT. Georg Thieme Verlag KG Stuttgart · New York.

Executive functions and social cognition in highly lethal self-injuring patients with borderline personality disorder.

PubMed

Williams, Gregory E; Daros, Alexander R; Graves, Bryanna; McMain, Shelley F; Links, Paul S; Ruocco, Anthony C

2015-04-01

Risk for potentially lethal self-injurious behavior in borderline personality disorder (BPD) may be associated with deficits in neuropsychological functions and social cognition. In particular, individuals with BPD engaging in more medically damaging self-injurious behaviors may have more severe executive function deficits and altered emotion perception as compared to patients engaging in less lethal acts. In the current study, 58 patients with BPD reporting a lifetime history of self-injurious behavior were administered neuropsychological measures of response inhibition, planning and problem-solving,and tests of facial emotion recognition and discrimination. Patients who engaged in more medically lethal self-injurious behaviors reported engaging in impulsive behaviors more frequently and displayed neuropsychological deficits in problem-solving and response inhibition. They were also less accurate in recognizing happy facial expressions and in discerning subtle differences in emotional intensity in sad facial expressions. These findings suggest that patients with BPD that engage in more physically damaging self-injurious behaviors may have greater difficulties with behavioral control and employ less efficient problem-solving strategies. Problems in facial emotion recognition and discrimination may contribute to interpersonal difficulties in patients with BPD who self-injure. (c) 2015 APA, all rights reserved).

Surgical support during the terrorist attacks in Paris, November 13, 2015: Experience at Bégin Military Teaching Hospital.

PubMed

Barbier, Olivier; Malgras, Brice; Choufani, Camille; Bouchard, Antoine; Ollat, Didier; Versier, Gilbert

2017-06-01

Recent conflicts have allowed the French Army Health Service to improve management quality for wartime-injured people during military operations. On November 13, 2015, it was in Paris that France was directly attacked and Bégin Military Teaching Hospital, like several hospitals in Paris, had to face a large number of gunshot victims. Thanks to our operational experience, injured people hospitalized in military hospitals benefited from a management based on triage and damage control (DC) principles. Forty-five patients were taken care of in our hospital with an average age of 32 years. During triage, eight patients were categorized T1 (with four extreme emergencies) and 10 were classified T2 and 27 as T3. Twenty-two patients underwent emergency surgery, 15 for soft tissue lesions of limbs, 8 for ballistic fractures (one of which was a cervical wound), and 5 for abdominal wounds. Two patients classified T1 died early. In total, more than 50 operations were performed including iterative debridements, bone fixation, three amputations, and two flaps. After 9 months, all of the patients had healed. One woman with limb stiffness required an arthrolysis. This event showed that terrorist attacks and mass casualties with war wounds can occur in France. Acquired experience regarding war wounds by the French Army Health Service is precious. Everyone must understand the importance of triage and the principles of damage control. Every hospital must be ready to face this type of massive influx of injured people (white plan). Epidemiological study, level V.

Recovery of Hypersomnia Concurrent With Recovery of an Injured Ascending Reticular Activating System in a Stroke Patient

PubMed Central

Jang, Sung Ho; Lee, Han Do; Chang, Chul Hoon; Jung, Young Jin

2016-01-01

Abstract We report on a stroke patient who showed recovery of hypersomnia concurrent with the recovery of an injured ascending reticular activating system (ARAS), which was demonstrated by diffusion tensor tractography (DTT). A 70-year-old female patient underwent coiling of the left ruptured posterior communicating artery after subarachnoid hemorrhage and both extraventricular drainage for management of an intraventricular hemorrhage. At 2 months after onset, when she started rehabilitation, she exhibited intact consciousness, with the full score on the Glasgow Coma Scale: 15. However, she showed severe hypersomnia: she always fell asleep without external stimulation and the Epworth Sleepiness Scale (EPS) score was 24 (full score: 24, cut off for hypersomnia: 10). She underwent comprehensive rehabilitative therapy, including neurotropic drugs, physical therapy, and occupational therapy. Her hypersomnia has shown improvement as 14 (3 months after onset), 11 (4 months after onset), 7 (12 months after onset), and 6 (24 months after onset), respectively. On 2-month DTT, narrowing of both lower dorsal and ventral ARASs was observed on both sides: in particular, among 4 neural tracts of the lower ARAS, the right lower ventral ARAS was the narrowest. By contrast, on 24-month DTT, the 4 narrowed neural tracts of both lower dorsal and ventral ARASs were thickened compared with those of 2-month DTT. Recovery of hypersomnia with recovery of an injured lower ARAS on DTT was observed in a stroke patient. Our results suggest that evaluation of the lower ARAS using DTT might be useful for stroke patients with hypersomnia. PMID:26765455

Impact of 2015 earthquakes on a local hospital in Nepal: A prospective hospital-based study

PubMed Central

Risnes, Kari; Uleberg, Oddvar; Rogne, Tormod; Shrestha, Sanu Krishna; Nygaard, Øystein Petter; Koju, Rajendra; Solligård, Erik

2018-01-01

Introduction Natural disasters pose a great challenge to the health systems and individual health facilities. In low-resource settings, disaster preparedness systems are often limited and not been well described. Two devastating earthquakes hit Nepal within a 17-days period in 2015. This study aims to describe the burden and distribution of emergency cases to a local hospital. Methods This is a prospective observational study of patients presenting to a local hospital for a period of 21 days following the earthquake on April 25, 2015. Demographic and clinical information was prospectively registered for all patients in the systematic emergency registry. Systematic telephone interviews were conducted in a random sample of the patients 90 days after admission to the hospital. Results A total of 2,003 emergency patients were registered during the period. The average daily number of emergency patients during the first five days was almost five times higher (n = 150) than the pre-incident daily average (n = 35). The majority of injuries were fractures (58%), 348 (56%) in the lower extremities. A total of 345 surgical procedures were performed and the hospital treated 111 patients with severe injuries related to the earthquake (compartment syndrome, crush injury, and internal injury). Among those with follow-up interviews, over 90% reported that they had been severely affected by the earthquakes; complete house damage, living in temporary shelter, or loss of close family member. Conclusion The hospital experienced a very high caseload during the first days, and the majority of patients needed orthopaedic services. The proportion of severely injured and in-hospital deaths were relatively low, probably indicating that the most severely injured did not reach the hospital in time. The experiences underline the need for robust and easily available local health services that can respond to disasters. PMID:29394265

[Damage control in field surgery].

PubMed

Samokhvalov, I M; Manukovskiĭ, V A; Badalov, V I; Severin, V V; Golovko, K P; Denisenko, V V

2011-09-01

Damage control surgery (DCS) is an important option in the store of war surgery and surgery of trauma. The main purpose of our investigation was to specify the percentage of the injured who need DCS. We performed retrospective study of the patients in the combat operations in Chechnya (1994-2002) and in peacetime (2005-2010). Total lethality in group with the standard surgical approach was 62.3%. It was significantly higher than the lethality in group of patients who underwent DCS - 50.0% (p < 0.05). Thus, the experience of DCS in War Surgery Department confirms that DCS is perspective tendency in treatment of patients with severe and extremely severe trauma, and allows decreasing lethality in 12.3%.

Facts and Fiction: The Impact of Hypothermia on Molecular Mechanisms following Major Challenge

PubMed Central

Frink, Michael; Flohé, Sascha; van Griensven, Martijn; Mommsen, Philipp; Hildebrand, Frank

2012-01-01

Numerous multiple trauma and surgical patients suffer from accidental hypothermia. While induced hypothermia is commonly used in elective cardiac surgery due to its protective effects, accidental hypothermia is associated with increased posttraumatic complications and even mortality in severely injured patients. This paper focuses on protective molecular mechanisms of hypothermia on apoptosis and the posttraumatic immune response. Although information regarding severe trauma is limited, there is evidence that induced hypothermia may have beneficial effects on the posttraumatic immune response as well as apoptosis in animal studies and certain clinical situations. However, more profound knowledge of mechanisms is necessary before randomized clinical trials in trauma patients can be initiated. PMID:22481864

The Role of Multimodal Invasive Monitoring in Acute Traumatic Brain Injury.

PubMed

Lazaridis, Christos; Robertson, Claudia S

2016-10-01

This article reviews the role of modalities that directly monitor brain parenchyma in patients with severe traumatic brain injury. The physiology monitored involves compartmental and perfusion pressures, tissue oxygenation and metabolism, quantitative blood flow, pressure autoregulation, and electrophysiology. There are several proposed roles for this multimodality monitoring, such as to track, prevent, and treat the cascade of secondary brain injury; monitor the neurologically injured patient; integrate various data into a composite, patient-specific, and dynamic picture; apply protocolized, pathophysiology-driven intensive care; use as a prognostic marker; and understand pathophysiologic mechanisms involved in secondary brain injury to develop preventive and abortive therapies, and to inform future clinical trials. Copyright © 2016 Elsevier Inc. All rights reserved.

Patient-identified information and communication needs in the context of major trauma.

PubMed

Braaf, Sandra; Ameratunga, Shanthi; Nunn, Andrew; Christie, Nicola; Teague, Warwick; Judson, Rodney; Gabbe, Belinda J

2018-03-07

Navigating complex health care systems during the multiple phases of recovery following major trauma entails many challenges for injured patients. Patients' experiences communicating with health professionals are of particular importance in this context. The aim of this study was to explore seriously injured patients' perceptions of communication with and information provided by health professionals in their first 3-years following injury. A qualitative study designed was used, nested within a population-based longitudinal cohort study. Semi-structured telephone interviews were undertaken with 65 major trauma patients, aged 17 years and older at the time of injury, identified through purposive sampling from the Victorian State Trauma Registry. A detailed thematic analysis was undertaken using a framework approach. Many seriously injured patients faced barriers to communication with health professionals in the hospital, rehabilitation and in the community settings. Key themes related to limited contact with health professionals, insufficient information provision, and challenges with information coordination. Communication difficulties were particularly apparent when many health professionals were involved in patient care, or when patients transitioned from hospital to rehabilitation or to the community. Difficulties in patient-health professional engagement compromised communication and exchange of information particularly at transitions of care, e.g., discharge from hospital. Conversely, positive attributes displayed by health professionals such as active discussion, clear language, listening and an empathetic manner, all facilitated effective communication. Most patients preferred communication consistent with patient-centred approaches, and the use of multiple modes to communicate information. The communication and information needs of seriously injured patients were inconsistently met over the course of their recovery continuum. To assist patients along their recovery trajectories, patient-centred communication approaches and considerations for environmental and patients' health literacy are recommended. Additionally, assistance with information coordination and comprehensive multimodal information provision should be available for injured patients.

The benefits and tradeoffs for varied high-severity injury risk thresholds for advanced automatic crash notification systems.

PubMed

Bahouth, George; Graygo, Jill; Digges, Kennerly; Schulman, Carl; Baur, Peter

2014-01-01

The objectives of this study are to (1) characterize the population of crashes meeting the Centers for Disease Control and Prevention (CDC)-recommended 20% risk of Injury Severity Score (ISS)>15 injury and (2) explore the positive and negative effects of an advanced automatic crash notification (AACN) system whose threshold for high-risk indications is 10% versus 20%. Binary logistic regression analysis was performed to predict the occurrence of motor vehicle crash injuries at both the ISS>15 and Maximum Abbreviated Injury Scale (MAIS) 3+ level. Models were trained using crash characteristics recommended by the CDC Committee on Advanced Automatic Collision Notification and Triage of the Injured Patient. Each model was used to assign the probability of severe injury (defined as MAIS 3+ or ISS>15 injury) to a subset of NASS-CDS cases based on crash attributes. Subsequently, actual AIS and ISS levels were compared with the predicted probability of injury to determine the extent to which the seriously injured had corresponding probabilities exceeding the 10% and 20% risk thresholds. Models were developed using an 80% sample of NASS-CDS data from 2002 to 2012 and evaluations were performed using the remaining 20% of cases from the same period. Within the population of seriously injured (i.e., those having one or more AIS 3 or higher injuries), the number of occupants whose injury risk did not exceed the 10% and 20% thresholds were estimated to be 11,700 and 18,600, respectively, each year using the MAIS 3+ injury model. For the ISS>15 model, 8,100 and 11,000 occupants sustained ISS>15 injuries yet their injury probability did not reach the 10% and 20% probability for severe injury respectively. Conversely, model predictions suggested that, at the 10% and 20% thresholds, 207,700 and 55,400 drivers respectively would be incorrectly flagged as injured when their injuries had not reached the AIS 3 level. For the ISS>15 model, 87,300 and 41,900 drivers would be incorrectly flagged as injured when injury severity had not reached the ISS>15 injury level. This article provides important information comparing the expected positive and negative effects of an AACN system with thresholds at the 10% and 20% levels using 2 outcome metrics. Overall, results suggest that the 20% risk threshold would not provide a useful notification to improve the quality of care for a large number of seriously injured crash victims. Alternately, a lower threshold may increase the over triage rate. Based on the vehicle damage observed for crashes reaching and exceeding the 10% risk threshold, we anticipate that rescue services would have been deployed based on current Public Safety Answering Point (PSAP) practices.

The impact of mild induced hypothermia on the rate of transfusion and the mortality in severely injured patients: a retrospective multi-centre study.

PubMed

Jensen, Kai Oliver; Held, Leonhard; Kraus, Andrea; Hildebrand, Frank; Mommsen, Philipp; Mica, Ladislav; Wanner, Guido A; Steiger, Peter; Moos, Rudolf M; Simmen, Hans-Peter; Sprengel, Kai

2016-10-06

Although under discussion, induced hypothermia (IH) is an established therapy for patients with cardiac arrest or traumatic brain injuries. The influences on coagulopathy and bleeding tendency in severely injured patients (SIP) with concomitant traumatic brain injury are most widely unclear. Therefore, the aim of this study was to quantify the effect of mild IH in SIP with concomitant severe traumatic brain injuries on transfusion rate and mortality. In this retrospective multi-centre study, SIP from three European level-1 trauma centres with an ISS ≥16 between 2009 and 2011 were included. At hospital A, patients qualified for IH with age ≤70 years and a severe head injury with an abbreviated injury scale (AIS Head ) of ≥3. IH was defined as target core body temperature of 35 °C. Hypothermic patients were matched with two patients, one from hospital B and one from hospital C using age and AIS Head . The effect of IH on the transfusion rate, complications and mortality was quantified with 95 % confidence intervals (CI). Patients not treated with IH in hospital A and those from hospital B and C, who were not matched, were used to adjust the CI for the effect of inter-hospital therapy protocol differences. Mean age of patients in the IH-group (n = 43) was 35.7 years, mean ISS 30 points and sex distribution showed 83.7 % male. Mean age of matched patients in the normotherm-group (n = 86) was 36.7 years, mean ISS 33 points and there were 75.6 % males. For the hypothermic patients, we pointed out an estimate of mean difference for the number of transfused units of packed red blood cells as well as for mortality which does not indicate a decrease in the benefit gained by hypothermia. It is suggested that hypothermic patients tend to a higher rate of lung failure and thromboembolisms. Though tending to an increased rate of complications, there is no evidence for a difference in both; rate of transfusion and mortality in SIP. Mild IH as an option for severe head injuries seems as well-being practicable in the presence of multiple severe injuries. Further, clinical studies regarding the side effects are necessary.

Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies.

PubMed

Villalobos, Miguel A; Hazelton, Joshua P; Choron, Rachel L; Capano-Wehrle, Lisa; Hunter, Krystal; Gaughan, John P; Ross, Steven E; Seamon, Mark J

2017-05-01

Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children. An American College of Surgeons-verified Level 1 trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann-Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications. Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11-17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17-42), pediatric trauma score 5 (6; 2-8), penetrating abdominal trauma index score [PATI] 29 (32; 12-44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14-18) vs. 16 (7; 10-17)) and were more severely injured (ISS, 33 [25; 17-42] vs. 16 [16; 9-25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5-16.5] vs. 1 (0; [0-1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8-25] vs. 7 [4; 4-8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18-41] vs. nonsurvivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18-39] days) requiring 3 (2; 2-4) laparotomies during 4 (6; 2-8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15-18 years) and period (1996-2006 vs. 2007-2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 - 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93-0.99], p = 0.0254) predicted mortality after severe injury. DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries. Therapeutic study, level IV.

Mobile health technology transforms injury severity scoring in South Africa.

PubMed

Spence, Richard Trafford; Zargaran, Eiman; Hameed, S Morad; Navsaria, Pradeep; Nicol, Andrew

2016-08-01

The burden of data collection associated with injury severity scoring has limited its application in areas of the world with the highest incidence of trauma. Since January 2014, electronic records (electronic Trauma Health Records [eTHRs]) replaced all handwritten records at the Groote Schuur Hospital Trauma Unit in South Africa. Data fields required for Glasgow Coma Scale, Revised Trauma Score, Kampala Trauma Score, Injury Severity Score (ISS), and Trauma Score-Injury Severity Score calculations are now prospectively collected. Fifteen months after implementation of eTHR, the injury severity scores were compared as predictors of mortality on three accounts: (1) ability to discriminate (area under receiver operating curve, ROC); (2) ability to calibrate (observed versus expected ratio, O/E); and (3) feasibility of data collection (rate of missing data). A total of 7460 admissions were recorded by eTHR from April 1, 2014 to July 7, 2015, including 770 severely injured patients (ISS > 15) and 950 operations. The mean age was 33.3 y (range 13-94), 77.6% were male, and the mechanism of injury was penetrating in 39.3% of cases. The cohort experienced a mortality rate of 2.5%. Patient reserve predictors required by the scores were 98.7% complete, physiological injury predictors were 95.1% complete, and anatomic injury predictors were 86.9% complete. The discrimination and calibration of Trauma Score-Injury Severity Score was superior for all admissions (ROC 0.9591 and O/E 1.01) and operatively managed patients (ROC 0.8427 and O/E 0.79). In the severely injured cohort, the discriminatory ability of Revised Trauma Score was superior (ROC 0.8315), but no score provided adequate calibration. Emerging mobile health technology enables reliable and sustainable injury severity scoring in a high-volume trauma center in South Africa. Copyright © 2016 Elsevier Inc. All rights reserved.

Central diabetes insipidus in pediatric severe traumatic brain injury.

PubMed

Alharfi, Ibrahim M; Stewart, Tanya Charyk; Foster, Jennifer; Morrison, Gavin C; Fraser, Douglas D

2013-02-01

To determine the occurrence rate of central diabetes insipidus in pediatric patients with severe traumatic brain injury and to describe the clinical, injury, biochemical, imaging, and intervention variables associated with mortality. Retrospective chart and imaging review. Children's Hospital, level 1 trauma center. Severely injured (Injury Severity Score ≥ 12) pediatric trauma patients (>1 month and <18 yr) with severe traumatic brain injury (presedation Glasgow Coma Scale ≤ 8 and head Maximum Abbreviated Injury Scale ≥ 4) that developed acute central diabetes insipidus between January 2000 and December 2011. Of 818 severely injured trauma patients, 180 had severe traumatic brain injury with an overall mortality rate of 27.2%. Thirty-two of the severe traumatic brain injury patients developed acute central diabetes insipidus that responded to desamino-8-D-arginine vasopressin and/or vasopressin infusion, providing an occurrence rate of 18%. At the time of central diabetes insipidus diagnosis, median urine output and serum sodium were 6.8 ml/kg/hr (interquartile range = 5-11) and 154 mmol/L (interquartile range = 149-159), respectively. The mortality rate of central diabetes insipidus patients was 87.5%, with 71.4% declared brain dead after central diabetes insipidus diagnosis. Early central diabetes insipidus onset, within the first 2 days of severe traumatic brain injury, was strongly associated with mortality (p < 0.001), as were a lower presedation Glasgow Coma Scale (p = 0.03), a lower motor Glasgow Coma Scale (p = 0.01), an occurrence of fixed pupils (p = 0.04), and a prolonged partial thromboplastin time (p = 0.04). Cerebral edema on the initial computed tomography, obtained in the first 24 hrs after injury, was the only imaging finding associated with death (p = 0.002). Survivors of central diabetes insipidus were more likely to have intracranial pressure monitoring (p = 0.03), have thiopental administered to induce coma (p = 0.04) and have received a decompressive craniectomy for elevated intracranial pressure (p = 0.04). The incidence of central diabetes insipidus in pediatric patients with severe traumatic brain injury is 18%. Mortality was associated with early central diabetes insipidus onset and cerebral edema on head computed tomography. Central diabetes insipidus nonsurvivors were less likely to have received intracranial pressure monitoring, thiopental coma and decompressive craniectomy.

An independent SSVEP-based brain-computer interface in locked-in syndrome

NASA Astrophysics Data System (ADS)

Lesenfants, D.; Habbal, D.; Lugo, Z.; Lebeau, M.; Horki, P.; Amico, E.; Pokorny, C.; Gómez, F.; Soddu, A.; Müller-Putz, G.; Laureys, S.; Noirhomme, Q.

2014-06-01

Objective. Steady-state visually evoked potential (SSVEP)-based brain-computer interfaces (BCIs) allow healthy subjects to communicate. However, their dependence on gaze control prevents their use with severely disabled patients. Gaze-independent SSVEP-BCIs have been designed but have shown a drop in accuracy and have not been tested in brain-injured patients. In the present paper, we propose a novel independent SSVEP-BCI based on covert attention with an improved classification rate. We study the influence of feature extraction algorithms and the number of harmonics. Finally, we test online communication on healthy volunteers and patients with locked-in syndrome (LIS). Approach. Twenty-four healthy subjects and six LIS patients participated in this study. An independent covert two-class SSVEP paradigm was used with a newly developed portable light emitting diode-based ‘interlaced squares' stimulation pattern. Main results. Mean offline and online accuracies on healthy subjects were respectively 85 ± 2% and 74 ± 13%, with eight out of twelve subjects succeeding to communicate efficiently with 80 ± 9% accuracy. Two out of six LIS patients reached an offline accuracy above the chance level, illustrating a response to a command. One out of four LIS patients could communicate online. Significance. We have demonstrated the feasibility of online communication with a covert SSVEP paradigm that is truly independent of all neuromuscular functions. The potential clinical use of the presented BCI system as a diagnostic (i.e., detecting command-following) and communication tool for severely brain-injured patients will need to be further explored.

[Decision making and executive function in severe traumatic brain injured patients: validation of a decision-making task and correlated features].

PubMed

Wiederkehr, S; Barat, M; Dehail, P; de Sèze, M; Lozes-Boudillon, S; Giroire, J-M

2005-02-01

At the chronic stage, severe traumatic brain injured (TBI) patients experience difficulty in making decisions. Several studies have demonstrated the involvement of the prefrontal cortex, in particular the orbitofrontal region, in decision-making. The aim of the present study was to validate a decision-making task in this population and to ascertain whether the components of their dysexecutive syndrome may affect their decision-making and lead to difficulties for social rehabilitation. Fifteen TBI patients and 15 controlled subjects matched for age, sex and years of education were assessed by a battery of executive tests (GREFEX) and by the gambling task (GT). The TBI subjects performed significantly worse than the controlled group in five out of six GREFEX tests. The TBI choices are significantly more disadvantageous than the choices of the control group when considering the three last blocks of 20 cards of the GT. The GT total score correlated significantly with execution time of the Stroop interference condition and the Trail Making Task B, as well as with the two measures (correct sequence span and number of crossed boxes) of the double condition of Baddeley's task. We postulate that executive functioning (supervisory attentional system) influence performance in the gambling task through mechanisms of inhibitory control, divided attention and working memory. Thus, this task seems to be determined by multiple factors; the process of decision-making may depend on frontal integrity.

[Changes in skiing accidents during the last 20 years].

PubMed

Röthlisberger, M

1990-01-01

Since 23 years the skiing-accidents are statistically surveyed in the private practice of the author. The number of injured patients is continuously decreasing. Specially the injuries in years with little snow fall are analyzed. It is evident that leg fractures are quite rare but severe injuries of the knee are increasing. 50% of ski accidents are minor injuries.

Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults.

PubMed

Ichwan, Brian; Darbha, Subrahmanyam; Shah, Manish N; Thompson, Laura; Evans, David C; Boulger, Creagh T; Caterino, Jeffrey M

2015-01-01

We evaluate the sensitivity of Ohio's 2009 emergency medical services (EMS) geriatric trauma triage criteria compared with the previous adult triage criteria in identifying need for trauma center care among older adults. We studied a retrospective cohort of injured patients aged 16 years or older in the 2006 to 2011 Ohio Trauma Registry. Patients aged 70 years or older were considered geriatric. We identified whether each patient met the geriatric and the adult triage criteria. The outcome measure was need for trauma center care, defined by surrogate markers: Injury Severity Score greater than 15, operating room in fewer than 48 hours, any ICU stay, and inhospital mortality. We calculated sensitivity and specificity of both triage criteria for both age groups. We included 101,577 patients; 33,379 (33%) were geriatric. Overall, 57% of patients met adult criteria and 68% met geriatric criteria. Using Injury Severity Score, for older adults geriatric criteria were more sensitive for need for trauma center care (93%; 95% confidence interval [CI] 92% to 93%) than adult criteria (61%; 95% CI 60% to 62%). Geriatric criteria decreased specificity in older adults from 61% (95% CI 61% to 62%) to 49% (95% CI 48% to 49%). Geriatric criteria in older adults (93% sensitivity, 49% specificity) performed similarly to the adult criteria in younger adults (sensitivity 87% and specificity 44%). Similar patterns were observed for other outcomes. Standard adult EMS triage guidelines provide poor sensitivity in older adults. Ohio's geriatric trauma triage guidelines significantly improve sensitivity in identifying Injury Severity Score and other surrogate markers of the need for trauma center care, with modest decreases in specificity for older adults. Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

The pre-hospital administration of tranexamic acid to patients with multiple injuries and its effects on rotational thrombelastometry: a prospective observational study in pre-hospital emergency medicine.

PubMed

Kunze-Szikszay, Nils; Krack, Lennart A; Wildenauer, Pauline; Wand, Saskia; Heyne, Tim; Walliser, Karoline; Spering, Christopher; Bauer, Martin; Quintel, Michael; Roessler, Markus

2016-10-10

Hyperfibrinolysis (HF) is a major contributor to coagulopathy and mortality in trauma patients. This study investigated (i) the rate of HF during the pre-hospital management of patients with multiple injuries and (ii) the effects of pre-hospital tranexamic acid (TxA) administration on the coagulation system. From 27 trauma patients with pre-hospital an estimated injury severity score (ISS) ≥16 points blood was obtained at the scene and on admission to the emergency department (ED). All patients received 1 g of TxA after the first blood sample was taken. Rotational thrombelastometry (ROTEM) was performed for both blood samples, and the results were compared. HF was defined as a maximum lysis (ML) >15 % in EXTEM. The median (min-max) ISS was 17 points (4-50 points). Four patients (15 %) had HF diagnosed via ROTEM at the scene, and 2 patients (7.5 %) had HF diagnosed via ROTEM on admission to the ED. The median ML before TxA administration was 11 % (3-99 %) vs. 10 % after TxA administration (4-18 %; p > 0.05). TxA was administered 37 min (10-85 min) before ED arrival. The ROTEM results before and after TxA administration did not significantly differ. No adverse drug reactions were observed after TxA administration. HF can be present in severely injured patients during pre-hospital care. Antifibrinolytic therapy administered at the scene is a significant time saver. Even in milder trauma fibrinogen can be decreased to critically low levels. Early administration of TxA cannot reverse or entirely stop this decrease. The pre-hospital use of TxA should be considered for severely injured patients to prevent the worsening of trauma-induced coagulopathy and unnecessarily high fibrinogen consumption. ClinicalTrials.gov ID NCT01938768 (Registered 5 September 2013).

Blast injury from explosive munitions.

PubMed

Cernak, I; Savic, J; Ignjatovic, D; Jevtic, M

1999-07-01

To evaluate the effect of blast in common war injuries. One thousand three hundred and three patients injured by explosive munitions and demonstrating extremity wounds without other penetrating injuries were admitted to the Military Medical Academy in Belgrade between 1991 and 1994. Of these, 665 patients (51%) had symptoms and physical signs that were compatible with the clinical diagnosis of primary blast injury, whereas the remaining 658 patients did not. Random sampling of 65 patients in the blast group during the early posttraumatic period showed statistically significant elevations in blood thromboxane A2 (TxA2), prostacyclin (PGI2), and sulfidopeptide leukotrienes compared with the random sample of 62 patients in the nonblast group. This difference could not be accounted for by differing injury severity between the groups, because the severity of wounds as measured by both the Injury Severity Score and the Red Cross Wound Classification was similar in both groups. Amongst blast patients, 200 patients (30%) had long-term (1 year) symptoms and signs reflecting central nervous system disorders. These symptoms and signs were only sporadically found in 4% of the nonblast patients. These findings indicate that primary blast injury is more common in war injuries than previously thought and that of those affected by blast, a surprisingly high proportion retain long-term neurologic disability. The elevation in eicosanoids could be used to confirm and monitor blast injury. In relation to the immediate management of patients injured by explosive weapons, it follows that particular attention should be paid to the presence and/or development of blast injury. Our findings indicate that blast is more common in war injuries than previously thought. Eicosanoid changes after blast injury suggest that blast injury causes a major physiologic stress. A variety of effects on the central nervous system suggest that blast injury could be responsible for some aspects of what is now considered to be the posttraumatic stress disorder.

The implications of alcohol intoxication and the Uniform Policy Provision Law on trauma centers; a national trauma data bank analysis of minimally injured patients.

PubMed

O'Keeffe, Terence; Shafi, Shahid; Sperry, Jason L; Gentilello, Larry M

2009-02-01

Alcohol intoxication may confound the initial assessment of trauma patients, resulting in increased use of diagnostic and therapeutic procedures, thereby increasing hospital costs. The Uniform Policy Provision Law (UPPL) exists in many states and allows insurance companies to deny payment for medical treatment for alcohol-related injuries. If intoxication increases resource utilization, these denials compound the financial burden of alcohol use on trauma centers. We hypothesized that patients injured while under the influence of alcohol require more diagnostic tests, procedures, and hospital admissions, leading to higher hospital charges. The National Trauma Databank (2000-2004) was analyzed to identify adult trauma patients (age > or = 16 years) who were discharged alive, had a length of stay < or = 1 day and minor injuries (Injury Severity Score < 9), and were tested for blood alcohol. The study was confined to minimally injured patients to facilitate identification of unexpected resource use most likely attributable to alcohol use. Resource utilization was compared among patients who tested positive or negative for alcohol use. Results are presented as odds ratio (OR) with 95% confidence intervals (CI). Sixty-eight thousand eight patients met study criteria, of which 31,020 were positive for alcohol. Despite similar baseline characteristics, alcohol-positive patients required significantly more invasive procedures, including intubation (OR 4.16, 95% CI = 3.56-4.85) and Foley catheter insertion (OR 1.52, 95% CI = 1.39-1.67) as well as diagnostic tests (CT scan OR 1.16, 95% CI = 1.12-1.20). They were also less likely to be discharged from the emergency department (OR 0.61, 95% CI = 0.58-0.64), and more frequently required hospital (OR 1.64, 95% CI = 1.57-1.73) or intensive care unit admission (OR 1.82, 95% CI = 1.71-1.94). Mean hospital charges were $1,833 greater ($10,405 +/- 225 vs. 8,572 +/- 68). A significant amount of trauma center costs are primarily attributable to alcohol use rather than injury severity or outcome. The financial costs associated with alcohol use and UPPL-related cost-shifting to trauma centers is a significant burden to trauma centers. UPPL laws that penalize trauma centers for identifying intoxicated patients should be repealed in states where they exist.

Hospital Stay as a Proxy Indicator for Severe Injury in Earthquakes: A Retrospective Analysis

PubMed Central

Zhao, Lu-Ping; Gerdin, Martin; Westman, Lina; Rodriguez-Llanes, Jose Manuel; Wu, Qi; van den Oever, Barbara; Pan, Liang; Albela, Manuel; Chen, Gao; Zhang, De-Sheng; Guha-Sapir, Debarati; von Schreeb, Johan

2013-01-01

Introduction Earthquakes are the most violent type of natural disasters and injuries are the dominant medical problem in the early phases after earthquakes. However, likely because of poor data availability, high-quality research on injuries after earthquakes is lacking. Length of hospital stay (LOS) has been validated as a proxy indicator for injury severity in high-income settings and could potentially be used in retrospective research of injuries after earthquakes. In this study, we assessed LOS as an adequate proxy indicator for severe injury in trauma survivors of an earthquake. Methods A retrospective analysis was conducted using a database of 1,878 injured patients from the 2008 Wenchuan earthquake. Our primary outcome was severe injury, defined as a composite measure of serious injury or resource use. Secondary outcomes were serious injury and resource use, analysed separately. Non-parametric receiver operating characteristics (ROC) and area under the curve (AUC) analysis was used to test the discriminatory accuracy of LOS when used to identify severe injury. An 0.7

Hospital stay as a proxy indicator for severe injury in earthquakes: a retrospective analysis.

PubMed

Zhao, Lu-Ping; Gerdin, Martin; Westman, Lina; Rodriguez-Llanes, Jose Manuel; Wu, Qi; van den Oever, Barbara; Pan, Liang; Albela, Manuel; Chen, Gao; Zhang, De-Sheng; Guha-Sapir, Debarati; von Schreeb, Johan

2013-01-01

Earthquakes are the most violent type of natural disasters and injuries are the dominant medical problem in the early phases after earthquakes. However, likely because of poor data availability, high-quality research on injuries after earthquakes is lacking. Length of hospital stay (LOS) has been validated as a proxy indicator for injury severity in high-income settings and could potentially be used in retrospective research of injuries after earthquakes. In this study, we assessed LOS as an adequate proxy indicator for severe injury in trauma survivors of an earthquake. A retrospective analysis was conducted using a database of 1,878 injured patients from the 2008 Wenchuan earthquake. Our primary outcome was severe injury, defined as a composite measure of serious injury or resource use. Secondary outcomes were serious injury and resource use, analysed separately. Non-parametric receiver operating characteristics (ROC) and area under the curve (AUC) analysis was used to test the discriminatory accuracy of LOS when used to identify severe injury. An 0.7

A novel perspective for burn-induced myopathy: Membrane repair defect

PubMed Central

Wang, Chao; Wang, Hongyu; Wu, Dan; Hu, Jianhong; Wu, Wei; Zhang, Yong; Peng, Xi

2016-01-01

Myopathy is a common complication of severe burn patients. One potential cause of this myopathy could be failure of the plasma membrane to undergo repair following injuries generated from toxin or exercise. The aim of this study is to assess systemic effect on muscle membrane repair deficiency in burn injury. Skeletal muscle fibers isolated from burn-injured mice were damaged with a UV laser and dye influx imaged confocally to evaluate membrane repair capacity. Membrane repair failure was also tested in burn-injured mice subjected to myotoxin or treadmill exercise. We further used C2C12 myotubules and animal models to investigate the role of MG53 in development of burn-induced membrane repair defect. We demonstrated that skeletal muscle myofibers in burn-injured mice showed significantly more dye uptake after laser damage than controls, indicating a membrane repair deficiency. Myotoxin or treadmill exercise also resulted in a higher-grade repair defect in burn-injured mice. Furthermore, we observed that burn injury induced a significant decrease in MG53 levels and its dimerization in skeletal muscles. Our findings highlight a new mechanism that implicates membrane repair failure as an underlying cause of burn-induced myopathy. And, the disorders in MG53 expression and MG53 dimerization are involved in this cellular pathology. PMID:27545095

Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport?

PubMed

Calhoun, Amanda; Keller, Martin; Shi, Junxin; Brancato, Celeste; Donovan, Kathy; Kraus, Diana; Leonard, Julie C

2017-01-01

Studies show that pediatric trauma centers produce better outcomes and reduced mortality for injured children. Yet, most children do not have timely access to a pediatric trauma center and require stabilization locally with subsequent transfer. Investigators have demonstrated that pediatric transport teams (PTT) improve outcomes for critically ill children; however, these studies did not differentiate outcomes for injured children. It may be that moderate to severely injured children actually fare worse with PTT due to slower transport times inherent to their remote locations and thus delays in important interventions. The purpose of this study was to determine if outcomes for injured children are affected by use of PTT for inter-hospital transfer. We conducted a retrospective chart review of 1,177 children transferred to a pediatric trauma center for injury care between March 1st, 2012 and December 31st, 2013. We compared children who were transported by PTT (ground/air) to those transported by ground advanced life support (ALS) and air critical care (ACC). We described patient characteristics and transport times. For PTT vs. ALS and ACC, we compared hospital length of stay (LOS), transport interventions and adverse events. 1,177 injured children were transferred by the following modes: 68% ALS, 13% ACC, 11% Ground PTT, and 9% Air PTT. Children transported by PTT were younger and had higher ISS and lower GCS scores. PTT had a longer total transport time, departure preparation time, and patient bedside time. After controlling for age, ISS, GCS, transport mode, distance, and time, we found no significant difference in LOS between PTT vs. ALS and ACC. A subgroup analysis of children with higher ISS scores demonstrated a 65% longer LOS for children transported by ACC vs. PTT. There were no differences between transport teams with regard to acidosis, hypocarbia or hypercarbia, or maintenance of tubes and lines. Children transported by PTT were younger and sicker (vs. ACC and ALS). Despite longer transport times, children transported by PTT did not have a longer hospital LOS or adverse events during transport. However, for those children with higher ISS, transport by ACC resulted in longer hospital LOS vs. PTT.

Residual cognitive disability after completion of inpatient rehabilitation among injured children.

PubMed

Zonfrillo, Mark R; Durbin, Dennis R; Winston, Flaura K; Zhang, Xuemei; Stineman, Margaret G

2014-01-01

To determine the prevalence and nature of residual cognitive disability after inpatient rehabilitation for children aged 7-18 years with traumatic injuries. This retrospective cohort study included children aged 7-18 years in the Uniform Data System for Medical Rehabilitation who underwent inpatient rehabilitation for traumatic injuries in 523 facilities from 2002-2011. Traumatic injuries were identified by standardized Medicare Inpatient Rehabilitation Facility-Patient Assessment Instrument codes. Cognitive outcomes were measured by the Functional Independence Measure instrument. A validated, categorical staging system derived from responses to the items in the cognitive domain of the functional independence measure was used and consisted of clinically relevant levels of cognitive achievement from stage 1 (total cognitive disability) to stage 7 (completely independent cognitive function). There were 13,798 injured children who completed inpatient rehabilitation during the 10-year period. On admission to inpatient rehabilitation, patients with traumatic brain injury (TBI) had more cognitive disability (median stage 2) than those with spinal cord injury or other injuries (median stage 5). Cognitive functioning improved for all patients, but children with TBI still tended to have significant residual cognitive disability (median stage on discharge, 4). Injured children gained cognitive functionality throughout inpatient rehabilitation. Those with TBI had more severe cognitive disability on admission and more residual disability on discharge. This is important not only for patient and family expectation setting but also for resource and service planning, as discharge from inpatient rehabilitation is a critical milestone for reintegration into society for children with serious injury. Copyright © 2014 Mosby, Inc. All rights reserved.

[Cost analysis of emergency room patients in the German diagnosis-related groups system. A practice relevant depiction subject to clinical parameters].

PubMed

Garving, C; Santosa, D; Bley, C; Pape, H-C

2014-08-01

Since the implementation of the diagnosis-related system there has been a continuous lack of finances in the treatment of multiple injured patients. The current investigation summarizes consecutive patients from a level I trauma centre and tests the hypothesis that an injury severity score (ISS) based reimbursement would be an improvement in the cost-effectiveness of this patient population. The study is based on multiple injured patients admitted to the emergency department in 2009. The ISS, intensive care unit (ICU) stay and cost data were recorded for every patient and two subgroups were formed: group I ISS < 16 and group II ISS ≥ 16. A total of 442 patients with an average age of 40.5 ± 9.1 years (ISS 12) were included. The average amount of coverage during an average length of stay of 13.15 ± 6.3 was -2,752 per patient. Patients in group I (n = 296, ISS 6.3) showed a value of -1,163 with an average length of stay of 8 ± 4.6 days. In group II (n = 146, ISS 23.6) the average amount of coverage was -5,973 during an average hospital stay of 23 ± 8.7 days. Improvements have been made with the recent adjustment of the reimbursement within the last year. Nevertheless, several factors identified in this study require additional adjustment: the ISS, the requirement of blood transfusion and the presence of additional chest trauma should be weighted in the calculation of reimbursement.

Effect of Melatonin Administration on Sleep Quality in Sulfur Mustard Exposed Patients with Sleep Disorders

PubMed Central

Mousavi, Seyyedeh Soghra; Shohrati, Majid; Vahedi, Ensieh; Abdollahpour-Alitappeh, Meghdad; Panahi, Yunes

2018-01-01

Sulfur mustard (SM) is a toxic agent that targets several tissues. It is the leading cause of persistent lung disease, progressive deterioration in lung function, and mortality among injured patients. Disturbed sleep and poor quality of sleep are common in SM-exposed patients with chronic respiratory problems. Melatonin is an alternative medication that has been widely used to treat poor sleep quality caused by several specific conditions. This study aimed to evaluate the efficacy of melatonin administration in improvement of sleep quality in SM-injured patients. In this randomized, double-blind and placebo-controlled trial study a total of 30 SM-exposed male patients were recruited. Patients received 3 mg melatonin (N = 15) or placebo (N = 15), orally in a single dose, 1 h before bedtime for 56 consecutive days. Sleep quality was evaluated by Pittsburgh Sleep Quality Index (PSQI); daytime sleepiness was measured by Epworth Sleepiness Scale (ESS), and the risk of obstructive sleep apnea was determined by STOP-Bang questionnaire. Compared with placebo, melatonin administration significantly improved global PSQI score, particularly sleep latency (P = 0.03) and subjective sleep quality (P = 0.004). Mean of global PSQI score was declined significantly (P = 0.01) from 10.13 ± 3.44 to 6.66 ± 3.08 in melatonin group. No differences in ESS and STOP-Bang scores were observed between two groups. Melatonin was effective in improving global PSQI score and sleep latency, but not daytime sleepiness and obstructive sleep apnea in SM-exposed patients. Further long-term studies involving larger number of patients are needed before melatonin can be safely recommended for the management of sleep disturbances in these patients.

Impact of the terrorist bombings of the Neve Shalom and Beth Israel Synagogues on a hospital in Istanbul, Turkey.

PubMed

Rodoplu, Ulkümen; Arnold, Jeffrey L; Tokyay, Rifat; Ersoy, Gurkan; Cetiner, Serkan; Yücel, Tayfun

2005-02-01

The authors sought to estimate the impact of the open-air mass-casualty terrorist bombings of the Neve Shalom and Beth Israel Synagogues in Istanbul, Turkey, on November 15, 2003, on the American Hospital (AH) in terms of resource utilization, epidemiologic outcomes, and time course of emergency needs. A retrospective descriptive study using data from hospital records of injured survivors who used the emergency department at AH on November 15, 2003, to determine the number and percentage of injured survivors who were hospitalized, received operative care, had specific injury types, had an Injury Severity Score >/=16, died, and arrived within certain time intervals. AH received 69 (91%) injured survivors from the scene, of which nine (12%) were hospitalized and three (4%) received operative care. Starting four hours after the initial blast, seven (9%) injured survivors were transferred to AH from other hospitals, of which five (7%) were hospitalized and four (5%) received operative care. Of the 49 injured survivors from the scene with documented injuries, 43 (88%) had injuries to the head or face, 42 (86%) had lacerations, five (10%) had fractures, one (2%) had a penetrating eye injury, one (2%) had a serious intracranial injury, and none had primary blast injuries. Four (5%) injured survivors at AH had an Injury Severity Score >/=16, and none died. Seventy-six injured survivors used the emergency department at AH, including a delayed wave of injured survivors transferred from other hospitals. The majority of injured survivors with documented injuries had non-life-threatening lacerations of the head or face, and relatively few injured survivors were hospitalized or received operative care.

Alcohol abuse and the injured host; Dysregulation of counteregulatory mechanisms Review

PubMed Central

Molina, Patricia E.; Sulzer, Jesse K.; Whitaker, Annie

2013-01-01

Traumatic injury ranks as the number one cause of death for the under 44 year old age group and 5th leading cause of death overall (www.nationaltraumainstitute.org/home/trauma_statistics.html). Although improved resuscitation of trauma patients has dramatically reduced immediate mortality from hemorrhagic shock, long-term morbidity and mortality continue to be unacceptably high during the post-resuscitation period, particularly as a result of impaired host immune responses to subsequent challenges such as surgery or infection. Acute alcohol intoxication (AAI) is a significant risk factor for traumatic injury; with intoxicating blood alcohol levels present in more than 40% of injured patients (1–5). Severity of trauma, hemorrhagic shock and injury is higher in intoxicated individuals than that of sober victims, resulting in higher mortality rates in this patient population. Necessary invasive procedures (surgery, anesthesia) and subsequent challenges (infection) that intoxicated trauma victims are frequently subjected to are additional stresses to an already compromised inflammatory and neuroendocrine milieu and further contribute to their morbidity and mortality. Thus, dissecting the dynamic imbalance produced by AAI during trauma is of critical relevance for a significant proportion of injured victims. This review outlines how AAI at the time of hemorrhagic shock not only prevents adequate responses to fluid resuscitation but also impairs the ability of the host to overcome a secondary infection. Moreover, it discusses the neuroendocrine mechanisms underlying alcohol-induced hemodynamic dysregulation and its relevance to host defense restoration of homeostasis following injury. PMID:23416555

Hypothermia and associated outcomes in seriously injured trauma patients in a predominantly sub-tropical climate.

PubMed

Aitken, L M; Hendrikz, J K; Dulhunty, J M; Rudd, M J

2009-02-01

This study aimed to determine factors linked to hypothermia (<35 degrees C) in Queensland trauma patients. The relationship of hypothermia with mortality, admission to intensive care and hospital length of stay was also explored. A retrospective analysis of data from the Queensland Trauma Registry was undertaken, and included all patients admitted to hospital for > or =24h during 2003 and 2004 with an injury severity score (ISS)>15. Demographic, injury, environmental, care and clinical status factors were considered. A total of 2182 patients were included; 124 (5.7%) had hypothermia on admission to the definitive care hospital, while a further 156 (7.1%) developed hypothermia during hospitalisation. Factors associated with hypothermia on admission included winter, direct admission to a definitive care hospital, an ISS> or =40, a Glasgow Coma Scale of 3 or ventilated and sedated, and hypotension on admission. Hypothermia on admission to the definitive care hospital was an independent predictor of mortality (odds ratio [OR]=4.05; 95% confidence interval [CI] 2.26-7.24) and hospital length of stay (incidence rate ratio [IRR]=1.22; 95% CI 1.03-1.43). Hypothermia during definitive care hospitalisation was independently associated with mortality (OR=2.52; 95% CI 1.52-4.17), intensive care admission (OR=1.73; 95% CI 1.20-2.93) and hospital length of stay (IRR=1.18; 95% CI 1.02-1.36). Trauma patients in a predominantly sub-tropical climate are at risk of accidental and endogenous hypothermia, with associated higher mortality and care requirements. Prevention of hypothermia is important for all severely injured patients.

Legal preparedness: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

PubMed

Courtney, Brooke; Hodge, James G; Toner, Eric S; Roxland, Beth E; Penn, Matthew S; Devereaux, Asha V; Dichter, Jeffrey R; Kissoon, Niranjan; Christian, Michael D; Powell, Tia

2014-10-01

Significant legal challenges arise when health-care resources become scarce and population-based approaches to care are implemented during severe disasters and pandemics. Recent emergencies highlight the serious legal, economic, and health impacts that can be associated with responding in austere conditions and the critical importance of comprehensive, collaborative health response system planning. This article discusses legal suggestions developed by the American College of Chest Physicians (CHEST) Task Force for Mass Critical Care to support planning and response efforts for mass casualty incidents involving critically ill or injured patients. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. Following the CHEST Guidelines Oversight Committee's methodology, the Legal Panel developed 35 key questions for which specific literature searches were then conducted. The literature in this field is not suitable to provide support for evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process resulting in seven final suggestions. Acceptance is widespread for the health-care community's duty to appropriately plan for and respond to severe disasters and pandemics. Hospitals, public health entities, and clinicians have an obligation to develop comprehensive, vetted plans for mass casualty incidents involving critically ill or injured patients. Such plans should address processes for evacuation and limited appeals and reviews of care decisions. To legitimize responses, deter independent actions, and trigger liability protections, mass critical care (MCC) plans should be formally activated when facilities and practitioners shift to providing MCC. Adherence to official MCC plans should contribute to protecting hospitals and practitioners who act in good faith from liability. Finally, to address anticipated staffing shortages during severe and prolonged disasters and pandemics, governments should develop approaches to formally expand the availability of qualified health-care workers, such as through using official foreign medical teams. As a fundamental element of health-care and public health emergency planning and preparedness, the law underlies critical aspects of disaster and pandemic responses. Effective responses require comprehensive advance planning efforts that include assessments of complex legal issues and authorities. Recent disasters have shown that although law is a critical response tool, it can also be used to hold health-care stakeholders who fail to appropriately plan for or respond to disasters and pandemics accountable for resulting patient or staff harm. Claims of liability from harms allegedly suffered during disasters and pandemics cannot be avoided altogether. However, appropriate planning and legal protections can help facilitate sound, consistent decision-making and support response participation among health-care entities and practitioners.

Quality of life following trauma before and after implementation of a physician-staffed helicopter.

PubMed

Funder, K S; Rasmussen, L S; Hesselfeldt, R; Siersma, V; Lohse, N; Sonne, A; Wulffeld, S; Steinmetz, J

2017-01-01

Implementation of a physician-staffed helicopter emergency medical service (PS-HEMS) in Denmark was associated with lower 30-day mortality in severely injured trauma patients and less time on social subsidy. However, the reduced 30-day mortality in severely injured patients might be at the expense of a worse functional outcome and quality of life (QoL) in those who survive. The aim of this study was to investigate the effect of a physician-staffed helicopter on long-term QoL in trauma patients. Prospective, observational study including trauma patients who survived at least 3 years after injury. A 5-month period prior to PS-HEMS implementation was compared with the first 12 months after PS-HEMS implementation. QoL was assessed 4.5 years after trauma by the SF-36 questionnaire. Primary endpoint was the Physical Component Summary score. Of the 1994 patients assessed by a trauma team, 1521 were eligible for inclusion in the study. Of these, 566 (37%) gave consent to participate and received a questionnaire by mail, and 402 (71%) of them returned the questionnaire (n = 114 before PS-HEMS; n = 288 after PS-HEMS implementation). Older patients, women and patients with trauma in the after PS-HEMS period were more likely to return the questionnaire. No significant association between QoL and period (before vs. after PS-HEMS) was found; the Physical Component Summary scores were 50.0 and 50.9 in the before and after PS-HEMS periods, respectively (P = 0.47). We also found no difference on multivariable analysis with adjustment for sex, age and injury severity score. No significant difference in QoL among trauma patients was found after implementation of a PS-HEMS. © 2016 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.

[Trauma network of the German Association of Trauma Surgery (DGU). Establishment, organization, and quality assurance of a regional trauma network of the DGU].

PubMed

Ruchholtz, S; Kühne, C A; Siebert, H

2007-04-01

The quality of care in Germany for seriously injured patients varies greatly in individual hospitals due to geographic variations among States and differences in resource allocation and treatment concepts. To assure and enhance treatment quality it seems sensible to establish a structured, quality assured network of clinics, which participate in the management of seriously injured patients according to different specified assignments. The conditions necessary for this type of network on a regional scale and for the clinics charged with the care of the seriously injured were summarized in the White Paper entitled "Management of the Seriously Injured-Recommendations for the Structure and Organization of Facilities in Germany for the Treatment of Seriously Injured Persons." The goal of this action is to ensure that every seriously injured person in Germany receives the best possible round-the-clock care in adherence to standardized quality criteria. This requires specialized expertise and the willingness of all involved parties-care providers, cost bearers, and hospital owners-to cooperate in further improving existing treatment concepts. As a logical consequence of long years of experience and scientific knowledge, the German Association of Trauma Surgery has developed a concept for establishing a regional trauma network of clinics, adapted to local conditions, for management of seriously injured patients. The participating facilities assume different responsibilities in the network depending on their equipment and structure. This article describes the individual steps toward establishing and organizing a network.

Beyond MICRA: new ideas for liability reform. American College of Physicians.

PubMed

1995-03-15

The existing medical liability system does not work. It does not deter negligence, provide timely compensation to injured persons, or resolve disputes fairly. Studies show that a large percentage of injured patients are not compensated and that physicians feel vulnerable to a lawsuit whether or not they practice high-quality medicine. The arbitrariness and inefficiency of the system disrupts the physician-patient relationship, increases health care costs, and, in some cases, hurts access to care. As a result, comprehensive changes to the liability system must be made. The American College of Physicians makes the following recommendations. 1. Congress should immediately pass the tort reforms contained in the California Medical Injury Compensation Reform Act (MICRA), particularly caps on noneconomic damages, as necessary short-term changes to a flawed system. 2. Federal legislation should be enacted that overturns recent court decisions that have relied on the Employee Retirement Income Security Act of 1974, a federal law that regulates pensions and other benefit plans, to bar plaintiffs from suing their health plan for negligence if the plan's benefits or treatment decisions lead to an injury. 3. Demonstration projects should be created and funded to examine the feasibility of using a set of caps for noneconomic damage awards that are based on the severity of injury suffered and the injured party's age. A set of caps could be seen as fairer to injured persons than flat caps but would still protect physicians from unlimited awards. 4. Demonstration projects should be authorized and funded to test enterprise liability and no-fault systems. These systems could take many forms, including administrative approaches; lists of accelerated compensation events; "early offer of settlement" approaches; and organizational liability for health plans, hospitals, or health systems. Such long-term reforms are consistent with trends in health care delivery and are necessary to promote quality of care, compensate injured persons, and protect physicians.

Out-of-hospital Hypertonic Resuscitation After Traumatic Hypovolemic Shock

PubMed Central

Bulger, Eileen M.; May, Susanne; Kerby, Jeffery D.; Emerson, Scott; Stiell, Ian G.; Schreiber, Martin A.; Brasel, Karen J.; Tisherman, Samuel A.; Coimbra, Raul; Rizoli, Sandro; Minei, Joseph P.; Hata, J. Steven; Sopko, George; Evans, David C.; Hoyt, David B.

2011-01-01

Objective To determine whether out-of-hospital administration of hypertonic fluids would improve survival after severe injury with hemorrhagic shock. Background Hypertonic fluids have potential benefit in the resuscitation of severely injured patients because of rapid restoration of tissue perfusion, with a smaller volume, and modulation of the inflammatory response, to reduce subsequent organ injury. Methods Multicenter, randomized, blinded clinical trial, May 2006 to August 2008, 114 emergency medical services agencies in North America within the Resuscitation Outcomes Consortium. Inclusion criteria: injured patients, age ≥ 15 years with hypovolemic shock (systolic blood pressure ≤ 70 mm Hg or systolic blood pressure 71–90 mm Hg with heart rate ≥ 108 beats per minute). Initial resuscitation fluid, 250 mL of either 7.5% saline per 6% dextran 70 (hypertonic saline/dextran, HSD), 7.5% saline (hypertonic saline, HS), or 0.9% saline (normal saline, NS) administered by out-of-hospital providers. Primary outcome was 28-day survival. On the recommendation of the data and safety monitoring board, the study was stopped early (23% of proposed sample size) for futility and potential safety concern. Results A total of 853 treated patients were enrolled, among whom 62% were with blunt trauma, 38% with penetrating. There was no difference in 28-day survival—HSD: 74.5% (0.1; 95% confidence interval [CI], −7.5 to 7.8); HS: 73.0% (−1.4; 95% CI, −8.7–6.0); and NS: 74.4%, P = 0.91. There was a higher mortality for the postrandomization subgroup of patients who did not receive blood transfusions in the first 24 hours, who received hypertonic fluids compared to NS [28-day mortality—HSD: 10% (5.2; 95% CI, 0.4–10.1); HS: 12.2% (7.4; 95% CI, 2.5–12.2); and NS: 4.8%, P < 0.01]. Conclusion Among injured patients with hypovolemic shock, initial resuscitation fluid treatment with either HS or HSD compared with NS, did not result in superior 28-day survival. However, interpretation of these findings is limited by the early stopping of the trial. PMID:21178763

The influence of injury severity on complication rates after primary closure or colostomy for penetrating colon trauma.

PubMed Central

Nelken, N; Lewis, F

1989-01-01

The management of penetrating colon injury has been frequently debated in the literature, yet few reports have evaluated primary closure versus diverting colostomy in similarly injured patients. Diverting colostomy is the standard of care when mucosal penetration is present, but primary closure in civilian practice has generally had excellent results, although it has been restricted to less severely injured patients. Because the degree of injury may influence choice of treatment in modern practice, various indices of injury severity have been proposed for assessment of patients with penetrating colon trauma. As yet, however, there has been no cross-comparison of repair type versus injury severity. A retrospective study 76 patients who sustained penetrating colon trauma between January 1, 1979 and December 31, 1985 and who survived for at least 24 hours was conducted. Different preferences among attending surgeons and a more aggressive approach to the use of primary closure during the years of study led to an essentially random use of primary closure and diverting colostomy for moderate levels of colon injury, with mandatory colostomy reserved for the most serious injuries. Primary closure was performed in 37 patients (three having resection and anastomosis), and colostomy was performed in 39 patients. Severity of injury was evaluated by the Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), and the Flint Colon Injury Score. Complications and outcome were evaluated as a function of severity of injury, and primary closure and colostomy were compared. Demographic profiles of the two groups did not differ regarding age, sex, mechanism of injury, shock, or delay between injury and operation. The mortality rate was 2.6% for each group. Major morbidity, including septic complications, occurred in 11% of the patients of the primary closure group and in 49% of those of the colostomy group. When PATI was less than 25, the Flint score was less than or equal to 2, or when the ISS was less than 25, primary closure resulted in fewer complications than did colostomy. Of the injury severity indices examined, the PATI most reliably predicted complications and specifically identified patients who whose outcome would be good with primary repair. These results suggest that the use of primary closure should be expanded in civilian penetrating colon trauma and that, even with moderate degrees of colon injury, primary closure provides an outcome equivalent to that provided by colostomy. In addition, the predictive value of the PATI suggests that it should be included along with other injury severity indices in trauma data bases. Images Fig. 3. Fig. 4. PMID:2930290

Injury severity of pedestrians, bicyclists and motorcyclists resulting from crashes with reversing cars.

PubMed

Decker, Sebastian; Otte, Dietmar; Cruz, Dana Leslie; Müller, Christian Walter; Omar, Mohamed; Krettek, Christian; Brand, Stephan

2016-09-01

Pedestrians, bicyclists and motorcyclists can suffer serious injury in road traffic crashes. To date, no studies examine the injury severity within this vulnerable cohort following collisions with reversing cars. Our institution prospectively maintains a database including medical and technical information regarding traffic accidents in our area, including urban and suburban regions. In a retrospective review of this database, the authors describe the injury severity of pedestrians, bicyclists and motorcyclists following traffic crashes involving reversing cars. Injury severity was described using the abbreviated injury scale (AIS) as well as the maximum abbreviated injury scale (MAIS). This study included 234 crashes occurring between 1999 and 2012. The lower extremity was injured most often while also suffering more severe injuries with a median AIS of 1 compared to 0 in all other documented body regions. The upper extremity was injured second most often. AIS ranging from 4 to 6 were infrequent. AIS 3 however, was documented for the legs in 4.3% of patients. MAIS 0, 1, 2, 3, 5 and 9 were found in 1, 164, 46, 14, 1, and 8 patients in the study cohort, respectively. Pedestrians and motorcyclists were seriously injured in 9.1% and 9.6% of cases, respectively. In contrast, no bicyclists suffered serious injuries. As to the zone of impact, most collisions occurred at the rear center of the vehicle (35%) followed by rear left (26%), rear right (20%), side rear (11%), side center (4%) and side front (3%). 204 (87.2%) collisions occurred during the day, 19 (8.1%) at night and 11 (4.7%) at twilight. Speed was similar in crashes involving pedestrians, bicyclists and motorcyclists, being as high as 7.0±3.6, 7.0±4.0 and 7.9±4.2km/h respectively. This is the first study that analyzes injury severity among these vulnerable road users following collisions with reversing vehicles. The majority of collisions occur at low impact speed during the day. Most injuries resulting from these collisions are not serious, however pedestrians are at greatest risk of severe injury to any body region. The lower extremities suffer the most serious and frequent injuries within this cohort. Copyright © 2016 Elsevier Ltd. All rights reserved.

One year ago not business as usual: wound management, infection and psychoemotional control during tertiary medical care following the 2004 Tsunami disaster in southeast Asia.

PubMed

Maegele, Marc; Gregor, Sven; Yuecel, Nedim; Simanski, Christian; Paffrath, Thomas; Rixen, Dieter; Heiss, Markus M; Rudroff, Claudia; Saad, Stefan; Perbix, Walter; Wappler, Frank; Harzheim, Andreas; Schwarz, Rosemarie; Bouillon, Bertil

2006-01-01

Following the 2004 tsunami disaster in southeast Asia severely injured tourists were repatriated via airlift to Germany. One cohort was triaged to the Cologne-Merheim Medical Center (Germany) for further medical care. We report on the tertiary medical care provided to this cohort of patients. This study is an observational report on complex wound management, infection and psychoemotional control associated with the 2004 Tsunami disaster. The setting was an adult intensive care unit (ICU) of a level I trauma center and subjects included severely injured tsunami victims repatriated from the disaster area (19 to 68 years old; 10 females and 7 males with unknown co-morbidities). Multiple large flap lacerations (2 x 3 to 60 x 60 cm) at various body sites were characteristic. Lower extremities were mostly affected (88%), followed by upper extremities (29%), and head (18%). Two-thirds of patients presented with combined injuries to the thorax or fractures. Near-drowning involved the aspiration of immersion fluids, marine and soil debris into the respiratory tract and all patients displayed signs of pneumonitis and pneumonia upon arrival. Three patients presented with severe sinusitis. Microbiology identified a variety of common but also uncommon isolates that were often multi-resistant. Wound management included aggressive debridement together with vacuum-assisted closure in the interim between initial wound surgery and secondary closure. All patients received empiric anti-infective therapy using quinolones and clindamycin, later adapted to incoming results from microbiology and resistance patterns. This approach was effective in all but one patient who died due to severe fungal sepsis. All patients displayed severe signs of post-traumatic stress response. Individuals evacuated to our facility sustained traumatic injuries to head, chest, and limbs that were often contaminated with highly resistant bacteria. Transferred patients from disaster areas should be isolated until their microbial flora is identified as they may introduce new pathogens into an ICU. Successful wound management, including aggressive debridement combined with vacuum-assisted closure was effective. Initial anti-infective therapy using quinolones combined with clindamycin was a good first-line choice. Psychoemotional intervention alleviated severe post-traumatic stress response. For optimum treatment and care a multidisciplinary approach is mandatory.

Thromboembolic Complications Following Trauma

DTIC Science & Technology

2009-12-01

subsequent neurologic deficit from these injuries approaches an inci- dence of 20 to 30 percent, the overall rate of stroke in the total trauma...investigating stroke and neurologic outcomes in blunt cerebrovascular injuries (BCVIs). In contrast, few reports of MI or mesenteric thrombosis in the...prohemostatic agents in uncontrolled studies of severely injured patients will only confuse rather than enlighten this area of research. No single paper has

Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children's hospital.

PubMed

Vernon, Donald D; Bolte, Robert G; Scaife, Eric; Hansen, Kristine W

2005-01-01

Freestanding children's hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways. At a tertiary care children's hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology. A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score > or =15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07. Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.

Engineering organs.

PubMed

Atala, Anthony

2009-10-01

Applications of regenerative medicine technology may offer novel therapies for patients with injuries, end-stage organ failure, or other clinical problems. Currently, patients suffering from diseased and injured organs can be treated with transplanted organs. However, there is a severe shortage of donor organs that is worsening yearly as the population ages and new cases of organ failure increase. Scientists in the field of regenerative medicine and tissue engineering are now applying the principles of cell transplantation, material science, and bioengineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. The stem cell field is also advancing rapidly, opening new avenues for this type of therapy. For example, therapeutic cloning and cellular reprogramming may one day provide a potentially limitless source of cells for tissue engineering applications. Although stem cells are still in the research phase, some therapies arising from tissue engineering endeavors have already entered the clinical setting successfully, indicating the promise regenerative medicine holds for the future.

Ice-skating and roller disco injuries in Dublin.

PubMed Central

Horner, C.; McCabe, M. J.

1984-01-01

A comparative study was carried out on a series of 72 ice-skating and 57 roller skating injuries over a sixteen month period. The average patient age was 20.5 years in the ice-skating group and 16.5 years in the roller skating group. Females predominated in both groups accounting for 72% of ice-skaters injured and 77% of roller skaters injured. Ice-skaters sustained more serious injuries than roller skaters as was evident from the significant difference in fracture numbers in the two groups. Ice-skating fractures accounted for 40% of all injuries while roller skating fractures were only 14% of their total injuries. The majority of ice-skating fractures occurred in females. As a result of our study we recommended several preventative measures. Images p207-a p207-b PMID:6487948

Access to specialist care: Optimizing the geographic configuration of trauma systems.

PubMed

Jansen, Jan O; Morrison, Jonathan J; Wang, Handing; He, Shan; Lawrenson, Robin; Hutchison, James D; Campbell, Marion K

2015-11-01

The optimal geographic configuration of health care systems is key to maximizing accessibility while promoting the efficient use of resources. This article reports the use of a novel approach to inform the optimal configuration of a national trauma system. This is a prospective cohort study of all trauma patients, 15 years and older, attended to by the Scottish Ambulance Service, between July 1, 2013, and June 30, 2014. Patients underwent notional triage to one of three levels of care (major trauma center [MTC], trauma unit, or local emergency hospital). We used geographic information systems software to calculate access times, by road and air, from all incident locations to all candidate hospitals. We then modeled the performance of all mathematically possible network configurations and used multiobjective optimization to determine geospatially optimized configurations. A total of 80,391 casualties were included. A network with only high- or moderate-volume MTCs (admitting at least 650 or 400 severely injured patients per year, respectively) would be optimally configured with a single MTC. A network accepting lower-volume MTCs (at least 240 severely injured patients per year) would be optimally configured with two MTCs. Both configurations would necessitate an increase in the number of helicopter retrievals. This study has shown that a novel combination of notional triage, network analysis, and mathematical optimization can be used to inform the planning of a national clinical network. Scotland's trauma system could be optimized with one or two MTCs. Care management study, level IV.

An anterior cruciate ligament injury does not affect the neuromuscular function of the non-injured leg except for dynamic balance and voluntary quadriceps activation.

PubMed

Zult, Tjerk; Gokeler, Alli; van Raay, Jos J A M; Brouwer, Reinoud W; Zijdewind, Inge; Hortobágyi, Tibor

2017-01-01

The function of the anterior cruciate ligament (ACL) patients' non-injured leg is relevant in light of the high incidence of secondary ACL injuries on the contralateral side. However, the non-injured leg's function has only been examined for a selected number of neuromuscular outcomes and often without appropriate control groups. We measured a broad array of neuromuscular functions between legs of ACL patients and compared outcomes to age, sex, and physical activity matched controls. Thirty-two ACL-deficient patients (208 ± 145 days post-injury) and active and less-active controls (N = 20 each) participated in the study. We measured single- and multi-joint neuromuscular function in both legs in each group and expressed the overall neuromuscular function in each leg by calculating a mean z-score across all neuromuscular measures. A group by leg MANOVA and ANOVA were performed to examine group and leg differences for the selected outcomes. After an ACL injury, duration (-4.3 h/week) and level (Tegner activity score of -3.9) of sports activity decreased and was comparable to less-active controls. ACL patients showed bilateral impairments in the star excursion balance test compared to both control groups (P ≤ 0.004) and for central activation ratio compared to active controls (P ≤ 0.002). There were between-leg differences within each group for maximal quadriceps and hamstring strength, voluntary quadriceps activation, star excursion balance test performance, and single-leg hop distance (all P < 0.05), but there were no significant differences in quadriceps force accuracy and variability, knee joint proprioception, and static balance. Overall neuromuscular function (mean z-score) did not differ between groups, but ACL patients' non-injured leg displayed better neuromuscular function than the injured leg (P < 0.05). Except for poorer dynamic balance and reduced quadriceps activation, ACL patients had no bilateral neuromuscular deficits despite reductions in physical activity after injury. Therapists can use the non-injured leg as a reference to assess the injured leg's function for tasks measured in the present study, excluding dynamic balance and quadriceps activation. Rehabilitation after an ACL injury should be mainly focused on the injured leg. III.

Coagulopathy: Its Pathophysiology and Treatment in the Injured Patient

DTIC Science & Technology

2007-03-30

death. In fact, in their series, 77% of brain-injured patients who died had a coagulopathy at the time of hospital admission.8 Similarly, Faringer et...coagulation process. Arch Surg 1996;131:923–927. 9. Faringer PD, Mullins RJ, Johnson RL, Trunkey DD. Blood component supplementation during massive

Emotional Labour of Caregivers Confronted With Aggressive Brain-injured Patients.

PubMed

Huet, Magali; Dany, Lionel; Apostolidis, Thémistoklis

2018-06-01

Aggressive behaviours are common with people who have suffered brain injuries and induce difficult emotions among certified nursing assistants and medical-psychological assistants who take care of them. These caregivers carry out emotional labour whose content and strategies are little known. The study explores the emotional labour of certified nursing assistants and medical-psychological assistants faced with the aggressive behaviours of brain-injured patients. Semi-structured interviews were conducted with 37 caregivers. Interviews were analysed via a thematic content analysis. The analysis shows that the emotional labour of caregivers varies in accordance with the state of "consciousness" or "non-consciousness" that they attribute to the brain-injured patient with regard to this aggressive behaviour. This is a deep acting strategy. Moreover, caregivers shut off their emotions in order not to transmit them to the patient. This surface acting has the first objective for the caregiver of maintaining control of the situation and a second objective of protecting the patient emotionally and therefore of being perceived as a "good" caregiver. Emotional labour also meets a need to preserve the professional self-image and professional status negatively affected in the interaction with the aggressive brain-injured patient. Our study specifies the different strategies of the emotional labour of caregivers and their circumstances of use when they are confronted with aggressive behaviour by brain-injured patients. Targeted support for this emotional labour, such as training and practical analysis, is essential for the development of care practices promoting a caring relationship. Copyright © 2017 Elsevier Inc. All rights reserved.

Safety of the use of group A plasma in trauma: the STAT study.

PubMed

Dunbar, Nancy M; Yazer, Mark H

2017-08-01

Use of universally ABO-compatible group AB plasma for trauma resuscitation can be challenging due to supply limitations. Many centers are now using group A plasma during the initial resuscitation of traumatically injured patients. This study was undertaken to evaluate the impact of this practice on mortality and hospital length of stay (LOS). Seventeen trauma centers using group A plasma in trauma patients of unknown ABO group participated in this study. Eligible patients were group A, B, and AB trauma patients who received at least 1 unit of group A plasma. Data collected included patient sex, age, mechanism of injury, Trauma Injury Severity Score (TRISS) probability of survival, and number of blood products transfused. The main outcome of this study was in-hospital mortality differences between group B and AB patients compared to group A patients. Data on early mortality (≤24 hr) and hospital LOS were also collected. There were 354 B and AB patients and 809 A patients. The two study groups were comparable in terms of age, sex, TRISS probability of survival, and total number of blood products transfused. The use of group A plasma during the initial resuscitation of traumatically injured patients of unknown ABO group was not associated with increased in-hospital mortality, early mortality, or hospital LOS for group B and AB patients compared to group A patients. These results support the practice of issuing thawed group A plasma for the initial resuscitation of trauma patients of unknown ABO group. © 2017 AABB.

Eye tracking detects disconjugate eye movements associated with structural traumatic brain injury and concussion.

PubMed

Samadani, Uzma; Ritlop, Robert; Reyes, Marleen; Nehrbass, Elena; Li, Meng; Lamm, Elizabeth; Schneider, Julia; Shimunov, David; Sava, Maria; Kolecki, Radek; Burris, Paige; Altomare, Lindsey; Mehmood, Talha; Smith, Theodore; Huang, Jason H; McStay, Christopher; Todd, S Rob; Qian, Meng; Kondziolka, Douglas; Wall, Stephen; Huang, Paul

2015-04-15

Disconjugate eye movements have been associated with traumatic brain injury since ancient times. Ocular motility dysfunction may be present in up to 90% of patients with concussion or blast injury. We developed an algorithm for eye tracking in which the Cartesian coordinates of the right and left pupils are tracked over 200 sec and compared to each other as a subject watches a short film clip moving inside an aperture on a computer screen. We prospectively eye tracked 64 normal healthy noninjured control subjects and compared findings to 75 trauma subjects with either a positive head computed tomography (CT) scan (n=13), negative head CT (n=39), or nonhead injury (n=23) to determine whether eye tracking would reveal the disconjugate gaze associated with both structural brain injury and concussion. Tracking metrics were then correlated to the clinical concussion measure Sport Concussion Assessment Tool 3 (SCAT3) in trauma patients. Five out of five measures of horizontal disconjugacy were increased in positive and negative head CT patients relative to noninjured control subjects. Only one of five vertical disconjugacy measures was significantly increased in brain-injured patients relative to controls. Linear regression analysis of all 75 trauma patients demonstrated that three metrics for horizontal disconjugacy negatively correlated with SCAT3 symptom severity score and positively correlated with total Standardized Assessment of Concussion score. Abnormal eye-tracking metrics improved over time toward baseline in brain-injured subjects observed in follow-up. Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury.

Eye Tracking Detects Disconjugate Eye Movements Associated with Structural Traumatic Brain Injury and Concussion

PubMed Central

Ritlop, Robert; Reyes, Marleen; Nehrbass, Elena; Li, Meng; Lamm, Elizabeth; Schneider, Julia; Shimunov, David; Sava, Maria; Kolecki, Radek; Burris, Paige; Altomare, Lindsey; Mehmood, Talha; Smith, Theodore; Huang, Jason H.; McStay, Christopher; Todd, S. Rob; Qian, Meng; Kondziolka, Douglas; Wall, Stephen; Huang, Paul

2015-01-01

Abstract Disconjugate eye movements have been associated with traumatic brain injury since ancient times. Ocular motility dysfunction may be present in up to 90% of patients with concussion or blast injury. We developed an algorithm for eye tracking in which the Cartesian coordinates of the right and left pupils are tracked over 200 sec and compared to each other as a subject watches a short film clip moving inside an aperture on a computer screen. We prospectively eye tracked 64 normal healthy noninjured control subjects and compared findings to 75 trauma subjects with either a positive head computed tomography (CT) scan (n=13), negative head CT (n=39), or nonhead injury (n=23) to determine whether eye tracking would reveal the disconjugate gaze associated with both structural brain injury and concussion. Tracking metrics were then correlated to the clinical concussion measure Sport Concussion Assessment Tool 3 (SCAT3) in trauma patients. Five out of five measures of horizontal disconjugacy were increased in positive and negative head CT patients relative to noninjured control subjects. Only one of five vertical disconjugacy measures was significantly increased in brain-injured patients relative to controls. Linear regression analysis of all 75 trauma patients demonstrated that three metrics for horizontal disconjugacy negatively correlated with SCAT3 symptom severity score and positively correlated with total Standardized Assessment of Concussion score. Abnormal eye-tracking metrics improved over time toward baseline in brain-injured subjects observed in follow-up. Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury. PMID:25582436

Major genitourinary-related bicycle trauma: Results from 20 years at a level-1 trauma center.

PubMed

Osterberg, E Charles; Awad, Mohannad A; Gaither, Thomas W; Sanford, Thomas; Alwaal, Amjad; Hampson, Lindsay A; Yoo, Jennie; McAninch, Jack W; Breyer, Benjamin N

2017-01-01

Epidemiological studies have shown that bicycle trauma is associated with genitourinary (GU) injuries. Our objective is to characterize GU-related bicycle trauma admitted to a level I trauma center. We queried a prospective trauma registry for bicycle injuries over a 20-year period. Patient demographics, triage data, operative interventions and hospital details were collected. In total, 1659 patients were admitted with major bicycle trauma. Of these, 48 cases involved a GU organ, specifically the bladder (n=7), testis (n=6), urethra (n=3), adrenal (n=4) and/or kidneys (n=36). The median age of cyclists with GU injuries was 29 (range 5-70). More men were injured versus women (35 versus 13). GU-related bicycle trauma involved a motor vehicle in 52% (25/48) of injuries. The median injury severity score for GU-related bicycle trauma was 17 (range 1-50). The median number of concomitant organ injuries was 2 (range 0-6), the most common of which was the lungs (13/48, 27%) and ribs (13/48, 27%). The majority of GU injured cyclists were admitted to an ICU (15/48, 31%) or hospital floor (12/48, 25%). Operative intervention for a GU-related trauma was low (12/48, 25%). The most common GU organ injured was the kidney (36/48, 75%) however most were managed nonoperatively (33/36, 92%). Bladder injuries most often required operative intervention (6/7, 86%). Mortality following GU-related bicycle trauma was low (2/48, 4%). In a large series of bicycle trauma, GU organs were injured in 3% of cases. The majority of cases were managed non-operatively and mortality was low. Published by Elsevier Ltd.

Rhabdomyolysis and acute kidney injury in the injured war fighter.

PubMed

Elterman, Joel; Zonies, David; Stewart, Ian; Fang, Raymond; Schreiber, Martin

2015-10-01

Rhabdomyolysis is a recognized complication of traumatic injury. The correlation of an elevated creatine kinase (CK) level and the development of acute kidney injury (AKI) has been studied in the civilian population. We sought to review the prevalence of rhabdomyolysis in injured war fighters and determine if peak CK levels correlate with AKI. This is a retrospective cohort study of patients admitted at a US military treatment facility from January to November 2010. Inclusion criteria were active duty patients transported after explosive, penetrating, or blunt injury. Patients with burns or non-trauma-related admissions were excluded. Rhabdomyolysis was defined as a CK level greater than 5,000 U/L. AKI was defined using the Kidney Disease: Improving Global Outcomes classification. Mann-Whitney U-tests were used to determine the significance for continuous data. Correlations were determined using Spearman's ρ. Significance was set at p < 0.05. Of the 318 patients included in our analysis, 310 (98%) were male, and the median age was 24 years (21-28 years). Blast was the predominant mechanism of injury (71%), with a median Injury Severity Score (ISS) of 22 (16-29). Rhabdomyolysis developed in 79 patients (24.8%). The median peak CK for all patients was 4,178 U/L and ranged from 208 U/L to 120,000 U/L. Stage 1, 2, and 3 AKI developed in 56 (17.6%), 3 (0.9%), and 7 (2.2%) patients, respectively. There was a weak but statistically significant correlation between peak CK and AKI (r = 0.26, p < 0.05). Elevated peak CK levels in the injured war fighter are weakly associated with the development of AKI but are not predictive. The development of clinical practice guidelines would help standardize treatment for rhabdomyolysis in combat casualties and would allow for standardized comparisons in future work. Epidemiologic/prognostic study, level III.

Case for tort reform in medical malpractice.

PubMed

DeLuke, Dean M

2006-05-01

Under tort law, injured parties have the basic right to seek indemnity for wrongful injury, including injury from medical malpractice. Unfortunately, the present system is associated with many undesirable secondary effects, including problems of patient access to care, excessive testing or overtreatment, and undertreatment due to doctors' fear of malpractice. Nationwide, there are innumerable cases of doctors abandoning obstetrical or other high risk practices, or migrating away from states with less friendly tort laws. The California MICRA legislation of 1976 is often cited as a model for tort reform, but even this model legislation may be insufficient to restore a beleaguered trust between medical providers and their patients. Several key research studies suggest that the jury system fails to fairly and reliably compensate injured patients, and fails to deter or discipline errant doctors. To adequately meet the common needs of patients and health care providers, there must be an appropriate emphasis on aggressive risk management, quality improvement, patient safety, professional oversight, and responsible insurance underwriting. Moreover, there must be a systemic improvement of the current tort system as it pertains to medical malpractice. Although incremental reforms at the state level are slowly occurring and should certainly be supported, a greater reward may ultimately stem from more radical restructuring to a system of medical tribunals.

Assessment of performance validity in the Stroop Color and Word Test in mild traumatic brain injury patients: a criterion-groups validation design.

PubMed

Guise, Brian J; Thompson, Matthew D; Greve, Kevin W; Bianchini, Kevin J; West, Laura

2014-03-01

The current study assessed performance validity on the Stroop Color and Word Test (Stroop) in mild traumatic brain injury (TBI) using criterion-groups validation. The sample consisted of 77 patients with a reported history of mild TBI. Data from 42 moderate-severe TBI and 75 non-head-injured patients with other clinical diagnoses were also examined. TBI patients were categorized on the basis of Slick, Sherman, and Iverson (1999) criteria for malingered neurocognitive dysfunction (MND). Classification accuracy is reported for three indicators (Word, Color, and Color-Word residual raw scores) from the Stroop across a range of injury severities. With false-positive rates set at approximately 5%, sensitivity was as high as 29%. The clinical implications of these findings are discussed. © 2012 The British Psychological Society.

ECMO support for right main bronchial disruption in multiple trauma patient with brain injury--a case report and literature review.

PubMed

Zhou, R; Liu, B; Lin, K; Wang, R; Qin, Z; Liao, R; Qiu, Y

2015-07-01

Extracorporeal membrane oxygenation (ECMO) may offer life-saving treatment in severe pulmonary contusion or acute respiratory distress syndrome when conventional treatments have failed. However, because of the bleeding risk of systemic anticoagulation, ECMO should be performed only as a last resort in multiple trauma victims. Here, we report ECMO as a bridge for right main bronchus reconstruction and recovery of traumatic wet lung in a 31-year-old male multi-trauma patient with right main bronchial disruption, bilateral pulmonary contusion, cerebral contusion and long bone fracture. The patient was discharged without any obvious complication. ECMO support in a traumatic brain injured patient with severe hypoxemia caused by lung contusion and/or tracheal bronchus disruption is not an absolute contraindication. © The Author(s) 2014.

Emergency Department Telemedicine Is Used for More Severely Injured Rural Trauma Patients, but Does Not Decrease Transfer: A Cohort Study.

PubMed

Mohr, Nicholas M; Harland, Karisa K; Chrischilles, Elizabeth A; Bell, Amanda; Shane, Dan M; Ward, Marcia M

2017-02-01

Traumatic injury is a leading cause of death in the United States, and rural populations are at increased risk of injury and death. Rural residents have limited access to trauma care, and telemedicine has been proposed as one strategy to improve the provision of trauma care locally. The objective of this study was to describe patient-level factors associated with telemedicine consultation in North Dakota critical-access hospital (CAH) emergency departments (EDs) and to measure the association between telemedicine consultation and interhospital transfer. Observational cohort study of all adult (age ≥ 18 years) trauma patients treated in North Dakota CAH EDs with an active telemedicine subscription between 2008 and 2014. Trauma cases were identified from the North Dakota Trauma Registry, and telemedicine-enabled care was determined using a probabilistic linking algorithm with the call records of the predominant telemedicine network in North Dakota. Multivariable generalized estimating equations were used to identify factors associated with telemedicine consultation and to measure the association between telemedicine consultation and interhospital transfer, adjusting for patient, injury, and hospital factors. Of the 9,281 North Dakota trauma patients seen in CAHs, 2,837 were treated in an ED with an active telemedicine subscription. Telemedicine was consulted for 11% of all trauma patients in telemedicine-capable EDs. Factors associated with telemedicine consultation included higher Injury Severity Score, penetrating injuries, burns, hypotension, tachycardia, and ambulance transport. Adjusting for severity of illness, injury mechanism, and type of injury, telemedicine use was not associated with interhospital transfer (adjusted odds ratio = 1.28, 95% confidence interval = 0.94 to 1.75). Emergency department-based telemedicine consultation is requested for the most severely injured rural trauma patients, especially with those with penetrating trauma, burns, and abnormal presenting vital signs. Telemedicine consultation was not independently associated with increased probability of transfer. Future work should evaluate how telemedicine impacts the timeliness of care and specific care interventions. © 2016 by the Society for Academic Emergency Medicine.

Prevalence and predictors of mental disorders in intentionally and unintentionally injured emergency centre patients

PubMed Central

van der Westhuizen, Claire; Wyatt, Gail; Williams, John K.; Stein, Dan J.; Sorsdahl, Katherine

2014-01-01

Little is known about the prevalence and predictors of mental disorders amongst injured emergency centre (EC) patients in low- and middle-income countries. Patients presenting with either an intentional or unintentional injury were recruited (n=200). Mental health, injury and psychological trauma histories were assessed. Descriptive statistics and logistic regressions were conducted and predictors for current mental disorder were identified. Diagnostic criteria for a current mental disorder, including substance use disorders, were met by 59.5% of participants. Compared to those with an unintentional injury, intentionally injured participants were more likely to be diagnosed with a current mental disorder (66.9% vs 48.8%; p=0.01). High frequencies of previous intentional injuries predicted for current mental disorder (OR = 1.460, 95% CI 1.08-1.98), while male gender and witnessed community violence predicted substance use disorder diagnoses. Findings indicate that injured EC patients, particularly those with intentional injuries, are at risk for mental disorders. Psychosocial interventions in the EC context can potentially make an important contribution in reducing the burden of mental disorders and injuries in low- and middle-income countries. PMID:25126754

Reduced mortality after severe head injury will increase the demands for rehabilitation services.

PubMed

Eker, C; Schalén, W; Asgeirsson, B; Grände, P O; Ranstam, J; Nordström, C H

2000-07-01

In 1989, a new therapy to reduce intracranial pressure in severely head-injured patients was introduced in Lund. The new treatment reduced mortality significantly. The present study describes the quality of life for the survivors. The study includes 53 patients treated during 1989-1994, according to a new treatment protocol for increased intracranial pressure ('Lund concept' group). During 1982-1986, 38 patients were managed according to a protocol including high dose thiopentone ('Thiopentone' group). The two groups are compared regarding neurophysical and psychiatric symptoms as well as aspects regarding the patient's role, performance, interpersonal relationship, frictions, feelings and satisfaction in work, areas of social and leisure activities, and extended family. Mortality was reduced from 47% to 8%, but the number of patients with a persistent vegetative state and/or remaining severe disability did not increase. However, the number of patients with persisting emotional and intellectual deficits increased significantly. The new treatment regime has dramatically increased the number of survivors after severe head trauma. Although most patients have a favourable outcome, there are more patients with remaining sequelae and disabilities, and the demand for qualified rehabilitation has increased.

Clear lens extraction for the treatment of persistent accommodative spasm after head trauma.

PubMed

McMurray, Catherine J; Burley, Celeste D; Elder, Mark J

2004-12-01

We report the case of a 28-year-old man with decreased visual acuity after closed head trauma sustained in a motor vehicle accident 16 weeks earlier. Several structures thought to be associated with the control of accommodation were injured. The patient had a persistent accommodative spasm causing up to 7.0 diopters of pseudomyopia. We present the patient's progress through the clinic, including manifest and cycloplegic refractions and results of a trial with atropine drops, and successful transition to bilateral pseudophakia 2 years and 9 months after the accident.

Single-stage in situ suture repair of multiple-ligament knee injury: a retrospective study of 17 patients (18 knees).

PubMed

Hua, Xingyi; Tao, Hui; Fang, Wang; Tang, Jian

2016-01-22

Multiple-ligament injured knee (MLIK) is a rare but severe injury. Although the principles of MLIK management have progressed over the past 40 years, there is a paucity of high-quality evidence upon which to base the management of MLIK. Treatment strategies for MLIK are challenging for most orthopedic surgeons, and the optimal treatment remains controversial, especially with regard to repair vs. reconstruction of the ligaments. The aim of the present study was to observe clinical outcomes of single-stage in situ suture repair of knee dislocation with multiple-ligament injury using nonabsorbable suture material. Consecutive patients with MLIK between 2002 and 2010 were included, for a total of 25 patients with knee dislocation. 17 patients (18 knees) with closed knee dislocation with a mean follow-up of 4.8 ± 1.3 years were retrospective analyzed. All patients were treated surgically with single-stage in situ suture repair for all injured ligaments and followed a standardized postoperative rehabilitation protocol. The VAS score, satisfactory score, total SF-36 score, Lysholm score, Tegner score, the Meyers functional rating and the ranges of motion and knee stability were used to evaluate outcomes. At final follow-up, mean visual analog scale score was 2.4 ± 0.9, patient satisfaction score was 8.0 ± 1.1, 36-item Short-Form Health Survey total score was 85.5 ± 10.4, and mean Lysholm score was 87.5 ± 7.7. There were significant differences between mean preinjury and postoperative Tegner activity scores (5.6 ± 1.4 and 3.4 ± 1.7, respectively; P < 0.01) and in mean range of motion between the injured and contralateral knees (112.5 ± 8.4° and 129.6 ± 10.3°, respectively; P < 0.01). At final follow-up, no patient demonstrated obvious ligamentous laxity, and only one patient was unable to return to work. Three patients had knee joint stiffness, two had wound problems (infection or fat liquefaction), and two had heterotopic bone formation. Single-stage in situ suture repair of injured ligaments confers advantages of reliable fixation and early exercise. It could be considered as an alternate and effective option in the dislocation knee with multiple-ligament injury.

Hand Injuries by the Killer Kite Manja and Their Management.

PubMed

Mir, Mohd Altaf; Ali, Adil Mahmud; Yaseen, Mohd; Khan, Arshad Hafeez

2017-05-01

Although hand injuries due to kite strings seem to be trivial, these injuries could be serious enough to lose the function of hand. This case series in the division of Plastic and Reconstructive Surgery of our institution from August 2014 to January 2016 evaluated the clinic-etiological profile, severity and management of hand injuries due to kite strings assessed clinically and radiologically. Eleven patients reported kite related injuries during two years, and 5 presented during 17 months. Of 11 patients, 8 were male and 3 were female with a M:F ratio of 2.66:1. The majority of patients presented with the mean age of 19.9±4.27 years. Eight patients presented acutely to the emergency while 3 believed the injury to be trivial and had delayed presentation. Injuries in the right hand were 8 and 3 in the left hand. Seven patients had injuries in zone II of the hand while 4 presented with zone III injuries. Total number of injured digits was 14 (1.4±1.11), total number of injured tendons was 26 (2.36±2.18), only one patient had nerve injury (mean=0.09), and no patient had any major vessel injury. So strict attention to safety measures and parental/guardian supervision while flying kites can avoid many preventable injuries to life and limb and also let the sport be an enjoyable and safe.

Comparison of outcomes in severely injured patients between a South Korean trauma center and matched patients treated in the United States.

PubMed

Jung, Kyoungwon; Matsumoto, Shokei; Smith, Alan; Hwang, Kyungjin; Lee, John Cook-Jong; Coimbra, Raul

2018-06-05

The South Korean government recently developed a master plan for establishing a national trauma system based on the implementation of regional trauma centers. We aimed to compare outcomes between severely injured patients treated at a recently established South Korean trauma center and matched patients treated in American level-1 trauma centers. Two cohorts were selected from an institutional trauma database at Ajou University Medical Center (AUMC) and the American National Trauma Data Bank. Adult patients with an Injury Severity Score of ≥9 were included. Patients were matched based on covariates that affect mortality, using 1:1 propensity score matching. We compared outcomes between the two datasets and performed survival analyses. We created 1,451 and 2,103 matched pairs for the pre-trauma center and post-trauma center periods, respectively. The in-hospital mortality rate was higher in the institutional trauma database pre-trauma center period compared with the American National Trauma Data Bank (11.6% versus 8.1%, P<.001). However, the mortality rate decreased in the institutional trauma database post-trauma center period and was similar to that in the American National Trauma Data Bank (6.9% versus 6.8%, P=.903). Being treated at Ajou University Medical Center Trauma Center was significantly associated with higher mortality during the pre-trauma center period (OR: 1.842, 95% CI: 1.336-2.540; P<.001), although no significant association was observed during the post-trauma center period (OR: 1.102, 95% CI: 0.827-1.468; P=.509). The mortality rate improved after a trauma center was established in a South Korean hospital and is similar to that from matched cases treated at American level-1 trauma centers. Thus, creating trauma centers and a regional trauma system may improve outcomes in major trauma cases. Copyright © 2018 Elsevier Inc. All rights reserved.

The current status of road user injuries among the elderly in Germany: a medical and technical accident analysis.

PubMed

Richter, Martinus; Pape, Hans-Christoph; Otte, Dietmar; Krettek, Christian

2005-03-01

The incidence and treatment of injuries involving the elderly road user are of increasing importance for all fields of trauma care to ensure the best possible outcomes. Traffic accident reports were analyzed through technical and medical investigation for the involvement of elderly citizens. In 12,309 documented traffic accidents between 1985 and 1998, 1,843 elderly citizens (65 years and older) were involved, 1,260 of which were reported to have been injured. The mean Injury Severity Score among the injured elderly citizens was 7.3. Of the injured elderly road users, 39.5% were car occupants, 27.4% were bicyclists, 29.6% were pedestrians, 1.8% were truck occupants, and 1.7% were motorcyclists. Of the elderly road users in cars, 53% were not injured, in contrast to only 1.1% of the bicyclists and 0.8% of the pedestrians. Serious or severe injuries (Maximum Abbreviated Injury Scale, >/=2] occurred for 36.5% of the injured elderly road users as car occupants (unrestrained, 58%; restrained, 34%), 57.4% as bicyclists, and 65.4% as pedestrians A high rate of motor injuries is associated with vehicle accidents and increased levels of severity among the elderly population. This finding is especially evident for elder pedestrians and bicyclists. Also of note, the elderly even appear to be at risk for sustaining an increased level of injury severity when they are restrained or belt protected.

Technology Use, Preferences, and Capacity in Injured Patients at Risk for Posttraumatic Stress Disorder.

PubMed

Kelly, Cory M; Van Eaton, Erik G; Russo, Joan E; Kelly, Victoria C; Jurkovich, Gregory J; Darnell, Doyanne A; Whiteside, Lauren K; Wang, Jin; Parker, Lea E; Payne, Thomas H; Mooney, Sean D; Bush, Nigel; Zatzick, Douglas F

2017-01-01

This investigation comprehensively assessed the technology use, preferences, and capacity of diverse injured trauma survivors with posttraumatic stress disorder (PTSD) symptoms. A total of 121 patients participating in a randomized clinical trial (RCT) of stepped collaborative care targeting PTSD symptoms were administered baseline one-, three-, and six-month interviews that assessed technology use. Longitudinal data about the instability of patient cell phone ownership and phone numbers were collected from follow-up interviews. PTSD symptoms were also assessed over the course of the six months after injury. Regression analyses explored the associations between cell phone instability and PTSD symptoms. At baseline, 71.9% (n = 87) of patients reported current cell phone ownership, and over half (58.2%, n = 46) of these patients possessed basic cell phones. Only 19.0% (n = 23) of patients had no change in cell phone number or physical phone over the course of the six months postinjury. In regression models that adjusted for relevant clinical and demographic characteristics, cell phone instability was associated with higher six-month postinjury PTSD symptom levels (p < 0.001). Diverse injured patients at risk for the development of PTSD have unique technology use patterns, including high rates of cell phone instability. These observations should be strongly considered when developing technology-supported interventions for injured patients with PTSD.

Return to work for severely injured survivors of the Christchurch earthquake: influences in the first 2 years.

PubMed

Nunnerley, Joanne; Dunn, Jennifer; McPherson, Kathryn; Hooper, Gary; Woodfield, Tim

2016-01-01

This study looked at the influences on the return to work (RTW) in the first 2 years for people severely injured in the 22 February 2011 Christchurch earthquake. We used a constructivist grounded theory approach using semi-structured interviews to collect data from 14 people injured in the earthquake. Analysis elicited three themes that appeared to influence the process of RTW following the Christchurch earthquake. Living the earthquake experience, the individual's experiences of the earthquake and how their injury framed their expectations; rebuilding normality, the desire of the participants to return to life as it was; while dealing with the secondary effects of the earthquake includes the earthquake specific effects which were both barriers and facilitators to returning to work. The consequences of the earthquake impacted on experience, process and outcome of RTW for those injured in the Christchurch Earthquake. Work and RTW appeared key tools to enhance recovery after serious injury following the earthquake. The altered physical, social and economic environment must be considered when working on the return to work (RTW) of individuals with earthquake injuries. Providing tangible emotional and social support so injured earthquake survivors feel safe in their workplace may facilitate RTW. Engaging early with employers may assist the RTW of injured earthquake survivors.

[Major emergency management in ship collusion].

PubMed

Mazzei, Sergio; Famà, Fausto; Vindigni, Angelo; Villari, Santa Alessandra; Gioffrè Florio, Maria Antonietta

2008-01-01

To prove that a correct management of a major emergency allowed a quick triage, trauma team, appropriate treatment, discharge and treatment of many patients injured patients when, in January 2007, a crush between a merchant ship and an hydrofoil happened in the Messina strait, that separate Sicily and Calabria. Four deaths and 105 injuries were observed. Our experience in the emergency care refers to 25 patients of them. All patients were investigated with routine blood tests, imaging techniques and classified according to AIS and ISS. Their classification in colour code was green for 14 of them (7 Males, 7 Females); yellow for 9 (5M, 4F) and red for 2, both males. Of the 105 injured patients, twenty five patients were referred to our Accident and Emergency Department. Ten were affected by cranial trauma, 6 by spinal injuries, 5 by thoracic injuries, 3 had bone fractures and 1 patient with severe wounds. Among all patients, 18 had an ISS <15; 7 had an ISS of 28 (range 17-45). Mean emergency room stay, discharge and transport of patients to wards was 103 minutes. Twelve patients were admitted to the hospital; 9 refused hospitalization, 4 were discharged. Twenty six ship-collisions occurred in the Messina Strait between 1950 and 2007, were documented 10 deaths, and other four death of Segesta Jet accident. The approach to Major Emergency was carried out in according to ATLS and P.E.I.M.A.F. This allowed specific and efficacious investigations.

Guilt, shame and need for a container: a study of post-traumatic stress among ambulance personnel.

PubMed

Jonsson, Anders; Segesten, Kerstin

2004-10-01

Post-traumatic stress symptoms among ambulance personnel are regarded as a natural behaviour and reaction to working with the severely injured, suicides, injured children and dead people. The findings show that post-traumatic stress symptoms, guilt, shame and self-reproach are common after duty-related traumatic events. To handle these overwhelming feelings it is necessary to talk about them with fellow workers, friends or family members. By using another person as a container it is possible to internalise the traumatic experience. Poor and un-emphatic behaviour towards a patient and their relatives can have its origin in untreated traumatic experiences. Personnel in ambulance organisations who perform defusing, debriefing and counselling have to be informed of the importance that the roll of guilt and shame may play in the developing of post-traumatic stress symptoms.

Biochemical metabolic changes assessed by 31P magnetic resonance spectroscopy after radiation-induced hepatic injury in rabbits

PubMed Central

Yu, Ri-Sheng; Hao, Liang; Dong, Fei; Mao, Jian-Shan; Sun, Jian-Zhong; Chen, Ying; Lin, Min; Wang, Zhi-Kang; Ding, Wen-Hong

2009-01-01

AIM: To compare the features of biochemical metabolic changes detected by hepatic phosphorus-31 magnetic resonance spectroscopy (31P MRS) with the liver damage score (LDS) and pathologic changes in rabbits and to investigate the diagnostic value of 31P MRS in acute hepatic radiation injury. METHODS: A total of 30 rabbits received different radiation doses (ranging 5-20 Gy) to establish acute hepatic injury models. Blood biochemical tests, 31P MRS and pathological examinations were carried out 24 h after irradiation. The degree of injury was evaluated according to LDS and pathology. Ten healthy rabbits served as controls. The MR examination was performed on a 1.5 T imager using a 1H/31P surface coil by the 2D chemical shift imaging technique. The relative quantities of phosphomonoesters (PME), phosphodiesters (PDE), inorganic phosphate (Pi) and adenosine triphosphate (ATP) were measured. The data were statistically analyzed. RESULTS: (1) Relative quantification of phosphorus metabolites: (a) ATP: there were significant differences (P < 0.05) (LDS-groups: control group vs mild group vs moderate group vs severe group, 1.83 ± 0.33 vs 1.55 ± 0.24 vs 1.27 ± 0.09 vs 0.98 ± 0.18; pathological groups: control group vs mild group vs moderate group vs severe group, 1.83 ± 0.33 vs 1.58 ± 0.25 vs 1.32 ± 0.07 vs 1.02 ± 0.18) of ATP relative quantification among control group, mild injured group, moderate injured group, and severe injured group according to both LDS grading and pathological grading, respectively, and it decreased progressively with the increased degree of injury (r = -0.723, P = 0.000). (b) PME and Pi; the relative quantification of PME and Pi decreased significantly in the severe injured group, and the difference between the control group and severe injured group was significant (P < 0.05) (PME: LDS-control group vs LDS-severe group, 0.86 ± 0.23 vs 0.58 ± 0.22, P = 0.031; pathological control group vs pathological severe group, 0.86 ± 0.23 vs 0.60 ± 0.21, P = 0.037; Pi: LDS-control group vs LDS-severe group, 0.74 ± 0.18 vs 0.43 ± 0.14, P = 0.013; pathological control group vs pathological severe group, 0.74 ± 0.18 vs 0.43 ± 0.14, P = 0.005) according to LDS grading and pathological grading, respectively. (c) PDE; there were no significant differences among groups according to LDS grading, and no significant differences between the control group and experimental groups according to pathological grading. (2) The ratio of relative quantification of phosphorus metabolites: significant differences (P < 0.05) (LDS-moderate group and LDS-severe group vs LDS-control group and LDS-mild group, 1.94 ± 0.50 and 1.96 ± 0.72 vs 1.43 ± 0.31 and 1.40 ± 0.38) were only found in PDE/ATP between the moderate injured group, the severe injured group and the control group, the mild injured group. No significant difference was found in other ratios of relative quantification of phosphorus metabolites. CONCLUSION: 31P MRS is a useful method to evaluate early acute hepatic radiation injury. The relative quantification of hepatic ATP levels, which can reflect the pathological severity of acute hepatic radiation injury, is correlated with LDS. PMID:19522022

Determination of awareness in patients with severe brain injury using EEG power spectral analysis

PubMed Central

Goldfine, Andrew M.; Victor, Jonathan D.; Conte, Mary M.; Bardin, Jonathan C.; Schiff, Nicholas D.

2011-01-01

Objective To determine whether EEG spectral analysis could be used to demonstrate awareness in patients with severe brain injury. Methods We recorded EEG from healthy controls and three patients with severe brain injury, ranging from minimally conscious state (MCS) to locked-in-state (LIS), while they were asked to imagine motor and spatial navigation tasks. We assessed EEG spectral differences from 4 to 24 Hz with univariate comparisons (individual frequencies) and multivariate comparisons (patterns across the frequency range). Results In controls, EEG spectral power differed at multiple frequency bands and channels during performance of both tasks compared to a resting baseline. As patterns of signal change were inconsistent between controls, we defined a positive response in patient subjects as consistent spectral changes across task performances. One patient in MCS and one in LIS showed evidence of motor imagery task performance, though with patterns of spectral change different from the controls. Conclusion EEG power spectral analysis demonstrates evidence for performance of mental imagery tasks in healthy controls and patients with severe brain injury. Significance EEG power spectral analysis can be used as a flexible bedside tool to demonstrate awareness in brain-injured patients who are otherwise unable to communicate. PMID:21514214

A Population-Based Survival Assessment of Categorizing Level III and IV Rural Hospitals as Trauma Centers

ERIC Educational Resources Information Center

Arthur, Melanie; Newgard, Craig D.; Mullins, Richard J.; Diggs, Brian S.; Stone, Judith V.; Adams, Annette L.; Hedges, Jerris R.

2009-01-01

Context: Patients injured in rural areas are hypothesized to have improved outcomes if statewide trauma systems categorize rural hospitals as Level III and IV trauma centers, though evidence to support this belief is sparse. Purpose: To determine if there is improved survival among injured patients hospitalized in states that categorize rural…

L-carnitine alleviates sciatic nerve crush injury in rats: functional and electron microscopy assessments

PubMed Central

Avsar, Ümmü Zeynep; Avsar, Umit; Aydin, Ali; Yayla, Muhammed; Ozturkkaragoz, Berna; Un, Harun; Saritemur, Murat; Mercantepe, Tolga

2014-01-01

Several studies have demonstrated that L-carnitine exhibits neuroprotective effects on injured sciatic nerve of rats with diabetes mellitus. It is hypothesized that L-carnitine exhibits neuroprotective effects on injured sciatic nerve of rats. Rat sciatic nerve was crush injured by a forceps and exhibited degenerative changes. After intragastric administration of 50 and 100 mg/kg L-carnitine for 30 days, axon area, myelin sheath area, axon diameter, myelin sheath diameter, and numerical density of the myelinated axons of injured sciatic nerve were similar to normal, and the function of injured sciatic nerve also improved significantly. These findings suggest that L-carnitine exhibits neuroprotective effects on sciatic nerve crush injury in rats. PMID:25206754

Scoring systems of severity in patients with multiple trauma.

PubMed

Rapsang, Amy Grace; Shyam, Devajit Chowlek

2015-04-01

Trauma is a major cause of morbidity and mortality; hence severity scales are important adjuncts to trauma care in order to characterize the nature and extent of injury. Trauma scoring models can assist with triage and help in evaluation and prediction of prognosis in order to organise and improve trauma systems. Given the wide variety of scoring instruments available to assess the injured patient, it is imperative that the choice of the severity score accurately match the application. Even though trauma scores are not the key elements of trauma treatment, they are however, an essential part of improvement in triage decisions and in identifying patients with unexpected outcomes. This article provides the reader with a compendium of trauma severity scales along with their predicted death rate calculation, which can be adopted in order to improve decision making, trauma care, research and in comparative analyses in quality assessment. Copyright © 2013 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Occult pneumothoraces in Chinese patients with significant blunt chest trauma: radiological classification and proposed clinical significance.

PubMed

Lee, Ryan K L; Graham, Colin A; Yeung, Janice H H; Ahuja, Anil T; Rainer, Timothy H

2012-12-01

An occult pneumothorax (OP) is a pneumothorax not seen on a supine chest X-ray (CXR) but detected on abdominal or thoracic computed tomography (CT) scanning. With the increasing use of CT in the management of significantly injured trauma patients, more OPs are being detected. The aim of this study was to classify OPs diagnosed on thoracic CT (TCT) and correlate them with their clinical significance. Retrospective analysis of prospectively collected trauma registry data. Total 36 (N=36) consecutive significantly injured trauma patients admitted through the emergency department (ED) who sustained blunt chest trauma and underwent TCT between 1 January 2007 and 31 December 2008 were included. OP was defined as the identification (by a consultant radiologist) of a pneumothorax on TCT that had not been detected on supine CXR. OPs were classified by laterality (unilateral/bilateral) and location (apical, basal, non apical/basal). The size of pneumothoraces, severity of injury [including number of associated thoracic injuries and injury severity score (ISS)], length of hospital stay and mortality were compared between groups. The need for tube thoracostomy and clinical outcome were also analysed. Patients with bilateral OPs (N=8) had significantly more associated thoracic injuries (median: 2 vs. 1, p=0.01), higher ISS (median: 35 vs. 23, p=0.02) and longer hospital stay (median: 20 days vs. 11 days, p=0.01) than those with a unilateral OP (N=28). Basal OPs (N=7) were significantly larger than apical (N=10) and non-apical/basal Ops (N=11). Basal OPs were associated with significantly more associated thoracic injuries (median: 2 vs. 1, p=0.01), higher ISS (median: 35 vs. 25, p=0.04) and longer hospital stays (median: 23 days vs. 17 days, p=0.02) than apical Ops, which had higher ISS (median: 35 vs. 25, p=0.04) and longer hospital stays (median: 23 days vs. 15 days, p=0.02) than non-apical/basal OPs. Non-apical/basal OPs were associated with more related injuries (median: 2 vs. 1, p=0.02) than apical OPs. All apical and non-apical/basal OPs were successfully managed expectantly without associated mortality. This TCT classification of OP is proposed to help clinicians to decide on subsequent management of the OP. Basal OPs are significantly larger in size, and both basal and bilateral OPs are associated with higher severity of injury and longer hospital stay. These groups of patient may benefit from prophylactic tube thoracostomy instead of conservative treatment. On the other hand, apical and non-apical/basal groups is smaller in size, less severely injured and thus can be successfully managed expectantly. Copyright © 2012 Elsevier Ltd. All rights reserved.

Geriatric fall-related injuries.

PubMed

Hefny, Ashraf F; Abbas, Alaa K; Abu-Zidan, Fikri M

2016-06-01

Falls are the leading cause of geriatric injury. We aimed to study the anatomical distribution, severity, and outcome of geriatric fall-related injuries in order to give recommendations regarding their prevention. All injured patients with an age ≥ 60 years who were admitted to Al-Ain Hospital or died in the Emergency Department due to falls were prospectively studied over a four year period. We studied 92 patients. Fifty six of them (60.9%) were females. The mean (standard deviation) of age was 72.2 (9.6) years. Seventy three (89%) of all incidents occurred at home. Eighty three patients (90.2%) fell on the same level. The median (range) ISS was 4 (1-16) and the median GCS (range) was 15 (12-15). The lower limb was the most common injured body region (63%). There were no statistical significant differences between males and females regarding age, ISS, and hospital stay (p = 0.85, p = 0.57, and p = 0.35 respectively). The majority of geriatric fall-related injuries were due to fall from the same level at home. Assessment of risk factors for falls including home hazards is essential for prevention of geriatric fall-related injuries.

[Mechanical injuries of the eyeball: frequency, structure, and possibility of the prevention].

PubMed

Jovanović, Milos

2006-01-01

Some factors significant for development of mechanical injuries of the eyeball have been analyzed in the study. Basic objective of such analysis was prevention and reduction of these injuries. Mechanical injuries of the eyeball in patients hospitalized at the institute of Eye Disease, CCS in Belgrade, in five-year period have been analyzed. Only patients with severe eye injuries were hospitalized. The following parameters were analyzed: sex, age, occupation of patients, residence, time of the inflicted injury, i.e. by months in a year, days in a week and hours in a day, place and way of inflicting the injury as well as visual acuity on admission. In addition, the type of injury was analyzed, i.e. contusion or penetrating with all resulting complications. Finally, the timing of primary surgical management of the eye injury was specified, if required. A total number of hospitalized patients with mechanical eye injuries was 1642 during the last five years, meaning that one injury occurred daily. There were 1381 males and 261 females, meaning that males were 5.3 times more the victims of mechanical eye injuries. Out of all the injured, 861 (52.4%) were from rural environment, while 781 (47.6%) were urban population. The proportion of injuries of the right or the left eye was nearly equal, while both eyes were simultaneously injured in 21 (1.3%) cases. The injuries were inflicted in all ages, but most frequently in working population ranging from 16 to 55 years, accounting for 60.8%. Unfortunately, a lot of the injured were children up to 15 years of age - 19.4%. The most commonly injured were workers - 39.8%, followed by students - 17.5%. A piece of wood was the cause of injury in 21.8%, sharp and pointed objects in 17.2%, hammer and metal in 14.2%, glass in 11.6%, and other different causes in varying percentage. There were also rare causes of injuries, such as those caused by zip, dog bite, rooster's bill, etc. According to months in a year and days in a week, the injuries were almost evenly distributed. Considering the period of a day, even 77.4% of the injuries occurred during daytime, from 10 a.m. to 10 p.m. The highest percentage - 43.5% - of the injuries occurred while working something out of working place, while 24.5% of injuries were inflicted at working places. On admission, the majority of patients - 32.9% had visual acuity L+P+, but this visual acuity ranged from amaurosis to 1.0. There were 746 (45.4%) contusion injuries and 870 (53.0%) penetrating injuries. The rest were the injuries of other ocular adnexa. The majority of primary wound managements were performed in the first 24 hours of the injury - 67.1%. It may be concluded that working population and students are most commonly injured, and that men are five times more frequently injured than women; then, a piece of wood, sharp objects and glass are the most often causes of injury; the number of contusion and penetrating injuries is equal, and that required primary surgical wound management is most often performed in the first 24 hours from the injury. Further analysis of these factors suggests that many of these injuries could have been prevented, and consequently long-term treatment and treatment costs could have been evaded. Most important is that permanent disability due to visual impairment or even blindness of the injured eye could have been avoided.

Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma.

PubMed

Feeney, James M; Neulander, Matthew; DiFiori, Monica; Kis, Lilla; Shapiro, David S; Jayaraman, Vijay; Marshall, William T; Montgomery, Stephanie C

2017-01-01

We queried our Trauma Quality Improvement Program registry for patients who presented between 6/1/2011 and 9/1/2015 with severe (injury severity score (ISS)>15) blunt traumatic injury during anticoagulant use. Patients were then grouped into those prescribed warfarin and patients prescribed any of the available novel Direct Oral Anticoagulants (DOAC) medications. We excluded severe (AIS≧4) head injuries. There were no differences between DOAC and warfarin groups in terms of age, gender mean ISS, median hospital or intensive care unit lengths of stay, complication proportions, numbers of complications per patient, or the proportion of patients requiring transfusion. Finally, excluding patients who died, the observed proportion of discharge to skilled nursing facility was similar. In our sample of trauma patients, DOAC use was associated with significantly lower mortality (DOAC group 8.3% vs. warfarin group 29.5%, p<0.015). The ratio of units transfused per patient was also lower in the DOAC group (2.8±1.8 units/patient in the DOAC group vs. 6.7±6.4 units per patient in the warfarin group; p=0.001). In conclusion, we report an association with decrease in mortality and a decrease in transfused blood products in severely injured trauma patients with likely minimal or no head injury taking novel DOACs over those anticoagulated with warfarin for outpatient anticoagulation. Copyright © 2016 Elsevier Ltd. All rights reserved.

Access to specialist care: Optimizing the geographic configuration of trauma systems

PubMed Central

Jansen, Jan O.; Morrison, Jonathan J.; Wang, Handing; He, Shan; Lawrenson, Robin; Hutchison, James D.; Campbell, Marion K.

2015-01-01

BACKGROUND The optimal geographic configuration of health care systems is key to maximizing accessibility while promoting the efficient use of resources. This article reports the use of a novel approach to inform the optimal configuration of a national trauma system. METHODS This is a prospective cohort study of all trauma patients, 15 years and older, attended to by the Scottish Ambulance Service, between July 1, 2013, and June 30, 2014. Patients underwent notional triage to one of three levels of care (major trauma center [MTC], trauma unit, or local emergency hospital). We used geographic information systems software to calculate access times, by road and air, from all incident locations to all candidate hospitals. We then modeled the performance of all mathematically possible network configurations and used multiobjective optimization to determine geospatially optimized configurations. RESULTS A total of 80,391 casualties were included. A network with only high- or moderate-volume MTCs (admitting at least 650 or 400 severely injured patients per year, respectively) would be optimally configured with a single MTC. A network accepting lower-volume MTCs (at least 240 severely injured patients per year) would be optimally configured with two MTCs. Both configurations would necessitate an increase in the number of helicopter retrievals. CONCLUSION This study has shown that a novel combination of notional triage, network analysis, and mathematical optimization can be used to inform the planning of a national clinical network. Scotland’s trauma system could be optimized with one or two MTCs. LEVEL OF EVIDENCE Care management study, level IV. PMID:26335775

Helicopter-based emergency medical services for a sparsely populated region: A study of 42,500 dispatches.

PubMed

Østerås, Ø; Brattebø, G; Heltne, J-K

2016-05-01

The Helicopter Emergency Medical Service (HEMS) in Norway is operated day and night, despite challenging geography and weather. In Western Norway, three ambulance helicopters, with a rapid response car as an alternative, cover close to 1 million inhabitants in an area of 45,000 km(2) . Our objective was to assess patterns of emergency medical problems and treatments in HEMS in a geographically large, but sparsely populated region. Data from all HEMS dispatches during 2004-2013 were assessed retrospectively. Information was analyzed with respect to patient treatment and characteristics, in addition to variations in services use during the day, week, and seasons. A total of 42,456 dispatches were analyzed. One third of the patients encountered were severely ill or injured, and two thirds of these received advanced treatment. Median activation time and on-scene time in primary helicopter missions were 5 and 11 min, respectively. Most patients (95%) were reached within 45 min by helicopter or rapid response car. Patterns of use did not change. More than one third of all dispatches were declined or aborted, mostly due to no longer medical indication, bad weather conditions, or competing missions. One third of the patients encountered were severely ill or injured, and more than two thirds of these received advanced treatment. HEMS use did not change over the 10-year period, however HEMS use peaked during daytime, weekends, and the summer. More than one third of all dispatches were declined or aborted. © 2015 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.

Multiple fMRI system-level baseline connectivity is disrupted in patients with consciousness alterations.

PubMed

Demertzi, Athena; Gómez, Francisco; Crone, Julia Sophia; Vanhaudenhuyse, Audrey; Tshibanda, Luaba; Noirhomme, Quentin; Thonnard, Marie; Charland-Verville, Vanessa; Kirsch, Murielle; Laureys, Steven; Soddu, Andrea

2014-03-01

In healthy conditions, group-level fMRI resting state analyses identify ten resting state networks (RSNs) of cognitive relevance. Here, we aim to assess the ten-network model in severely brain-injured patients suffering from disorders of consciousness and to identify those networks which will be most relevant to discriminate between patients and healthy subjects. 300 fMRI volumes were obtained in 27 healthy controls and 53 patients in minimally conscious state (MCS), vegetative state/unresponsive wakefulness syndrome (VS/UWS) and coma. Independent component analysis (ICA) reduced data dimensionality. The ten networks were identified by means of a multiple template-matching procedure and were tested on neuronality properties (neuronal vs non-neuronal) in a data-driven way. Univariate analyses detected between-group differences in networks' neuronal properties and estimated voxel-wise functional connectivity in the networks, which were significantly less identifiable in patients. A nearest-neighbor "clinical" classifier was used to determine the networks with high between-group discriminative accuracy. Healthy controls were characterized by more neuronal components compared to patients in VS/UWS and in coma. Compared to healthy controls, fewer patients in MCS and VS/UWS showed components of neuronal origin for the left executive control network, default mode network (DMN), auditory, and right executive control network. The "clinical" classifier indicated the DMN and auditory network with the highest accuracy (85.3%) in discriminating patients from healthy subjects. FMRI multiple-network resting state connectivity is disrupted in severely brain-injured patients suffering from disorders of consciousness. When performing ICA, multiple-network testing and control for neuronal properties of the identified RSNs can advance fMRI system-level characterization. Automatic data-driven patient classification is the first step towards future single-subject objective diagnostics based on fMRI resting state acquisitions. Copyright © 2013 Elsevier Ltd. All rights reserved.

Use of recombinant factor VIIa in US military casualties for a five-year period.

PubMed

Wade, Charles E; Eastridge, Brian J; Jones, John A; West, Susan A; Spinella, Philip C; Perkins, Jeremy G; Dubick, Michael A; Blackbourne, Lorne H; Holcomb, John B

2010-08-01

Two prospective randomized trauma trials have shown recombinant factor VIIa (rFVIIa) to be safe and to decrease transfusion requirements. rFVIIa is presently used in 22% of massively transfused civilian trauma patients. The US Military has used rFVIIa in combat trauma patients for five years, and two small studies of massively transfused patients described an association with improved outcomes. This study was undertaken to assess how deployed physicians are using rFVIIa and its impact on casualty outcomes. US combat casualties (n = 2,050) receiving any blood transfusion from 2003 to 2009 were reviewed to compare patients receiving rFVIIa (n = 506) with those who did not (n = 1,544). Propensity-score matching (primary analysis) and multivariable logistic regression were used to compare outcomes. Differences were determined at p < 0.05. Twenty-five percent of patients received rFVIIa. Significant differences were noted between groups in indices of injury severity (Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Scale score), admission physiology (systolic blood pressure, diastolic blood pressure, heart rate, temperature, base deficit, hemoglobin, and international normalization ratio), and use of blood products, indicating that patients treated with rFVIIa were more severely injured, in shock, and coagulopathic. For propensity-score matching, factors associated with death were used: Injury Severity Score, Glasgow Coma Scale score, heart rate, systolic blood pressure, diastolic blood pressure, Hgb, and total packed red blood cell. A total of 266 patients per group were matched; 52% of the rFVIIa group. After pairing, there were no significant differences in any of the demographics, including incidence of massive transfusion (53% vs. 51%). There was no difference in the rate of complications (21% vs. 21%) or mortality (14% vs. 20%) for patients not treated or receiving rFVIIa, respectively. In military casualties, rFVIIa is used in the most severely injured patients based on physician selection rather than on guideline criteria. Use of rFVIIa is not associated with an improvement in survival or an increase in complications. The undetected bias of physician selection of patients for treatment with rFVIIa, likely, has an impact on case matching to achieve equivalence similar to that of randomized control studies. This inability to match populations, thus, prevents definitive interpretation of this study and others studies of similar design. This problem emphasizes the need to develop entry criteria to identify patients who could potentially benefit from use of rFVIIa and the need to subsequently perform efficacy studies.

Rib fractures in trauma patients: does operative fixation improve outcome?

PubMed

Majak, Peter; Næss, Pål A

2016-12-01

Renewed interest in surgical fixation of rib fractures has emerged. However, conservative treatment is still preferred at most surgical departments. We wanted to evaluate whether operative treatment of rib fractures may benefit severely injured patients. Several studies report a reduction in mechanical ventilation time, ICU length of stay (LOS), hospital LOS, pneumonia, need for tracheostomy, pain and costs in operatively treated patients with multiple rib fractures compared with patients treated nonoperatively. Although patient selection and timing of the operation seem crucial for successful outcome, no consensus exists. Mortality reduction has only been shown in a few studies. Most studies are retrospective cohort and case-control studies. Only four randomized control trials exist. Conservative treatment, consisting of respiratory assistance and pain control, is still the treatment of choice in the vast majority of patients with multiple rib fractures. In selected patients, operative fixation of fractured ribs within 72 h postinjury may lead to better outcome. More randomized control trials are needed to further determine who benefits from surgical fixation of rib fractures.

Helicopter patient transportation service on the Ulleung Island, South Korea.

PubMed

Yi, Jin-Wook; Lee, Kyu Eun; Kim, Young-Heon; Youn, Yeo-Kyu

2014-01-01

Despite numerous studies of helicopter emergency medical services, few reports have examined the outcomes of patients transported by helicopter across the sea from isolated islands. We analyzed helicopter transportation from the isolated Ulleung Island, which lies to the east of the South Korean mainland. This study included 284 patients transported from the Ulleung Island to mainland hospitals between January 2007 and March 2013. Emergency Severity Index and Injury Severity Score were calculated. Hospital stay time and flight duration was measured. Data were analyzed using Student's t-test. The mean age of the patients was 53.5 years. Of the transported patients, 19.0% were visitors to the island and 29.6% were traumatically injured. The mortality rate after transportation was 11.6% (33 patients). Helicopter transportation has been very beneficial for the treatment of emergency patients on Ulleung Island. A national level of interest and investment is required to improve this service. Copyright © 2014 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.

The epidemiology of horse-related injuries for different horse exposures, activities, and age groups in Queensland, Australia.

PubMed

Lang, Jacelle; Sathivelu, Maria; Tetsworth, Kevin; Pollard, Cliff; Harvey, Kathy; Bellamy, Nicholas

2014-01-01

The dangers associated with horse riding, a popular activity throughout Australia, are well documented; yet, few studies have comprehensively described injuries caused by horses to nonriders. This study aimed to facilitate targeted injury prevention strategies and appropriate trauma management by describing all horse-related injuries, for both riders and nonriders, in Queensland, and identifying those at greatest risk. Horse-related injury data from 2005 to 2009 were extracted from the Queensland Trauma Registry. Descriptive comparisons were undertaken for demographic, injury, and acute care characteristics between riders and nonriders, between pediatric and adult cases, and between sports/leisure and work injuries. The relative risk of surgery by sex and between riders and nonriders was assessed. More than 25% of injuries occurred in people not riding a horse. Nonriders sustained a significantly higher proportion of internal organ injuries, open wounds, as well as facial and pelvic/abdominal injuries. Females accounted for more than 80% of children who were injured while riding a horse. For adults, 25% were injured while working, and more than 66% of injured workers were male. Injuries most commonly occurred in regional areas. Surgery was most common among children, nonriders, and those with Injury Severity Score (ISS) of 1 to 8. The likelihood of surgery was 25% higher for nonriders (95% confidence interval, 1.14-1.38%). Horse-related injuries are most prevalent in identifiable populations, particularly young female riders and adult males injured while working. Injuries inflicted by horses to nonriders contribute more than 27% of all horse-related injuries; however, most previous research has been limited to injured riders. Compared with riders, nonriders more frequently sustain internal, facial, and pelvic injuries; are male; and undergo surgery. The results of this study may be used to tailor prevention strategies and inform trauma management specific to the type of horse exposure, patient age, and activity engaged in when injured. Epidemiologic study, level III.

Frequency of alcohol use among injured adult patients presenting to a Ghanaian emergency department

PubMed Central

Forson, Paa Kobina; Gardner, Andrew; Oduro, George; Bonney, Joseph; Biney, Eno Akua; Oppong, Chris; Momade, Ezster; Maio, Ronald F.

2016-01-01

Objective Injuries are the cause of almost six million deaths annually worldwide, with 15–20% alcohol-associated. The frequency of alcohol-associated injury varies among countries, and is unknown in Ghana. We determined the frequency of positive alcohol tests among injured adults in a Ghanaian Emergency Department (ED). Methods This is a cross-sectional chart review of consecutive injured patients 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within eight hours of injury. Patients were tested for alcohol using a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death prior to admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals (95%CIs) were calculated. Results 2,488 injured adult patients presented to the ED from November 2014 to April 2015 with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95%CI 32–38) tested alcohol positive. Forty-two percent of males (320/756), 40% of subjects 25–44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assaults (82/166), 40% of the seriously injured (124/311), and 53% of subjects who died in the ED (8/15) were positive for alcohol. Conclusions The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary hospital ED. These findings have implications for health policy, ED and legislative-based interventions, and acute care. PMID:27241887

Lung-protective Ventilation in Patients with Brain Injury: A Multicenter Cross-sectional Study and Questionnaire Survey in China

PubMed Central

Luo, Xu-Ying; Hu, Ying-Hong; Cao, Xiang-Yuan; Kang, Yan; Liu, Li-Ping; Wang, Shou-Hong; Yu, Rong-Guo; Yu, Xiang-You; Zhang, Xia; Li, Bao-Shan; Ma, Zeng-Xiang; Weng, Yi-Bing; Zhang, Heng; Chen, De-Chang; Chen, Wei; Chen, Wen-Jin; Chen, Xiu-Mei; Du, Bin; Duan, Mei-Li; Hu, Jin; Huang, Yun-Feng; Jia, Gui-Jun; Li, Li-Hong; Liang, Yu-Min; Qin, Bing-Yu; Wang, Xian-Dong; Xiong, Jian; Yan, Li-Mei; Yang, Zheng-Ping; Dong, Chen-Ming; Wang, Dong-Xin; Zhan, Qing-Yuan; Fu, Shuang-Lin; Zhao, Lin; Huang, Qi-Bing; Xie, Ying-Guang; Huang, Xiao-Bo; Zhang, Guo-Bin; Xu, Wang-Bin; Xu, Yuan; Liu, Ya-Ling; Zhao, He-Ling; Sun, Rong-Qing; Sun, Ming; Cheng, Qing-Hong; Qu, Xin; Yang, Xiao-Feng; Xu, Ming; Shi, Zhong-Hua; Chen, Han; He, Xuan; Yang, Yan-Lin; Chen, Guang-Qiang; Sun, Xiu-Mei; Zhou, Jian-Xin

2016-01-01

Background: Over the years, the mechanical ventilation (MV) strategy has changed worldwide. The aim of the present study was to describe the ventilation practices, particularly lung-protective ventilation (LPV), among brain-injured patients in China. Methods: This study was a multicenter, 1-day, cross-sectional study in 47 Intensive Care Units (ICUs) across China. Mechanically ventilated patients (18 years and older) with brain injury in a participating ICU during the time of the study, including traumatic brain injury, stroke, postoperation with intracranial tumor, hypoxic-ischemic encephalopathy, intracranial infection, and idiopathic epilepsy, were enrolled. Demographic data, primary diagnoses, indications for MV, MV modes and settings, and prognoses on the 60th day were collected. Multivariable logistic analysis was used to assess factors that might affect the use of LPV. Results: A total of 104 patients were enrolled in the present study, 87 (83.7%) of whom were identified with severe brain injury based on a Glasgow Coma Scale ≤8 points. Synchronized intermittent mandatory ventilation (SIMV) was the most frequent ventilator mode, accounting for 46.2% of the entire cohort. The median tidal volume was set to 8.0 ml/kg (interquartile range [IQR], 7.0–8.9 ml/kg) of the predicted body weight; 50 (48.1%) patients received LPV. The median positive end-expiratory pressure (PEEP) was set to 5 cmH2O (IQR, 5–6 cmH2O). No PEEP values were higher than 10 cmH2O. Compared with partially mandatory ventilation, supportive and spontaneous ventilation practices were associated with LPV. There were no significant differences in mortality and MV duration between patients subjected to LPV and those were not. Conclusions: Among brain-injured patients in China, SIMV was the most frequent ventilation mode. Nearly one-half of the brain-injured patients received LPV. Patients under supportive and spontaneous ventilation were more likely to receive LPV. Trial Registration: ClinicalTrials.org NCT02517073 https://clinicaltrials.gov/ct2/show/NCT02517073. PMID:27411450

Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial.

PubMed

Lecky, Fiona Elizabeth; Russell, Wanda; McClelland, Graham; Pennington, Elspeth; Fuller, Gordon; Goodacre, Steve; Han, Kyee; Curran, Andrew; Holliman, Damian; Chapman, Nathan; Freeman, Jennifer; Byers, Sonia; Mason, Suzanne; Potter, Hugh; Coats, Timothy; Mackway-Jones, Kevin; Peters, Mary; Shewan, Jane

2017-10-05

Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)-bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI -directly into SNCs-producing a measurable effect. Two English Ambulance Services. 74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults-injured nearest to an NSAH-with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC. Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC. Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes. 56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7-14.0)% vs intervention=9.4(2.3-14.0)%). Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely. ISRCTN68087745. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Cryoprecipitate use in the PROMMTT study.

PubMed

Holcomb, John B; Fox, Erin E; Zhang, Xuan; White, Nathan; Wade, Charles E; Cotton, Bryan A; del Junco, Deborah J; Bulger, Eileen M; Cohen, Mitchell J; Schreiber, Martin A; Myers, John G; Brasel, Karen J; Phelan, Herb A; Alarcon, Louis H; Muskat, Peter; Rahbar, Mohammad H

2013-07-01

There are few clinical data to guide the use of cryoprecipitate in severely injured trauma patients. Cryoprecipitate is a rich source of fibrinogen and has been associated with improved survival in animal as well as limited human studies. Our objectives were to identify patterns and predictors of cryoprecipitate use and determine whether transfusing cryoprecipitate was associated with improved survival. This secondary analysis of 1,238 of 1,245 PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study patients who had timed transfusion data included 359 (29%) who received cryoprecipitate. For this analysis, one dose of cryoprecipitate was defined as 10 U. Unadjusted predictors of cryoprecipitate use were identified using logistic regression. Multivariable time-dependent Cox models were performed to examine the association of cryoprecipitate on time to in-hospital death. Cryoprecipitate use varied significantly by center, ranging from 7% to 82%. Among patients who received cryoprecipitate, the median number of units infused by 24 hours was 10 (interquartile range, 10-20). The median time from admission to first cryoprecipitate unit was 2.7 hours (interquartile range, 1.7-4.4 hours). Of those who died of a hemorrhagic death within 6 hours of admission, 72% received no cryoprecipitate. Other unadjusted predictors of cryoprecipitate use included Injury Severity Score (ISS), initial fibrinogen levels, base deficit, international normalized ratio, prothrombin time/partial thromboplastin time, hemoglobin, damage-control surgery, and surgical intervention of the chest and abdomen. Cryoprecipitate use was not associated with in-hospital mortality after adjusting for initial pH, initial hemoglobin, emergency department systolic blood pressure, emergency department Glasgow Coma Scale (GCS) score, blood product use, ISS, and center. Ten US Level 1 trauma centers vary greatly in their timing and use of cryoprecipitate in severely injured trauma patients. We could not identify any association of cryoprecipitate use with in-hospital mortality, although most patients did not receive this product. Randomized controlled studies are needed to determine if cryoprecipitate (or fibrinogen concentrates) have a beneficial effect.

Utility of magnetic resonance imaging in diagnosing cervical spine injury in children with severe traumatic brain injury.

PubMed

Qualls, David; Leonard, Jeffrey R; Keller, Martin; Pineda, Jose; Leonard, Julie C

2015-06-01

Evaluation of children for cervical spine injuries (CSIs) after blunt trauma is complicated, particularly if the patient is unresponsive because of severe traumatic brain injury. Plain radiography and computed tomography (CT) are commonly used, but CT combined with magnetic resonance imaging (MRI) is still considered the gold standard in CSI detection. However, MRI is expensive and can delay cervical clearance. The purpose of this study is to determine the added benefit of MRI as an adjunct to CT in the clearance of children with severe head trauma. We performed a retrospective chart review of pediatric head trauma patients admitted to the pediatric intensive care unit at St. Louis Children's Hospital from 2002 to 2012. Patients who received both cervical spine CT and MRI and presented with a Glasgow Coma Scale score of 8 or lower were included in the study. Imaging was analyzed by two pediatric trauma subspecialists and classified as demonstrating "no injury," "stable injury," or "unstable injury." Results were compared, and discrepancies between CT and MRI findings were noted. A total of 1,196 head-injured children were admitted to the pediatric intensive care unit between January 2002 and December 2012. Sixty-three children underwent CT and MRI and met Glasgow Coma Scale criteria. Seven children were identified with negative CT and positive MRI findings, but none of these injuries were considered unstable by our criteria. Five children were determined to have unstable injuries, and all were detected on CT. The results of this study suggest that MRI does not detect unstable CSIs in the setting of negative CT imaging. Given the limited patient population for this study, further and more extensive studies investigating the utility of MRI in the head-injured pediatric patient are warranted. Diagnostic and care management study, level IV.

A novel first aid stretcher for immobilization and transportation of spine injured patients.

PubMed

Liu, Yan-Sheng; Feng, Ya-Ping; Xie, Jia-Xin; Luo, Zhuo-Jing; Shen, Cai-Hong; Niu, Fang; Zou, Jian; Tang, Shao-Feng; Hao, Jiang; Xu, Jia-Xiang; Xiao, Li-Ping; Xu, Xiao-Ming; Zhu, Hui

2012-01-01

Effective immobilization and transportation are vital to the life-saving acute medical care needed when treating critically injured people. However, the most common types of stretchers used today are wrought with problems that can lead to further medical complications, difficulty in employment and rescue, and ineffective transitions to hospital treatment. Here we report a novel first aid stretcher called the "emergency carpet", which solves these problems with a unique design for spine injured patients. Polyurethane composite material, obtained by a novel process of manually mixing isocyanate and additives, can be poured into a specially designed fabric bag and allowed to harden to form a rigid human-shaped stretcher. The effectiveness of the emergency carpet was examined in the pre-hospital management of victims with spinal fractures. Additionally, it was tested on flat ground and complex terrain as well as in the sea and air. We demonstrated that the emergency carpet can be assembled and solidified on the scene in 5 minutes, providing effective immobilization to the entire injured body. With the protection of the emergency carpet, none of the 20 patients, who were finally confirmed to have spinal column fracture or dislocation, had any neurological deterioration during transportation. Furthermore, the carpet can be handled and transported by multiple means under differing conditions, without compromising immobilization. Finally, the emergency carpet allows the critically injured patient to receive multiple examinations such as X-ray, CT, and MRI without being removed from the carpet. Our results demonstrate that the emergency carpet has ideal capabilities for immobilization, extrication, and transportation of the spine injured patients. Compared with other stretchers, it allows for better mobility, effective immobilization, remarkable conformity to the body, and various means for transportation. The emergency carpet is promising for its intrinsic advantages in the pre-hospital management of accident victims.

Use of a novel saline/bipolar radiofrequency energy instrument as an adjunct for arresting ongoing solid organ surface and laceration bleeding in critically injured patients.

PubMed

Ball, Chad G; Campbell, Andre; Grondin, Sean C; Dixon, Elijah; DuBose, Joseph; McBeth, Paul B; Lall, Rohan

2016-09-01

Solid organ (liver, spleen and kidney) haemorrhage is often life threatening and can be difficult to stop in critically ill patients. Traditional techniques for arresting this ongoing bleeding include coagulation by high voltage cautery (Bovie), topical haemostatic application, and the delivery of ignited argon gas. The goal of this study was to evaluate the efficacy of a new energy device for arresting persistent solid organ haemorrhage. A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a simple hand piece was employed to arrest ongoing bleeding from solid organ injuries at 2 high volume, level 1 trauma centres. This instrument is extrapolated from experience within elective hepatic resections. Standard statistics were employed (p<0.05=significant). From January 2013 to January 2015, 36 severely injured patients (mean injury severity score=31; blunt mechanisms=32/36 (89%)) underwent use of this new saline/RF energy instrument to arrest ongoing haemorrhage from the liver (29), spleen (5) and kidney (2). Of these patients, 25 received instrument use during an initial laparotomy, while 11 patients underwent use following removal of sponges during a return laparotomy after an initial damage control procedure. Success in arresting ongoing haemorrhage was 97% (35/36) in these highly selected cases. The surgeons reported an 'ease of use' score of 4.9 out of 5. No postoperative complications (including delayed haemorrhage) were noted as a direct result of the energy instrument. This simple saline/RF energy instrument has the potential to arrest ongoing solid organ surface/capsular bleeding, as well as moderate haemorrhage associated with deep lacerations. Copyright © 2016 Elsevier Ltd. All rights reserved.

Injuries to the upper extremities in polytrauma: limited effect on outcome more than ten years after injury - a cohort study in 629 patients.

PubMed

Macke, C; Winkelmann, M; Mommsen, P; Probst, C; Zelle, B; Krettek, C; Zeckey, C

2017-02-01

To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients' injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255-60. ©2017 The British Editorial Society of Bone & Joint Surgery.

Design Challenges in Converting a Paper Checklist to Digital Format for Dynamic Medical Settings

PubMed Central

Sarcevic, Aleksandra; Rosen, Brett J.; Kulp, Leah J.; Marsic, Ivan; Burd, Randall S.

2016-01-01

We describe a mobile digital checklist that we designed and developed for trauma resuscitation—a dynamic, fast-paced medical process of treating severely injured patients. The checklist design was informed by our analysis of user interactions with a paper checklist that was introduced to improve team performance during resuscitations. The design process followed an iterative approach and involved several medical experts. We discuss design challenges in converting a paper checklist to its digital counterpart, as well as our approaches for addressing those challenges. While we show that using a digital checklist during a fast-paced medical event is feasible, we also recognize several design constraints, including limited display size, difficulties in entering notes about the medical process and patient, and difficulties in replicating user experience with paper checklists. PMID:28480116

Managing mild casualties in mass-casualty incidents: lessons learned from an aborted terrorist attack.

PubMed

Bloch, Yuval H; Leiba, Adi; Veaacnin, Nurit; Paizer, Yohanan; Schwartz, Dagan; Kraskas, Ahuva; Weiss, Gali; Goldberg, Avishay; Bar-Dayan, Yaron

2007-01-01

Mildly injured and "worried well" patients can have profound effects on the management of a mass-casualty incident. The objective of this study is to describe the characteristics and lessons learned from an event that occurred on 28 August 2005 near the central bus station in Beer-Sheva, Israel. The unique profile of injuries allows for the examination of the medical and operational aspects of the management of mild casualties. Data were collected during and after the event, using patient records and formal debriefings. They were processed focusing on the characteristics of patient complaints, medical response, and the dynamics of admission. A total of 64 patients presented to the local emergency department, including two critical casualties. The remaining 62 patients were mildly injured or suffered from stress. Patient presentation to the emergency department was bi-phasic; during the first two hours following the attack (i.e., early phase), the rate of arrival was high (one patient every three minutes), and anxiety was the most frequent chief complaint. During the second phase, the rate of arrival was lower (one patient every 27 minutes), and the typical chief complaint was somatic. Additionally, tinnitus and complaints related to minor trauma also were recorded frequently. Psychiatric consultation was obtained for 58 (91%) of the patients. Social services were involved in the care of 47 of the patients (73%). Otolaryngology and surgery consultations were obtained for 45% and 44%, respectively. The need for some medical specialties (e.g., surgery and orthopedics) mainly was during the first phase, whereas others, mainly psychiatry and otolaryngology, were needed during both phases. Only 13 patients (20%) needed a consultation from internal medicine. Following a terrorist attack, a large number of mildly injured victims and those experiencing stress are to be expected, without a direct relation to the effectiveness of the attack. Mildly injured patients tend to appear in two phases. In the first phase, the rate of admission is expected to be higher. Due to the high incidence of anxiety and other stress-related phenomena, many mildly injured patients will require psychiatric evaluation. In the case of a bombing attack, many of the victims must be evaluated by an otolaryngologist.

Evaluation of lower leg function in patients with Achilles tendinopathy.

PubMed

Silbernagel, Karin Grävare; Gustavsson, Alexander; Thomeé, Roland; Karlsson, Jon

2006-11-01

Achilles tendinopathy is considered to be one of the most common overuse injuries in elite and recreational athletes. However, the effect that the Achilles tendinopathy has on patients' physical performance is still unclear. The purpose of this study was to evaluate if Achilles tendinopathy caused functional deficits on the injured side compared with the non-injured side in patients. A test battery comprised of tests for different aspects of muscle-tendon function of the gastrocnemius, soleus and Achilles tendon complex was developed to evaluate lower leg function. The test battery's test-retest reliability and sensitivity (the percent probability that the tests would demonstrate abnormal lower limb symmetry index in patients) were also evaluated. The test battery consisted of three jump tests, a counter movements jump (CMJ), a drop counter movement jump (drop CMJ) and hopping, and two strength tests, concentric toe-raises, eccentric-concentric toe-raises and toe-raises for endurance. The reliability was evaluated through a test-retest design on 15 healthy subjects. The test battery's sensitivity and possible functional deficits in patients with Achilles tendinopathy were evaluated on 42 patients (19 women and 23 men). An excellent reliability was found between test days 1-2 and 2-3 for all tests (ICC = 0.76-0.94) except for concentric toe-raise, test 2-3, which had fair reliability (ICC = 0.73). The methodological error ranged from 8 to 17%. There were significant differences (P = 0.001-0.049) between the non-injured (or least symptomatic) side and injured (most symptomatic) side for hopping, drop CMJ, concentric and eccentric-concentric toe-raises, and significant differences (P = 0.000-0.012) in the level of pain during CMJ, hopping, and drop CMJ. The sensitivity of the test battery at a 90% capacity was 88. Achilles tendinopathy causes not only pain and symptoms in patients but also apparent impairments in various aspects of lower leg muscle-tendon function as measured with the test battery. This test battery is reliable and able to detect differences in lower leg function between the injured or "most symptomatic" and non-injured or "least symptomatic" side in patients with Achilles tendinopathy. The test battery has higher demand on patients' function compared with each individual test.

The clinical significance of platelet counts in the first 24 hours after severe injury.

PubMed

Stansbury, Lynn G; Hess, Aaron S; Thompson, Kwaku; Kramer, Betsy; Scalea, Thomas M; Hess, John R

2013-04-01

Admission platelet (PLT) counts are known to be associated with all-cause mortality for seriously injured patients admitted to a trauma center. The course of subsequent PLT counts, their implications, and the effects of PLT therapy are less well known. Trauma center patients who were directly admitted from the scene of injury, received 1 or more units of uncrossmatched red blood cells in the first hour of care, survived for at least 15 minutes, and had a PLT count measured in the first hour were analyzed for the association of their admission and subsequent PLT counts in the first 24 hours with injury severity and hemorrhagic and central nervous system (CNS) causes of in-hospital mortality. Over an 8.25-year period, 1292 of 45,849 direct trauma admissions met entry criteria. Admission PLT counts averaged 228×10(9) ±90×10(9) /L and decreased by 104×10(9) /L by the second hour and 1×10(9) /L each hour thereafter. The admission count was not related to time to admission. Each 1-point increase in the injury severity score was associated with a 1×10(9) /L decrease in the PLT count at all times in the first 24 hours of care. Admission PLT counts were strongly associated with hemorrhagic and CNS injury mortality and subsequent PLT counts. Effects of PLT therapy could not be ascertained. Admission PLT counts in critically injured trauma patients are usually normal, decreasing after admission. Low PLT counts at admission and during the course of trauma care are strongly associated with mortality. © 2012 American Association of Blood Banks.

Organizational characteristics of the austere intensive care unit: the evolution of military trauma and critical care medicine; applications for civilian medical care systems.

PubMed

Grathwohl, Kurt W; Venticinque, Steven G

2008-07-01

Critical care in the U.S. military has significantly evolved in the last decade. More recently, the U.S. military has implemented organizational changes, including the use of multidisciplinary teams in austere environments to improve outcomes in severely injured polytrauma combat patients. Specifically, organizational changes in combat support hospitals located in combat zones during Operation Iraqi Freedom have led to decreased intensive care unit mortality and length of stay as well as resource use. These changes were implemented without increases in logistic support or the addition of highly technologic equipment. The mechanism for improvement in mortality is likely attributable to the adherence of basic critical care medicine fundamentals. This intensivist-directed team model provides sophisticated critical care even in the most austere environments. To optimize critically injured patients' outcomes, intensive care organizational models similar to the U.S. military, described in this article, can possibly be adapted to those of civilian care during disaster management to meet the challenges of emergency mass critical care.

The significance of a small, level-3 'semi evacuation' hospital in a terrorist attack in a nearby town.

PubMed

Pinkert, Moshe; Leiba, Adi; Zaltsman, Eilon; Erez, Onn; Blumenfeld, Amir; Avinoam, Shkolnick; Laor, Daniel; Schwartz, Dagan; Goldberg, Avishay; Levi, Yehezkel; Bar-Dayan, Yaron

2007-09-01

Terrorist attacks can occur in remote areas causing mass-casualty incidents MCIs far away from level-1 trauma centres. This study draws lessons from an MCI pertaining to the management of primary and secondary evacuation and the operational mode practiced. Data was collected from formal debriefings during and after the event, and the medical response, interactions and main outcomes analysed using Disastrous Incidents Systematic Analysis through Components, Interactions and Results (DISAST-CIR) methodology. A total of 112 people were evacuated from the scene-66 to the nearby level 3 Laniado hospital, including the eight critically and severely injured patients. Laniado hospital was instructed to act as an evacuation hospital but the flow of patients ended rapidly and it was decided to admit moderately injured victims. We introduce a novel concept of a 'semi-evacuation hospital'. This mode of operation should be selected for small-scale events in which the evacuation hospital has hospitalization capacity and is not geographically isolated. We suggest that level-3 hospitals in remote areas should be prepared and drilled to work in semi-evacuation mode during MCIs.

Whole blood neutrophil gelatinase-associated lipocalin predicts acute kidney injury in burn patients.

PubMed

Sen, Soman; Godwin, Zack R; Palmieri, Tina; Greenhalgh, David; Steele, Amanda N; Tran, Nam K

2015-06-15

Early detection of acute kidney injury (AKI) in severely burn-injured patients can help alter treatment to prevent progression to acute failure and reduce the need for renal replacement therapy. We hypothesized that whole blood neutrophil gelatinase-associated lipocalin (NGAL) will be increased in severely burn-injured patients who develop AKI during acute resuscitation. We performed a prospective observation study of adult burn patients with a 20% total body surface area (TBSA) burned or greater burn injury. Two-hour serial measurements of NGAL, serum creatinine (Cr), and hourly urine output (UO) were collected for 48 h after admission. Our primary goal was to correlate the risk of AKI in the first week after burn injury with serial NGAL levels in the first 48 h after admission. Our secondary goal was to determine if NGAL was an earlier independent predictor of AKI compared with Cr and UO. We enrolled 30 adult (age ≥ 18 y) burn patients with the mean ± standard deviation age of 40.9 ± 15.4 and mean TBSA of 46.4 ± 22.4. Fourteen patients developed AKI within the first 7 d after burn injury. There were no differences in age, TBSA, fluid administration, mean arterial pressure, UO, and Cr between AKI and no-AKI patients. NGAL was significantly increased as early as 4 h after injury (182.67 ± 83.3 versus 107.37 ± 46.15) in the AKI group. Controlling for age, TBSA, and inhalation injury, NGAL was a predictor of AKI at 4 h after injury (odds ratio, 1.02) and remained predictive of AKI for the period of more than the first 24 h after admission. UO and Cr were not predictive of AKI in the first 24 h after admission. Whole blood NGAL is markedly increased in burn patients who develop AKI in the first week after injury. In addition, NGAL is an early independent predictor of AKI during acute resuscitation for severe burn injury. UO and Cr are not predictive of AKI during this time period. Copyright © 2015 Elsevier Inc. All rights reserved.

Child pedestrian injury and fatality in a developing country.

PubMed

Solagberu, Babatunde Akibu; Osuoji, Roland I; Ibrahim, Nasiru Akanmu; Oludara, Mobolaji A; Balogun, Rufai A; Ajani, Abdulwahab Olanrewaju; Idowu, Olufemi Emmanuel; Mustafa, Ibrahim A; Sanni, Felix O

2014-06-01

Child pedestrian injuries and fatalities in developing countries continue to increase. We examined child pedestrian injuries and fatalities in the most populated urban agglomeration in Africa in order to develop control measures. Two-year prospective study of injured child pedestrians (≤15 years) at the Surgical Emergency Room (SER) to determine demography, vehicles involved, road location, injury mechanism, pre-hospital transport, injury-arrival time, regions injured, injury severity and fatalities was done. Some 226 pedestrians (114 boys and 112 girls) comprising 42 children aged ≤4 years, 91 aged 5-9 years and 93 aged 10-15 years were seen with car collisions (83 pedestrians, 36.7%), motorcycles (76, 33.6%), buses (41, 18.1%), others (15, 6.6%) and 11 undetermined vehicles. Injuries on the highways were 147 (65%); inner-city roads 77 (34.1%) and two undetermined roads. Crossing the road was responsible for 168 (74.3%) pedestrian injuries; while three other mechanisms produced 58 (25.7%) patients. Regions injured were head (42.9%), lower limbs (35.4%) and others (21.7%). Relatives, bystanders and police/ambulance brought 186 (82.3%), 31 (13.7%) and eight (3.5%) children, respectively; and within 6 h (43.4, 11.5 and 2.2%) and after (38.9, 2.2 and 1.3%). Nineteen deaths (10 brought-in-dead, nine SER deaths) occurred; 15 of them girls, 15 had severe head injury, 15 were brought by relatives. However, fatality risks were truck collisions (OR 5.97), female child (OR 4.25), head injury (OR 4.18) and age ≤4 years (OR 3.7). The equal sex incidence, worse female fatality despite similar exposure and injury severity with male, deserve further research. Improved pre-hospital and SER care is needed.

Severe tracheal stenosis with tracheopathia osteoplastica-like changes due to traumatic blunt injury.

PubMed

Kakinuma, Kazutaka; Morikawa, Kei; Miyamoto, Yasuhiro; Saji, Hisashi; Mineshita, Masamichi; Miyazawa, Teruomi

2014-12-01

A 17-year-old man was injured in a motorcycle accident, leading to a complex cerebral contusion and hepatic injury. Approximately one month after being discharged from the hospital, the patient experienced gradually progressive dyspnea on exertion. Chest computed tomography revealed severe upper tracheal stenosis; thus, emergency tracheotomy and subsequent tracheoplasty were performed. Microscopically, the deformation of tracheal cartilage and extensive interstitial ossification/fibro-elastic changes were observed. To our knowledge, this is the first report documenting the ossification of the trachea that rapidly progressed after injury, which was confirmed by surgical resection of the upper trachea.

Accuracy of external cause-of-injury coding in VA polytrauma patient discharge records.

PubMed

Carlson, Kathleen F; Nugent, Sean M; Grill, Joseph; Sayer, Nina A

2010-01-01

Valid and efficient methods of identifying the etiology of treated injuries are critical for characterizing patient populations and developing prevention and rehabilitation strategies. We examined the accuracy of external cause-of-injury codes (E-codes) in Veterans Health Administration (VHA) administrative data for a population of injured patients. Chart notes and E-codes were extracted for 566 patients treated at any one of four VHA Polytrauma Rehabilitation Center sites between 2001 and 2006. Two expert coders, blinded to VHA E-codes, used chart notes to assign "gold standard" E-codes to injured patients. The accuracy of VHA E-coding was examined based on these gold standard E-codes. Only 382 of 517 (74%) injured patients were assigned E-codes in VHA records. Sensitivity of VHA E-codes varied significantly by site (range: 59%-91%, p < 0.001). Sensitivity was highest for combat-related injuries (81%) and lowest for fall-related injuries (60%). Overall specificity of E-codes was high (92%). E-coding accuracy was markedly higher when we restricted analyses to records that had been assigned VHA E-codes. E-codes may not be valid for ascertaining source-of-injury data for all injuries among VHA rehabilitation inpatients at this time. Enhanced training and policies may ensure more widespread, standardized use and accuracy of E-codes for injured veterans treated in the VHA.

Road Traffic Related Injury Severity in Truck Drivers: A Prospective Medical and Technical Analysis of 582 Truck Crashes.

PubMed

Decker, Sebastian; Otte, Dietmar; Muller, Christian Walter; Omar, Mohamed; Krettek, Christian; Haasper, Carl; Brand, Stephan

2016-06-01

While cyclists and pedestrians are known to be at significant risk for severe injuries when exposed to road traffic accidents (RTA) involving trucks, little is known about RTA injury risk for truck drivers. The aim of this study was to analyze the injury severity in truck drivers following RTAs. Our local accident research unit prospectively documented 43000 RTAs involving 582 trucks between 2000 and 2011. Injury severity, including the abbreviated injury scale (AIS) and the maximum abbreviated injury scale (MAIS) were analyzed. Technical parameters (e.g. delta-v, direction of impact), the location of accident, and its dependency on the road type were also taken into consideration. Thirteen percent (77/582) of truck drivers were injured. Extremities were found to be at highest risk of injury with the lower extremities (36x) being injured most severely (10x: AIS 2 and 3). Death occurred only after collisions with other trucks, and severity of injuries increased with an increased speed limit. The maximum abbreviated injury scale was higher in the crash opponents (56x MAIS ≥ 3) compared to the truck drivers (8x MAIS ≥ 3). Overall, 82% of the crash opponents were injured. The safety of truck drivers is assured by their vehicles, the consequence being that the risk of becoming injured is likely to be low. However, the legs especially are at high risk for severe injuries during RTAs. This probability increases in the instance of a collision with another truck. Nevertheless, in RTAs involving trucks and regular passenger vehicles, the other party is in higher risk of injury.

False fracture of the penis: Different pathology but similar clinical presentation and management.

PubMed

Kurkar, Adel; Elderwy, Ahmad A; Orabi, Hazem

2014-01-01

Penile fracture is the most common presentation of acute penis. Rupture of the superficial dorsal penile vein (s) may mimic penile fractures with similar clinical presentation but with intact corporeal bodies. Our aim of the study is to highlight superficial dorsal penile vein (s) injury as true emergency with better prognosis. Sixty-eight patients with suspected penile fractures presented to our hospital between June 2007 and January 2013. Out of these, 11 patients showed intact tunica albuginea on exploration with injured dorsal penile vein (s) identified. Records of such 11 cases were reviewed regarding age, etiology, symptoms, physical signs, findings of surgical exploration and post-operative erectile function. All 11 patients were injured during sexual intercourse and presented with penile swelling and ecchymosis and gradual detumescence. Mild penile pain was encountered in 5 cases and the "snap" sound was noted in 2 cases. Examination revealed no localized tenderness, or tunical defect. All the patients regained penile potency without deformity after surgical ligation of the severed vessels. One patient developed penile hypoesthesia. Although the classic "snap" sound and immediate detumescence are usually lacking in the symptomology of dorsal penile vein rupture, its clinical presentation can be indistinguishable from true penile fracture. Surgical exploration is still required to avoid missing tunical tear with possible future complications. The long-term outcome and prognosis are excellent.

False fracture of the penis: Different pathology but similar clinical presentation and management

PubMed Central

Kurkar, Adel; Elderwy, Ahmad A.; Orabi, Elderwy

2014-01-01

Introduction: Penile fracture is the most common presentation of acute penis. Rupture of the superficial dorsal penile vein (s) may mimic penile fractures with similar clinical presentation but with intact corporeal bodies. Our aim of the study is to highlight superficial dorsal penile vein (s) injury as true emergency with better prognosis. Subjects and Methods: Sixty-eight patients with suspected penile fractures presented to our hospital between June 2007 and January 2013. Out of these, 11 patients showed intact tunica albuginea on exploration with injured dorsal penile vein (s) identified. Records of such 11 cases were reviewed regarding age, etiology, symptoms, physical signs, findings of surgical exploration and post-operative erectile function. Results: All 11 patients were injured during sexual intercourse and presented with penile swelling and ecchymosis and gradual detumescence. Mild penile pain was encountered in 5 cases and the “snap” sound was noted in 2 cases. Examination revealed no localized tenderness, or tunical defect. All the patients regained penile potency without deformity after surgical ligation of the severed vessels. One patient developed penile hypoesthesia. Conclusion: Although the classic “snap” sound and immediate detumescence are usually lacking in the symptomology of dorsal penile vein rupture, its clinical presentation can be indistinguishable from true penile fracture. Surgical exploration is still required to avoid missing tunical tear with possible future complications. The long-term outcome and prognosis are excellent. PMID:24669117

Anterolateral ligament abnormalities in patients with acute anterior cruciate ligament rupture are associated with lateral meniscal and osseous injuries.

PubMed

Van Dyck, Pieter; Clockaerts, Stefan; Vanhoenacker, Filip M; Lambrecht, Valérie; Wouters, Kristien; De Smet, Eline; Gielen, Jan L; Parizel, Paul M

2016-10-01

To determine the frequency of anterolateral ligament (ALL) injury in patients with acute anterior cruciate ligament (ACL) rupture and to analyse its associated injury patterns. Ninety patients with acute ACL rupture for which MRI was obtained within 8 weeks after the initial trauma were retrospectively identified. Two radiologists assessed the status of the ALL on MRI by consensus. The presence or absence of an ALL abnormality was compared with the existence of medial and lateral meniscal tears diagnosed during arthroscopy. Associated collateral ligament and osseous injuries were documented with MRI. Forty-one of 90 knees (46 %) demonstrated ALL abnormalities on MRI. Of 49 knees with intact ALL, 15 (31 %) had a torn lateral meniscus as compared to 25 torn lateral menisci in 41 knees (61 %) with abnormal ALL (p = 0.008). Collateral ligament (p ≤ 0.05) and osseous injuries (p = 0.0037) were more frequent and severe in ALL-injured as compared with ALL-intact knees. ALL injuries are fairly common in patients with acute ACL rupture and are statistically significantly associated with lateral meniscal, collateral ligament and osseous injuries. • ALL injuries are fairly common in patients with acute ACL rupture. • ALL injuries are highly associated with lateral meniscal and osseous injuries. • MRI assessment of ACL-injured knees should include evaluation of the ALL.

A Case of Traumatic Retrograde Type A Aortic Dissection Accompanied by Multiorgan Injuries.

PubMed

Tsukioka, Katsuaki; Kono, Tetsuya; Takahashi, Kohei; Kehara, Hiromu; Urashita, Shuichi; Komatsu, Kazunori

2018-03-25

A 75-year-old woman was involved in a traffic accident and suffered retrograde type A aortic dissection, multiple rib fractures, and grade II hepatic injury accompanied by intraperitoneal bleeding. We performed total arch replacement using an open stent graft with cardiopulmonary bypass and circulatory arrest. This procedure requires anticoagulation and hypothermia, which are principally contraindicated in severe trauma patients. However, this situation was resolved by managing the patient non-operatively for 7 days, confirming the stabilization of other injured organs, and then performing the surgery. She required prolonged postoperative rehabilitation; however, she recovered steadily.

Recovery of nerve injury-induced alexia for Braille using forearm anaesthesia.

PubMed

Björkman, Anders; Rosén, Birgitta; Lundborg, Göran

2008-04-16

Nerve injuries in the upper extremity may severely affect hand function. Cutaneous forearm anaesthesia has been shown to improve hand sensation in nerve-injured patients. A blind man who lost his Braille reading capability after an axillary plexus injury was treated with temporary cutaneous forearm anaesthesia. After treatment sensory functions of the hand improved and the patient regained his Braille reading capability. The mechanism behind the improvement is likely unmasking of inhibited or silent neurons, but after repeated treatment sessions at increasing intervals the improvement has remained at 1-year follow-up, implying a structural change in the somatosensory cortex.

Management of lower extremity riding lawn mower injuries in children.

PubMed

Kroening, L; Davids, J R

2000-01-01

Eight children are injured by riding lawn mowers every day. The child, usually a bystander or passenger on the mower, can sustain life-threatening and limb-threatening injuries. Multidisciplinary care must be available to manage the numerous issues presented by the unique circumstance of a child with a severe injury in the acute and chronic settings. Whether the limb is salvaged or amputated, the ultimate goal is optimal functional outcome for the patient. We have developed a team approach to address these injuries from their onset until patient maturity, maximizing our ability to achieve this goal.

Trampoline trauma in children: is it preventable?

PubMed

Sandler, Gideon; Nguyen, Linh; Lam, Lawrence; Manglick, Maria P; Soundappan, Soundappan S V; Holland, Andrew J A

2011-11-01

Trampoline injuries represent a preventable cause of injury in children. This study identified the characteristics of children injured while using trampolines who presented to a pediatric trauma center in Sydney, Australia. The Pediatric Trauma Database at our institution was reviewed to identify children with trampoline-related injuries between January 1999 and June 2008. Data collected included age, sex, Injury Severity Score, anatomical region injured, type of injury, mechanism of injury, site of injury and surface fallen onto, level of supervision, treatment, and hospital length of stay. Over the 9.5-year review period, 383 children presented with trampoline-related injuries: 193 (50.4%) were female. Just over a quarter (n = 106, 27.7%) were treated and discharged the same day. The remaining patients accounted for 725 hospital bed days with a mean length of stay of 2.3 days. The most common area of the body injured was the upper limb (n = 246, 64.2%), with a fall from the trampoline to the ground being the most frequent mechanism of injury (n = 257, 67.1%). The majority (n = 345, 90.1%) of children were injured in their home or at the home of a friend or relative. Surgery was required in 236 (61.6%), with closed reduction of an upper limb fracture being the most common procedure (n = 107, 27.9%). Trampoline-related injuries remain common in children. Implementation of current guidelines and the introduction of innovative trampoline designs should reduce the risk of this injury in children.

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

PubMed Central

Evriviades, Demetrius; Jeffery, Steven; Cubison, Tania; Lawton, Graham; Gill, Martin; Mortiboy, Deborah

2011-01-01

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges. PMID:21149357

Injury analysis of patients according to impact patterns involved in pedestrian traffic crashes.

PubMed

Lee, Hee Young; Youk, Hyun; Ii Lee, Jeong; Kang, Chan Young; Kong, Joon Seok; Sung, Sil; Kang, In Hye; Lee, Jung Hun; Kim, Oh Hyun; Jung, Woo Jin; Lee, Kang Hyun; Youn, Young Han; Park, Jong Chan

2018-02-28

In cases of car-to-person pedestrian traffic crashes (PTCs), the principal issue is determining at what point the car collided with the pedestrian. Accordingly, the objective of the present study was to use the medical records of patients injured in PTCs to investigate the characteristics of crash types and the areas and injury severity and to determine whether there are differences in injuries due to the angle, motion, and position at the point of impact. The present study examined 231 PTC patients admitted to the emergency room (ER) between January and December 2014. Electronic medical records from the hospital were used to divide the patient data according to Abbreviated Injury Scale (AIS) codes for injured areas based on sex, age, time of the crash, outcomes after ER treatment, and major symptoms. Among 231 patients, police reports on 67 crash cases, involving 70 people, were obtained with the help of local police departments, and these reports were used to reconstruct details of the actual crash. For statistical analysis, a chi-square test and a one-way analysis of variance calculation were used to compare the Injury Severity Score (ISS) based on groups and stages, with a statistical significance level set to P < .05. With respect to patients who were admitted for PTC, 52.4% were females and 47.6% were males. The frequency of crashes was high in middle-aged and elderly groups, as well as for youths between 10 and 19 years old. With respect to outcomes after ER treatment, discharge to home after symptom improvement was the most common outcome (24.6%). Admissions to the intensive care unit (25.1%) and to the general ward (23.8%) were also high. In terms of major symptoms, the most common injuries were to the head, resulting from a rotatory motion post impact (35.9%), and injuries to the legs, resulting from the impact of a direct collision with an object (25.1%). This study demonstrated that injuries to the chest and abdomen were the most severe in the fender vault group and head and neck injuries were the most severe in the roof vault group. In particular, the Injury Severity Score was highest in the roof vault group.

Psychological Distress and Post-Traumatic Symptoms Following Occupational Accidents

PubMed Central

Ghisi, Marta; Novara, Caterina; Buodo, Giulia; Kimble, Matthew O.; Scozzari, Simona; Di Natale, Arianna; Sanavio, Ezio; Palomba, Daniela

2013-01-01

Depression and post-traumatic stress disorder frequently occur as a consequence of occupational accidents. To date, research has been primarily focused on high-risk workers, such as police officers or firefighters, and has rarely considered individuals whose occupational environment involves the risk of severe, but not necessarily life-threatening, injury. Therefore, the present study was aimed at assessing the psychological consequences of accidents occurring in several occupational settings (e.g., construction and industry). Thirty-eight victims of occupational accidents (injured workers) and 38 gender-, age-, and years of education-matched workers who never experienced a work accident (control group) were recruited. All participants underwent a semi-structured interview administered by a trained psychologist, and then were requested to fill in the questionnaires. Injured workers reported more severe anxious, post-traumatic and depressive symptoms, and poorer coping skills, as compared to controls. In the injured group low levels of resilience predicted post-traumatic symptomatology, whereas the degree of physical injury and the length of time since the accident did not play a predictive role. The results suggest that occupational accidents may result in a disabling psychopathological condition, and that a brief psychological evaluation should be included in the assessment of seriously injured workers. PMID:25379258

Interjoint coordination in lower limbs in patients with a rupture of the anterior cruciate ligament of the knee joint.

PubMed

St-Onge, N; Duval, N; Yahia, L'H; Feldman, A G

2004-05-01

Previous studies of movement kinematics in patients with a ruptured anterior cruciate ligament (ACL) have focused on changes in angular displacement in a single joint, usually flexion/extension of the knee. In the present study, we investigated the effect of an ACL injury on the overall limb interjoint coordination. We asked healthy and chronic ACL-deficient male subjects to perform eight types of movements: forward squats, backward squats, sideways squats, squats on one leg, going up a step, going down a step, walking three steps, and stepping in place. Depending on the movement concerned, we applied principal component (PC) analysis to 3 or 4 degrees of freedom (DFs): thigh flexion/extension, knee flexion/extension, ankle flexion/extension, thigh abduction/adduction. The first three DFs were investigated in all movements. PC analysis identifies linear combinations of DFs. Movements with a fixed ratio between DFs are thus described by only one PC or synergy. PCs were computed for the entire movement as well as for the period of time when the foot was in contact with the ground. For both the control and the injured groups, two synergies (PC vectors) usually accounted for more than 95% of the DFs' angular excursions. It was possible to describe 95-99% of some movements using only one synergy. Compared to control subjects, injured subjects employed different synergies for going up a step, walking three steps, squatting sideways, and squatting forward, both in the injured and uninjured legs. Those movements may thus be more indicative of injury than other movements. Although ACL-deficiency did not increase asymmetry (angle between the PCs of the same movement performed on the right and the left sides), this result is not conclusive because of the comparatively low number of subjects who participated in the study. However, the finding that synergies in both legs of patients were different from those in control subjects for going up a step and walking three steps suggests that interjoint coordination was affected for both legs, so that the asymmetry index might have been preserved despite the injury. There was also a relationship between the asymmetry index for squatting on one leg, squatting forward, walking three steps and some of the outcomes of the knee injury and osteoarthritis outcome score (pain, symptoms, activities of daily living, sport and recreation function, and knee-related quality of life). This suggests that significant differences in the asymmetry index could be obtained if more severely-injured patients participated in this study. It is possible that subjects compensated for their mechanical deficiencies by modifying muscle activation patterns. Synergies were not only modified in injured subjects, but also rearranged: the percentage of movement explained by the first PC was different for the injured and/or uninjured legs of patients, as compared to the legs of the control group, for going up a step, going down a step, walking three steps, and squatting forward. We concluded that the analysis of interjoint coordination may be efficient in characterizing motor deficits in people with knee injuries.

[Case control study on the treatment of acromioclavicular dislocation with Endobutton plates combined with an anchor].

PubMed

Hu, Jin-Tao; Lu, Jian-Wei; Fu, Li-Feng

2016-09-25

To compare the clinical effect of Endobutton plates combined with an anchor and clavicle hook plate in the treatment of acromioclavicular dislocation. From January 2012 to August 2014, 83 patients with Rockwood type III acromioclavicular dislocation underwent surgical treatments. Among them, 34 patients were treated with Endobutton plate and anchor repair(Endobutton group), including 23 males and 11 females, and the mean age was(39.0±6.3) years old (26 to 51 years old); the average time from injury to operation was(4.1±1.3) days(3 to 7 days);the injured side:14 left, 20 right; the dislocation in 28 patients dues to fall, 6 patients dues traffic accident. There were 49 patients treated with clavicular hook plate(hook plate group), including 33 males and 16 females;the mean age was(37.9±6.3) years old (27 to 53 years old); the average time from injury to operation was(4.1±1.1) days (2 to 7 days);the injured side: 18 left, 31 right;the dislication in 36 patients dues to fall, 13 patients dues traffic accidents. The indexes such as intraoperative bleeding volume, operation time, incision size, postoperative complication and postoperative coracoclavicular space, shoulder joint function, and life quality were compared between two groups. In the hook plate group with 49 patients, the plates in 43 patients were removed at the secondary operation, and 32 patients had shoulder pain or limited active range. Thirty four patients in the Endobutton group had no pain symptoms and limited active range. All the patients did not suffer acromioclavicular dislocation again. There was no significant difference between the two groups in operation time, and intraoperative bleeding volume( P >0.05). The incision length in the hook plate group was longer than that in Endobutton group( P <0.05). The coracoclavicular space of the uninjured and injured side in two groups respectively had no significant differences, and the coracoclavicular space in the injured side between two group had no significant difference( P >0.05). There were no significant differences of Constant score and SF-36 between two groups 2 months after operation( P >0.05). Sixteen months after operation, the Constant score in the injured side of both groups was higher than that in 2 months postoperative. But the Constant score in the injured side of hook plate group was higher than that in Endobutton group( P <0.05). The Constant score in the uninjured side had no significant differences between two group( P >0.05). In hook plate group, the Constant score in the uninjured side was higher than that in the injured side. In Endobutton group, there were no significant differences of Constant score between two sides. The 16 month postoperative SF-36 in the injured side of both groups was higher than the 2 month postoperative one, but 16 month postoperative SF-36 in hook plate group was lower than that in Endobutton group ( P <0.05). Endobutton plate combined with an anchor can effectively fix Rockwood type III or more acute acromioclavicular dislocation. The method has less complications, avoiding secondary removal of internal fixation.

Recovery of planted loblolly pine 5 years after severe ice storms in Arkansas

Treesearch

Don C. Bragg; Michael G. Shelton

2010-01-01

Following a severe ice storm, one of a landowner’s first considerations regarding the future of their damaged stands should be on the recovery potential of injured crop trees. The ice storms that struck Arkansas in December 2000 provided an opportunity to monitor 410 injured loblolly pines (Pinus taeda L.), representing a wide range of damage in 18 –20-year-old...

Phenol and menthol in the treatment of chronic skin lesions following mustard gas exposure.

PubMed

Panahi, Y; Davoodi, S M; Khalili, H; Dashti-Khavidaki, S; Bigdeli, M

2007-05-01

Chronic skin lesions are common late complications of sulphur mustard exposure in veterans injured in chemical warfare. Pruritus is the most common complaint in the chronic phase, with significant effects on the patient's quality of life. The current study evaluated the efficacy of a combination of one percent phenol and one percent menthol in the control of pruritus in these affected patients. This randomised, double-blinded clinical trial was performed in chemical warfare-injured veterans with mustard gas-induced pruritus. 80 subjects were selected randomly and divided into two equal groups. One group was treated with a combination of one percent phenol and one percent menthol twice a day, while the other group received a placebo. The therapeutic effects and side effects were evaluated during a six-week treatment course. Pruritus score with a range of 1-48 points was used to calculate the severity of pruritus before and after treatment in both groups. The final pruritus score in the drug group was significantly different, compared with the placebo group (p-value equals 0.03). There was also a statistically-significant difference between the pre-treatment (19 points) and post-treatment (15.5 points) pruritus scores in the drug group (p-value equals 0.001), but there was no significant difference in the response in the placebo group (p-value equals 0.66). Only a few patients had complaints about the drug, and these were generally minor. The most common complaints were of the greasy nature of the drug and its intolerable odour. A phenol one percent and menthol one percent combination has significant therapeutic effects for mustard gas-induced pruritus in chemical warfare-injured veterans, in comparison with the placebo.

Acute over-the-counter pharmacological intervention does not adversely affect behavioral outcome following diffuse traumatic brain injury in the mouse.

PubMed

Harrison, Jordan L; Rowe, Rachel K; O'Hara, Bruce F; Adelson, P David; Lifshitz, Jonathan

2014-09-01

Following mild traumatic brain injury (TBI), patients may self-treat symptoms of concussion, including post-traumatic headache, taking over-the-counter (OTC) analgesics. Administering one dose of OTC analgesics immediately following experimental brain injury mimics the at-home treated population of concussed patients and may accelerate the understanding of the relationship between brain injury and OTC pharmacological intervention. In the current study, we investigate the effect of acute administration of OTC analgesics on neurological function and cortical cytokine levels after experimental diffuse TBI in the mouse. Adult, male C57BL/6 mice were injured using a midline fluid percussion (mFPI) injury model of concussion (6-10 min righting reflex time for brain-injured mice). Experimental groups included mFPI paired with either ibuprofen (60 mg/kg, i.p.; n = 16), acetaminophen (40 mg/kg, i.p.; n = 9), or vehicle (15% ethanol (v/v) in 0.9% saline; n = 13) and sham injury paired OTC medicine or vehicle (n = 7-10 per group). At 24 h after injury, functional outcome was assessed using the rotarod task and a modified neurological severity score. Following behavior assessment, cortical cytokine levels were measured by multiplex ELISA at 24 h post-injury. To evaluate efficacy on acute inflammation, cortical cytokine levels were measured also at 6 h post-injury. In the diffuse brain-injured mouse, immediate pharmacological intervention did not attenuate or exacerbate TBI-induced functional deficits. Cortical cytokine levels were affected by injury, time, or their interaction. However, levels were not affected by treatment at 6 or 24 h post-injury. These data indicate that acute administration of OTC analgesics did not exacerbate or attenuate brain-injury deficits which may inform clinical recommendations for the at-home treated mildly concussed patient.

Characterization of wound infections among patients injured during the 2011 Libyan conflict.

PubMed

Dau, A A; Tloba, S; Daw, M A

2013-04-01

Few studies have analysed the bacterial pathogenesis of infections associated with war-wound in the Eastern Mediterranean region. We analysed surgical wound infections of 1200 patients injured during the Libyan conflict in 2011 and admitted to the emergency services at Tripoli medical centre. Culture swabs or surgical wound debridement samples were collected and cultures were identified and tested for antimicrobial resistance. Of the 1200 patients studied, 498 (42%) were infected with at least 1 pathogen and 57 with >2 pathogens. The most common species were Acinetobacter spp. (isolated from 144 patients), coagulase-negative staphylococci (122), Escherichia coli (107), Pseudomnonas aeruginosa (92) and Klebsiella spp. (86). A high level of resistance to the antibiotics tested was found, especially among Acinetobacter spp. Multi-drug-resistant Gram-negative bacilli were an important complicating factor in wound infections associated with war injuries among injured patients in Libya. Effective policies are needed to control and treat such infections particularly in trauma and emergency services.

A Comprehensive Overview of the Frequency and the Severity of Injuries Sustained by Car Occupants and Subsequent Implications in Terms of Injury Prevention

PubMed Central

Page, Yves; Cuny, Sophie; Hermitte, Thierry; Labrousse, Maxime

2012-01-01

The objective of the paper is to give an overview of the road injuries issues in France in the 2010’s by determining the frequency and the severity of injuries sustained by car occupants, and to infer the implications in terms of vehicule safety. Three types of analysis are conducted. First, we present a time series analysis at a macro statistical level showing a dramatic decrease of injured and fatally injured occupants in passenger cars compared to other modes of road transport. Secondly, we propose a descriptive statistical analysis of the injuries (frequency and severity) sustained by car occupants, by body regions, using the AIS. Finally we propose some insights into the effectiveness of some safety features. French National crash census (BAAC) is used for a general overview of injury frequencies and raw severity scores (fatal, hospitalized, slighty injured) in car crashes. In-depth crash investigations data are used to specify the body regions and the severity of the injuries sustained by car occupants. Data show that car occupants mortality and morbidity decreased more over the last decade than other road modes: −58 % fatalities and −64 % hospitalized (compared to −39% and −55% for pedestrians, and −21% and −44% for motorcyclists for example). In crashes for which at least one person has been injured, 19 % of occupants are uninjured, 49 % of occupants sustain MAIS 1 injuries, 15 % MAIS2, 8% MAIS 3, and 9 % MAIS 4+. Regardless of seat belt use, the body regions most often injured are head, upper and lower extremities and thorax. However, at least two third up to 92% of involved persons sustain no injury at each of these body regions. The frequency of severe injuries is low, often less than 10 % and concern head and thorax mainly. Finally, the frequency and severity of injuries decrease for belted occupants in newer cars compared to older cars, whatever body regions. The frequency of severe injuries decreased by almost 50 % in these newer cars. PMID:23169126

A comprehensive overview of the frequency and the severity of injuries sustained by car occupants and subsequent implications in terms of injury prevention.

PubMed

Page, Yves; Cuny, Sophie; Hermitte, Thierry; Labrousse, Maxime

2012-01-01

The objective of the paper is to give an overview of the road injuries issues in France in the 2010's by determining the frequency and the severity of injuries sustained by car occupants, and to infer the implications in terms of vehicule safety. Three types of analysis are conducted. First, we present a time series analysis at a macro statistical level showing a dramatic decrease of injured and fatally injured occupants in passenger cars compared to other modes of road transport. Secondly, we propose a descriptive statistical analysis of the injuries (frequency and severity) sustained by car occupants, by body regions, using the AIS. Finally we propose some insights into the effectiveness of some safety features. French National crash census (BAAC) is used for a general overview of injury frequencies and raw severity scores (fatal, hospitalized, slighty injured) in car crashes. In-depth crash investigations data are used to specify the body regions and the severity of the injuries sustained by car occupants. Data show that car occupants mortality and morbidity decreased more over the last decade than other road modes: -58 % fatalities and -64 % hospitalized (compared to -39% and -55% for pedestrians, and -21% and -44% for motorcyclists for example). In crashes for which at least one person has been injured, 19 % of occupants are uninjured, 49 % of occupants sustain MAIS 1 injuries, 15 % MAIS2, 8% MAIS 3, and 9 % MAIS 4+. Regardless of seat belt use, the body regions most often injured are head, upper and lower extremities and thorax. However, at least two third up to 92% of involved persons sustain no injury at each of these body regions. The frequency of severe injuries is low, often less than 10 % and concern head and thorax mainly. Finally, the frequency and severity of injuries decrease for belted occupants in newer cars compared to older cars, whatever body regions. The frequency of severe injuries decreased by almost 50 % in these newer cars.

[Long-term results after multiple trauma with ISS ≥ 25. Outcome and predictors of quality of life].

PubMed

Simmel, S; Drisch, S; Haag, S; Bühren, V

2013-09-01

The survival chances of multiple trauma patients have continually improved over the last decades; therefore, it is often not a question of whether a patient survives a severe accident but rather how the patient survives. In a retrospective study 127 patients were questioned regarding quality of life and health and possible influencing factors using the POLO chart an average of 70 months after suffering severe trauma (ISS Ø 35.6). The quality of life of severely injured patients is significantly reduced compared with the normal population even years after the trauma. In addition to four pretraumatic factors (older age, female gender, low education and previous illnesses) four posttraumatic variables (difficulties with authorities/institutions and unemployment as a consequence of the accident, long duration and subjectively inadequate treatment in hospital) were identified that have a negative impact on long-term quality of life. The self-reported quality of life after multiple trauma no longer permanently achieves the original level despite extensive rehabilitation measures. Post-traumatic factors have a greater impact on the long-term quality of life than the injury severity. A long-term care and specialized rehabilitation services are needed to improve outcome further.

From 9-1-1 call to death: evaluating traumatic deaths in seven regions for early recognition of high-risk patients.

PubMed

Dean, Dylan; Wetzel, Brian; White, Nathan; Kuppermann, Nathan; Wang, Nancy Ewen; Haukoos, Jason S; Hsia, Renee Y; Mann, N Clay; Barton, Erik D; Newgard, Craig D

2014-03-01

This study aimed to characterize initial clinical presentations of patients served by emergency medical services (EMS) who die following injury, with particular attention to patients with occult ("talk-and-die") presentations. This was a population-based, multiregion, mixed-methods retrospective cohort study of fatally injured children and adults evaluated by 94 EMS agencies transporting to 122 hospitals in seven Western US regions from 2006 to 2008. Fatalities were divided into two main groups: occult injuries (talk-and-die; Glasgow Coma Scale [GCS] score ≥ 13, no cardiopulmonary arrest, and no intubation) versus overt injuries (all other patients). These groups were further subdivided by timing of death: early (<48 hours) versus late (>48 hours). We then compared demographic, physiologic, procedural, and injury patterns using descriptive statistics. We also used qualitative methods to analyze available EMS chart narratives for contextual information from the out-of-hospital encounter. During the 3-year study period, 3,358 persons served by 9-1-1 EMS providers died, with 1,225 (37.1%) in the field, 1,016 (30.8%) early in the hospital, and 1,060 (32.1%) late in the hospital. Of the 2,133 patients transported to a hospital, there were 612 (28.7%) talk-and-die patients, of whom 114 (18.6%) died early. Talk-and-die patients were older (median age, 81 years; interquartile range, 67-87 years), normotensive (median systolic blood pressure, 138 mm Hg; interquartile range, 116-160 mm Hg), commonly injured by falls (71.3%), and frequently (52.4%) died in nontrauma hospitals. Compared with overtly injured patients, talk-and-die patients had relatively fewer serious head injuries (13.7%) but more frequent extremity injuries (20.3% vs. 10.6%) and orthopedic interventions (25.3% vs. 5.0%). EMS personnel often found talk-and-die patients lying on the ground with hip pain or extremity injuries. Patients served by EMS who "talk-and-die" are typically older adults with falls, transported to nontrauma hospitals, with subtle clinical indications of the severity of their injuries. Improving recognition of talk-and-die patients may avoid fatal outcomes in a portion of these patients. Epidemiologic study, level III.

Nursing care of the brain injury patient on a locked neurobehavioral unit.

PubMed

Becker, Christine

2012-01-01

Behavioral problems after a brain injury can be extremely challenging for those working with brain injured people. Nursing staff must be familiar with commonly used post brain injury medications and their effects, behavioral management plans, appropriate use of restrictive devices, and verbal or physical crisis intervention techniques when necessary. Rehabilitation nurses caring for brain injured patients on a locked neurobehavioral unit must maintain continual training and specific competence in this environment to ensure patient and staff safety. © 2012 Association of Rehabilitation Nurses.

Frequency of Alcohol Use Among Injured Adult Patients Presenting to a Ghanaian Emergency Department.

PubMed

Forson, Paa Kobina; Gardner, Andrew; Oduro, George; Bonney, Joseph; Biney, Eno Akua; Oppong, Chris; Momade, Eszter; Maio, Ronald F

2016-10-01

Injuries are the cause of almost 6 million deaths annually worldwide, with 15% to 20% alcohol associated. The frequency of alcohol-associated injury varies among countries and is unknown in Ghana. We determined the frequency of positive alcohol test results among injured adults in a Ghanaian emergency department (ED). This is a cross-sectional chart review of consecutive injured patients aged 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within 8 hours of injury. Patients were tested for presence of alcohol with a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death before admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals were calculated. Injured adult patients (2,488) presented to the ED from November 2014 to April 2015, with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95% confidence interval 32% to 38%) tested alcohol positive. Forty-two percent of men (320/756), 40% of subjects aged 25 to 44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assault victims (82/166), 40% of those seriously injured (124/311), and 53% of subjects who died in the ED (8/15) had positive results for presence of alcohol. The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary care hospital ED. These findings have implications for health policy-, ED- and legislative-based interventions, and acute care. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Psycho-social and Mental Variables and Post-Traumatic Stress Disorder in Traffic Accident Survivors in Northern Iran.

PubMed

Khodadadi-Hassankiadeh, Naema; Dehghan-Nayeri, Nahid; Shahsavari, Hooman; Yousefzadeh-Chabok, Shahrokh; Haghani, Hamid

2017-07-01

To assess the psycho-social and mental variables associated with post-traumatic stress disorder (PTSD) in a series of Iranian patients. A total of 528 eligible accident survivors in pre-sampling of a randomized controlled trial targeting PTSD were included in this cross-sectional study. Psycho-social characteristics associated to PTSD were explored in these survivors in an outpatient clinic. They completed the questionnaires via interview between six weeks to six months after accident. Data collection tools were PSS (DSM-V version) for PTSD and BDI-II for depression and a researcher-made questionnaire for psycho-social variables. There was a significant association between PTSD and the following variables; family communication, current depression, return to work, history of death of relatives, witnessed the death, length of amnesia, hospitalization, injured situation, and accident severity. Multivariate logistic regression indicated that some variables were associated with PTSD such as accident severity, ( p <0.001), injured situation, ( p <0.001), current depression, ( p <0.001), RTW ( p <0.001), and family communication ( p =0.01). Psychiatric nursing prevention efforts is best directed toward motorcycle depressed drivers with severe accident and poor family communication who do not return to work. Thus, routine assessment of PTSD, depression and psycho-social variables after traffic accidents must be taken into account.

Management of blunt hepatic trauma at a Connecticut Level I trauma center.

PubMed

Scalora, Matthew A; Gross, Ronald I; Burns, Karyl J

2007-10-01

This study examined the management of patients with hepatic trauma treated at a Level I trauma center in Connecticut from January 1, 2003 to December 31, 2003. Forty-four patients over the age of 16 years sustained blunt liver injury and were brought to Hartford Hospital during the study period. Eight of these patients died; three of these deaths occurred in the emergency department (ED) shortly after arrival. Thirty-four patients (82.9%) with blunt liver injuries were managed nonoperatively. Only one of these patients died, not as a direct result of hepatic injury. The average Injury Severity Score (ISS) for these patients decreased as the injury grade increased but this was not statistically significant (P=0.684). A moderate positive and statistically significant relationship was noted between the length of hospital stay and the ISS (r=0.597, P=0.000). Our findings suggest that the current standard of care for most patients with blunt hepatic injuries is nonoperative management. It is the rare and most severely injured patient that will require operative management. As reported in the literature, mortality for these patients remains unchanged.

Hemodynamic responses to dexmedetomidine in critically injured intubated pediatric burned patients: a preliminary study.

PubMed

Shank, Erik S; Sheridan, Robert L; Ryan, Colleen M; Keaney, Timothy J; Martyn, J A Jeevendra

2013-01-01

Because of ineffectiveness and tolerance to benzodiazepines and opioids developing with time, drugs acting via other receptor systems (eg, α-2 agonists) have been advocated in burn patients to improve sedation and analgesia. This study in severely burned pediatric subjects examined the hemodynamic consequences of dexmedetomidine (Dex) administration. Eight intubated patients with ≥20 to 79% TBSA burns were studied between 7 and 35 days after injury. After baseline measurements of mean arterial blood pressure and heart rhythm were taken, each patient received a 1.0 µg/kg bolus of Dex followed by an ascending dose infusion protocol (0.7-2.5 µg/kg/hr), with each dose administered for 15 minutes. There was significant hypotension (27±7.5%, average drop in mean arterial pressure [MAP] ± SD), and a decrease in heart rate (HR; 19% ± 7, average drop in HR ± SD). The average HR decreased from 146 beats per minute to 120. No bradycardia (HR < 60) or heart blocks were observed. In three patients, the MAP decreased to <50mm Hg with the bolus dose of Dex. Of the remaining five patients, three patients completed the study receiving the highest infusion dose of Dex (2.5 µg/kg/hr), whereas in 2 patients the infusion part of the study was begun, but the study was stopped due to persistent hypotension (MAP < 50mm Hg). These observations indicate that a bolus dose of Dex (1.0 µg/kg for 10 minutes) and high infusion rates may require fluid resuscitation or vasopressor support to maintain normotension in critically injured pediatric burn patients.

Trauma patient discharge and care transition experiences: Identifying opportunities for quality improvement in trauma centres.

PubMed

Gotlib Conn, Lesley; Zwaiman, Ashley; DasGupta, Tracey; Hales, Brigette; Watamaniuk, Aaron; Nathens, Avery B

2018-01-01

Challenges delivering quality care are especially salient during hospital discharge and care transitions. Severely injured patients discharged from a trauma centre will go either home, to rehabilitation or another acute care hospital with complex management needs. This purpose of this study was to explore the experiences of trauma patients and families treated in a regional academic trauma centre to better understand and improve their discharge and care transition experiences. A qualitative study using inductive thematic analysis was conducted between March and October 2016. Telephone interviews were conducted with trauma patients and/or a family member after discharge from the trauma centre. Data collection and analysis were completed inductively and iteratively consistent with a qualitative approach. Twenty-four interviews included 19 patients and 7 family members. Participants' experiences drew attention to discharge and transfer processes that either (1) Fostered quality discharge or (2) Impeded quality discharge. Fostering quality discharge was ward staff preparation efforts; establishing effective care continuity; and, adequate emotional support. Impeding discharge quality was perceived pressure to leave the hospital; imposed transfer decisions; and, sub-optimal communication and coordination around discharge. Patient-provider communication was viewed to be driven by system, rather than patient need. Inter-facility information gaps raised concern about receiving facilities' ability to care for injured patients. The quality of trauma patient discharge and transition experiences is undermined by system- and ward-level processes that compete, rather than align, in producing high quality patient-centred discharge. Local improvement solutions focused on modifiable factors within the trauma centre include patient-oriented discharge education and patient navigation; however, these approaches alone may be insufficient to enhance patient experiences. Trauma patients encounter complex barriers to quality discharge that likely require a comprehensive, multimodal intervention. Copyright © 2017 Elsevier Ltd. All rights reserved.

Burn Wound Infections

PubMed Central

Church, Deirdre; Elsayed, Sameer; Reid, Owen; Winston, Brent; Lindsay, Robert

2006-01-01

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices. PMID:16614255

[Management of spine injuries in polytraumatized patients].

PubMed

Heyde, C E; Ertel, W; Kayser, R

2005-09-01

The management of spine injuries in polytraumatized patients remains a great challenge for the diagnostic procedures and institution of appropriate treatment by integrating spinal trauma treatment into the whole treatment concept as well as following the treatment steps for the injured spine itself. The established concept of "damage control" and criteria regarding the optimal time and manner for operative treatment of the injured spine in the polytrauma setting is presented and discussed.

Cognitive Rehabilitation and the Head-Injured Child.

ERIC Educational Resources Information Center

Henry, Kevin

1983-01-01

Discusses development of cognitive rehabilitation therapy (which attempts to address intervention needs of traumatically brain-injured child), particular concerns at various stages of patients' recovery, some fundamental principles of treatment, and framework for viewing cognition functionally. Considers questions clinicians ask and strategies for…

The changing nature of death on the trauma service.

PubMed

Kahl, Jessica E; Calvo, Richard Y; Sise, Michael J; Sise, C Beth; Thorndike, Jonathan F; Shackford, Steven R

2013-08-01

Recent innovations in care have improved survival following injury. Coincidentally, the population of elderly injured patients with preexisting comorbidities has increased. We hypothesized that this increase in elderly injured patients may have combined with recent care innovations to alter the causes of death after trauma. We reviewed demographics, injury characteristics, and cause of death of in-hospital deaths of patients admitted to our Level I trauma service from 2000 through 2011. Cause of death was classified as acute hemorrhagic shock; severe traumatic brain injury or high spinal cord injury; complications of preexisting medical condition only (PM); survivable trauma combined with complications of preexisting medical condition (TCoM); multiple-organ failure, sepsis, or adult respiratory distress syndrome (MOF/S/ARDS), or trauma not otherwise categorized (e.g., asphyxiation). Major trauma care advances implemented on our service during the period were identified, and trends in the causes of death were analyzed. Of the 27,276 admissions, 819 (3%) eligible nonsurvivors were identified for the cause-of-death analyses. Causes of death were severe traumatic brain injury or high spinal cord injury at 44%, acute hemorrhagic shock at 28%, PM at 11%, TCoM at 10%, MOF/S/ARDS at 2%, and trauma not otherwise categorized at 5%. Mean age at death increased across the study interval (range, 47-57 years), while mean Injury Severity Score (ISS) decreased (range, 28-35). There was a significant increase in deaths because of TCoM (3.3-20.9%) and PM (6.7-16.4%), while deaths caused by MOF/S/ARDS decreased from 5% to 0% by 2007. Compared with year 2000, the annual adjusted mortality rate decreased consistently starting in 2009, after the 2002 to 2007 adoption of four major trauma practice guidelines. Mortality caused by preexisting medical conditions has increased, while markedly fewer deaths resulted from the complications of injury. Future improvements in outcomes will require improvement in the management of elderly trauma patients with comorbid conditions.

Motorcycle-related injuries at a university teaching hospital in north central Nigeria

PubMed Central

Elachi, Itodo C.; Okunola, Benjamin B.; Yongu, Williams T.; Onyemaechi, Ndubuisi OC; Odatuwa-Omagbemi, Odoyoh D.; Ahachi, Chukwukadibia N.; Mue, Daniel D.

2014-01-01

Background: Motorcycle-related injuries lead to considerable morbidity and mortality. The aim of this study is to determine the pattern and outcome of motorcycle-related injuries at Benue State University Teaching Hospital, Makurdi, Nigeria. Patients and Methods: Case records of all patients who presented to the accident and emergency department with motorcycle-related injuries between July 2012 and June 2013 were analysed for age, gender, injury host status (i.e. rider, pillion or pedestrian), nature of collision (motorcycle versus other vehicles, motorcycle versus motorcycle, motorcycle versus pedestrian or lone riders), body region injured, injury severity score (ISS) at arrival, length of hospital stay (LOS) and mortality. Results: Seventy - nine patients with motorcycle-related injuries were included in the study. They consisted of 63 males (61.8%) and 16 females (15.7%). The age range was 5-65 years with a mean of 32.4 ± 14.0. Motorcycle versus vehicle collisions were the most common mechanism of injury (n = 46, 58.2%). Musculoskeletal injuries constituted the most common injuries sustained (n = 50, 47.6%) and the tibia was the most frequently fractured bone (n = 14, 35.9%). The majority of patients (57.0%) sustained mild/moderate injuries (ISS ≤ 15). There was no statistically significant difference between the sexes for sustaining mild/moderate injuries or severe/profound injuries (P > 0.05). Mortality rate was 6.3% with head injuries being involved in all cases. Conclusion: Young males were mostly injured in motorcycle-related trauma. Musculoskeletal injuries were the most common injuries sustained and head injuries were involved in all the deaths. Enforcement of motorcycle crash bars and helmet usage is recommended. PMID:25538360

Clinical Review: Communication and logistics in the response to the 1998 terrorist bombing in Omagh, Northern Ireland

PubMed Central

Lavery, Gavin G; Horan, Ene

2005-01-01

The Omagh bombing in August 1998 produced many of the problems documented in other major incidents. An initial imbalance between the demand and supply of clinical resources at the local hospital, poor information due to telecommunication problems, the need to triage victims and the need to transport the most severely injured significant distances were the most serious issues. The Royal Group Hospitals Trust (RGHT) received 30 severely injured secondary transfers over a 5-hour period, which stressed the hospital's systems even with the presence of extra staff that arrived voluntarily before the hospital's major incident plan was activated. Many patients were transferred to the RGHT by helicopter, but much of the time the gained advantage was lost due to lack of a helipad within the RGHT site. Identifying patients and tracking them through the hospital system was problematic. While the major incident plan ensured that communication with the relatives and the media was effective and timely, communication between the key clinical and managerial staff was hampered by the need to be mobile and by the limitations of the internal telephone system. The use of mobile anaesthetic teams helped maintain the flow of patients between the Emergency Department and radiology, operating theatres or the intensive care unit (ICU). The mobile anaesthetic teams were also responsible for efficient and timely resupply of the Emergency Department, which worked well. In the days that followed many victims required further surgical procedures. Coordination of the multidisciplinary teams required for many of these procedures was difficult. Although only seven patients required admission to adult general intensive care, no ICU beds were available for other admissions over the following 5 days. A total of 165 days of adult ICU treatment were required for the victims of the bombing. PMID:16137391

Clinical review: communication and logistics in the response to the 1998 terrorist bombing in Omagh, Northern Ireland.

PubMed

Lavery, Gavin G; Horan, Ene

2005-08-01

The Omagh bombing in August 1998 produced many of the problems documented in other major incidents. An initial imbalance between the demand and supply of clinical resources at the local hospital, poor information due to telecommunication problems, the need to triage victims and the need to transport the most severely injured significant distances were the most serious issues. The Royal Group Hospitals Trust (RGHT) received 30 severely injured secondary transfers over a 5-hour period, which stressed the hospital's systems even with the presence of extra staff that arrived voluntarily before the hospital's major incident plan was activated. Many patients were transferred to the RGHT by helicopter, but much of the time the gained advantage was lost due to lack of a helipad within the RGHT site. Identifying patients and tracking them through the hospital system was problematic. While the major incident plan ensured that communication with the relatives and the media was effective and timely, communication between the key clinical and managerial staff was hampered by the need to be mobile and by the limitations of the internal telephone system. The use of mobile anaesthetic teams helped maintain the flow of patients between the Emergency Department and radiology, operating theatres or the intensive care unit (ICU). The mobile anaesthetic teams were also responsible for efficient and timely resupply of the Emergency Department, which worked well. In the days that followed many victims required further surgical procedures. Coordination of the multidisciplinary teams required for many of these procedures was difficult. Although only seven patients required admission to adult general intensive care, no ICU beds were available for other admissions over the following 5 days. A total of 165 days of adult ICU treatment were required for the victims of the bombing.

[Expectations from the TraumaNetwork DGU®: Which goals have been achieved? What can be improved?].

PubMed

Debus, F; Mand, C; Geraedts, M; Kühne, C A; Frink, M; Siebert, H; Ruchholtz, S

2016-04-01

Following the establishment of the first trauma networks in 2009 an almost nationwide certification could be achieved. Despite the impressive number of 46 certified networks, little is known about the actual improvements and the satisfaction of the participating hospitals. This article aims to give a first representative overview of the expectations and actual achievements. An online survey with a total of 36 questions was conducted in 884 hospitals. The questionnaire could be filled out online, sent by post or fax to the AKUT- Office. Descriptive statistical analyses were performed with Microsoft Excel. With 326 responses, a response rate of 48.9% of all active hospitals was achieved. Of the participating hospitals 64.1% (209) were certified and had taken part in the project for an average of 3.9 years. The average score for satisfaction was 2.3, 72.4% (236) felt that there was a need for improvement in the care of severely injured patients and 46.6% (152) in the transfer of patients. In 47.2% (142) no improvement in cooperation with the ambulance service could be determined, 25.2% (82) documented an increase in the number of severely injured patients since participating in the trauma network (TNW-DGU) and 93.9% (306) of all hospitals wanted to participate in the trauma network in the future. It could be shown that important goals, such as simplification of patient transfer or general improvement in cooperation have been achieved. Overall there was a high level of satisfaction among the participating hospitals; however, the survey has identified some points which need to be improved by further intensive work.

Developing a culture of safety in a reluctant audience

PubMed Central

Schieber, Richard A; Olson, Sarah J

2002-01-01

Objective To describe the injury pattern of skateboarding injuriestoday. Methods The pattern of injuries, circumstances, and severitywere investigated in a study of 139 people injured in skateboarding accidentsduring 1995 through 1998 inclusive and admitted to the University Hospital ofUmeå, Umeå, Sweden. This is the only hospital in the area, servinga population of 135,000. Results Of the 139 injured, 3 were pedestrainshit by a skateboard rider; the rest were riders. The age range was 7 to 47years (mean, 16.0). The severity of the injuries was minor (Abbreviated InjuryScale 1) to moderate (Abbreviated Injury Scale 2); fractures were classifiedas moderate. The annual number of injuries increased during the study period.Fractures were found in 29% of the casualties, and four children hadconcussion. The most common fractures were of the ankle and wrist. Olderpatients had less severe injuries, mainly sprains and soft tissue injuries.Most children were injured while skateboarding on ramps and at arenas; only 12(9%) were injured while skateboarding on roads. Some 37% of the injuriesoccurred because of a loss of balance and 26% because of a failed trickattempt. Falls caused by surface irregularities resulted in the highestproportion of the moderate injuries. Conclusions Skateboarding shouldbe restricted to supervised skateboard parks, and skateboarders should berequired to wear protective gear. These measures would reduce the number ofskateboarders injured in motor vehicle collisions, the personal injuries amongskateboarders, and the number of pedestrians injured in collisions withskateboarders. PMID:12016256

The experiences, unmet needs and outcomes of parents of severely injured children: a longitudinal mixed methods study protocol.

PubMed

Foster, Kim; Curtis, Kate; Mitchell, Rebecca; Van, Connie; Young, Alexandra

2016-09-06

Being the parent of a severely injured child involves many stressors throughout the trauma journey. Internationally, little is known about the experiences or levels of emotional distress, parenting stress, quality of life, and resilience for parents of injured children. The aim of this study is to investigate the experiences, unmet needs and outcomes of parents of physically injured children 0-12 years over the 2 year period following injury. This is a prospective longitudinal study using an embedded mixed methods design. This design has a primary qualitative strand which incorporates supplementary quantitative data on child quality of life, and parental quality of life, parenting stress, emotional distress, and resilience at four time points; the acute hospitalisation phase, and at 6, 12 and 24 months following injury. The primary sample are parents of injured children 0-12 years hospitalised in the Australian states of New South Wales, Queensland, Victoria and South Australia. Primary data sources are child and parent demographic data; survey data; and semi-structured interview data across a 24 month period. This study aims to address the existing gap in knowledge on the experiences and unmet support needs of parents in the 2 years following child injury to provide guidance for care provision for these families. There is a lack of evidence-based recommendations for supporting parents and families of injured children and strengthening their capacity to address the challenges they face.

Ocular trauma resulting from paintball injury.

PubMed

Pahk, Patricia J; Adelman, Ron A

2009-04-01

Paintball-related ocular injuries result in severe damage and loss of vision. Despite efforts to increase public awareness and improve safety features, the incidence of eye injuries has increased over time. We examined the characteristics and ocular effects of paintball injury at our tertiary referral center. Retrospective review of charts of patients with paintball injury between 1998-2005. Fourteen patients were evaluated for paintball injury; 13 (93%) were male and one (7%) was female. Average age was 17 years (range from 9 to 30). Thirteen patients (95%) did not wear eye protection; one is unknown. Injuries occurred while playing paintball in three patients (21%); ten (71%) were injured in either accidental (four patients) or intentional (six patients) shootings not associated with play. Minimum follow-up was 6 weeks, except for one patient who was lost to follow-up. Seven patients (50%) had final visual acuity (VA) better than 20/200, six patients (43%) were 20/200 or worse, and information on one patient was not available. VA, except in one case, improved with treatment. Decreased VA in this case was due to proliferative vitreoretinopathy (PVR). Hyphema was noted in ten patients (71%), vitreous hemorrhage in eight (57%), retinal hemorrhage in six (43%), retinal tear or detachment in six (43%), commotio retinae in six (43%), iris injury in five (36%), keratopathy in four (29%), lens injury in two (14%), subluxation of lens in two (14%), secondary glaucoma in two (14%), open globe/intraocular foreign body (IOFB) in one (7%), choroidal rupture in one (7%), and proliferative vitreoretinopathy (PVR) in one (7%). Ten patients (71%) required intervention (surgery, laser retinopexy or cryotherapy). Paintball trauma results in significant ocular injury and loss of vision. Most injuries occur in unsupervised settings without proper eye protection. Ten patients (71%) were injured in accidental or intentional shootings. Lack of supervision and use of paintball materials as assault weapons make the risk for ocular injury more significant. Improved safety features of paintball equipment, along with continued education of proper eye protection, may reduce the incidence of severe ocular injuries.

Special populations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

PubMed

Dries, David; Reed, Mary Jane; Kissoon, Niranjan; Christian, Michael D; Dichter, Jeffrey R; Devereaux, Asha V; Upperman, Jeffrey S

2014-10-01

Past disasters have highlighted the need to prepare for subsets of critically ill, medically fragile patients. These special patient populations require focused disaster planning that will address their medical needs throughout the event to prevent clinical deterioration. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with multiple critically ill or injured patients, including frontline clinicians, hospital administrators, and public health or government officials. Key questions regarding the care of critically ill or injured special populations during disasters or pandemics were identified, and a systematic literature review (1985-2013) was performed. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. The panel did not include pediatrics as a separate special population because pediatrics issues are embedded in each consensus document. Fourteen suggestions were formulated regarding the care of critically ill and injured patients from special populations during pandemics and disasters. The suggestions cover the following areas: defining special populations for mass critical care, special population planning, planning for access to regionalized service for special populations, triage and resource allocation of special populations, therapeutic considerations, and crisis standards of care for special populations. Chronically ill, technologically dependent, and complex critically ill patients present a unique challenge to preparing and implementing mass critical care. There are, however, unique opportunities to engage patients, primary physicians, advocacy groups, and professional organizations to lessen the impact of disaster on these special populations.

Lawn mower injuries in children: a 30-year experience.

PubMed

Nguyen, Anh; Raymond, Simon; Morgan, Vanessa; Peters, Julian; Macgill, Kirstie; Johnstone, Bruce

2008-09-01

Lawn mowers cause severe injuries that are particularly devastating to children. This study analyses the patterns and trends in lawn mower injuries involving children referred to Victoria's principal children's hospital. A retrospective review of the patient medical records at the Royal Children's Hospital (Melbourne) Victoria, Australia was carried out. The series included all patients admitted for lawn mower injury during the 30-year period spanning 1975-2004. Lawn mower injuries treated at Royal Children's Hospital were severe and included partially amputated limbs. Overall, admissions for lawn mower injury generally decreased over time from n = 26 in the 1975-1979 interval to n = 14 in the 2000-2004 interval. However, the frequency of admission for injuries caused by ride-on mowers contradicted the overall trend and generally increased over time from n = 5 in the 1975-1979 interval to n = 11 in the 2000-2004 interval. This is of particular concern. Ride-on lawn mowers caused significantly more severe injuries requiring longer periods of admission and more operations during admission in comparison to standard mowers. Rural location at the time of injury was a risk factor associated with requiring longer periods of admission and more operations during admission. Children injured while operating mowers were generally older than children injured as bystanders. Lawn mower injuries are a significant cause of morbidity. These injuries are particularly devastating to children. The tragedy is keenly felt in the realization that these devastating injuries to children could all be prevented. Strategic preventative measures should be developed through partnership between the medical profession, the media, industry specialists and the wider community.

Screening injured children for physical abuse or neglect in emergency departments: a systematic review.

PubMed

Woodman, J; Lecky, F; Hodes, D; Pitt, M; Taylor, B; Gilbert, Ruth

2010-03-01

Screening markers are used in emergency departments (EDs) to identify children who should be assessed for possible physical abuse and neglect. We conducted three systematic reviews evaluating age, repeat attendance and injury type as markers for physical abuse or neglect in injured children attending EDs. We included studies comparing markers in physically abused or neglected children and non-abused injured children attending ED or hospital. We calculated likelihood ratios (LRs) for age group, repeat attendance and injury type (head injury, bruises, fractures, burns or other). Given the low prevalence of abuse or neglect, we considered that an LR of 10 or more would be clinically useful. All studies were poor quality. Infancy increased the risk of physical abuse or neglect in severely injured or admitted children (LRs 7.7-13.0, 2 studies) but was not strongly associated in children attending the ED (LR 1.5, 95% CI: 0.9, 2.8; one study). Repeat attendance did not substantially increase the risk of abuse or neglect and may be confounded by chronic disease and socio-economic status (LRs 0.8-3.9, 3 studies). One study showed no evidence that the type of injury substantially increased the risk of physical abuse or neglect in severely injured children. There was no evidence that any of the markers (infancy, type of injury, repeated attendance) were sufficiently accurate (i.e. LR >or= 10) to screen injured children in the ED to identify those requiring paediatric assessment for possible physical abuse or neglect. Clinicians should be aware that among injured children at ED a high proportion of abused children will present without these characteristics and a high proportion of non-abused children will present with them. Information about age, injury type and repeat attendances should be interpreted in this context.

A “virtually minimal” visuo-haptic training of attention in severe traumatic brain injury

PubMed Central

2013-01-01

Background Although common during the early stages of recovery from severe traumatic brain injury (TBI), attention deficits have been scarcely investigated. Encouraging evidence suggests beneficial effects of attention training in more chronic and higher functioning patients. Interactive technology may provide new opportunities for rehabilitation in inpatients who are earlier in their recovery. Methods We designed a “virtually minimal” approach using robot-rendered haptics in a virtual environment to train severely injured inpatients in the early stages of recovery to sustain attention to a visuo-motor task. 21 inpatients with severe TBI completed repetitive reaching toward targets that were both seen and felt. Patients were tested over two consecutive days, experiencing 3 conditions (no haptic feedback, a break-through force, and haptic nudge) in 12 successive, 4-minute blocks. Results The interactive visuo-haptic environments were well-tolerated and engaging. Patients typically remained attentive to the task. However, patients exhibited attention loss both before (prolonged initiation) and during (pauses during motion) a movement. Compared to no haptic feedback, patients benefited from haptic nudge cues but not break-through forces. As training progressed, patients increased the number of targets acquired and spontaneously improved from one day to the next. Conclusions Interactive visuo-haptic environments could be beneficial for attention training for severe TBI patients in the early stages of recovery and warrants further and more prolonged clinical testing. PMID:23938101

A "virtually minimal" visuo-haptic training of attention in severe traumatic brain injury.

PubMed

Dvorkin, Assaf Y; Ramaiya, Milan; Larson, Eric B; Zollman, Felise S; Hsu, Nancy; Pacini, Sonia; Shah, Amit; Patton, James L

2013-08-09

Although common during the early stages of recovery from severe traumatic brain injury (TBI), attention deficits have been scarcely investigated. Encouraging evidence suggests beneficial effects of attention training in more chronic and higher functioning patients. Interactive technology may provide new opportunities for rehabilitation in inpatients who are earlier in their recovery. We designed a "virtually minimal" approach using robot-rendered haptics in a virtual environment to train severely injured inpatients in the early stages of recovery to sustain attention to a visuo-motor task. 21 inpatients with severe TBI completed repetitive reaching toward targets that were both seen and felt. Patients were tested over two consecutive days, experiencing 3 conditions (no haptic feedback, a break-through force, and haptic nudge) in 12 successive, 4-minute blocks. The interactive visuo-haptic environments were well-tolerated and engaging. Patients typically remained attentive to the task. However, patients exhibited attention loss both before (prolonged initiation) and during (pauses during motion) a movement. Compared to no haptic feedback, patients benefited from haptic nudge cues but not break-through forces. As training progressed, patients increased the number of targets acquired and spontaneously improved from one day to the next. Interactive visuo-haptic environments could be beneficial for attention training for severe TBI patients in the early stages of recovery and warrants further and more prolonged clinical testing.

Traumatic Injury in the United States: In-Patient Epidemiology 2000–2011

PubMed Central

DiMaggio, Charles; Ayoung-Chee, Patricia; Shinseki, Matthew; Wilson, Chad; Marshall, Gary; Lee, David C.; Wall, Stephen; Maulana, Shale; Pachter, H. Leon; Frangos, Spiros

2017-01-01

Background Trauma is a leading cause of death and disability in the United States (US). This analysis describes trends and annual changes in in-hospital trauma morbidity and mortality; evaluates changes in age and gender specific outcomes, diagnoses, causes of injury, injury severity and surgical procedures performed; examines the role of teaching hospitals and Level 1 trauma centers in the care of severely injured patients. Methods We conducted a retrospective descriptive and analytic epidemiologic study of an inpatient database representing 20,659,684 traumatic injury discharges from US hospitals between 2000 and 2011. The main outcomes and measures were survey-adjusted counts, proportions, means, standard errors, and 95% confidence intervals. We plotted time series of yearly data with overlying loess smoothing, created tables of proportions of common injuries and surgical procedures, and conducted survey-adjusted logistic regression analysis for the effect of year on the odds of in-hospital death with control variables for age, gender, weekday vs. weekend admission, trauma-center status, teaching-hospital status, injury severity and Charlson index score. Results The mean age of a person discharged from a US hospital with a trauma diagnosis increased from 54.08 (s.e.= 0.71) in 2000 to 59.58 (s.e. = 0.79) in 2011. Persons age 45 to 64 were the only age group to experience increasing rates of hospital discharges for trauma. The proportion of trauma discharges with a Charlson Comorbidity Index score greater than or equal to 3 nearly tripled from 0.048 (s.e. = 0.0015) of all traumatic injury discharges in 2000 to 0.139 (s.e. = 0.005) in 2011. The proportion of patients with traumatic injury classified as severe increased from 22% of all trauma discharges in 2000 (95% CI 21, 24) to 28% in 2011 (95% CI 26, 30). Level 1 trauma centers accounted for approximately 3.3% of hospitals. The proportion of severely injured trauma discharges from Level 1 trauma centers was 39.4% (95% CI 36.8, 42.1). Falls, followed by motor-vehicle crashes, were the most common causes of all injuries. The total cost of trauma-related inpatient care between 2001 and 2011 in the US was $240.7 billion (95% CI 231.0, 250.5). Annual total US inpatient trauma-related hospital costs increased each year between 2001 and 2011, more than doubling from $12.0 billion (95% CI 10.5, 13.4) in 2001 to 29.1 billion (95% CI 25.2, 32.9) in 2011. Conclusions Trauma, which has traditionally been viewed as a predicament of the young, is increasingly a disease of the old. The strain of managing the progressively complex and costly care associated with this shift rests with a small number of trauma centers. Optimal care of injured patients requires a reappraisal of the resources required to effectively provide it given a mounting burden. PMID:27157986

Epidemiology of severe trauma.

PubMed

Alberdi, F; García, I; Atutxa, L; Zabarte, M

2014-12-01

Major injury is the sixth leading cause of death worldwide. Among those under 35 years of age, it is the leading cause of death and disability. Traffic accidents alone are the main cause, fundamentally in low- and middle-income countries. Patients over 65 years of age are an increasingly affected group. For similar levels of injury, these patients have twice the mortality rate of young individuals, due to the existence of important comorbidities and associated treatments, and are more likely to die of medical complications late during hospital admission. No worldwide, standardized definitions exist for documenting, reporting and comparing data on severely injured trauma patients. The most common trauma scores are the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS) and the Trauma and Injury severity Score (TRISS). Documenting the burden of injury also requires evaluation of the impact of post-trauma impairments, disabilities and handicaps. Trauma epidemiology helps define health service and research priorities, contributes to identify disadvantaged groups, and also facilitates the elaboration of comparable measures for outcome predictions. Copyright © 2014 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Benchmarking Outcomes in the Critically Injured Burn Patient

PubMed Central

Klein, Matthew B.; Goverman, Jeremy; Hayden, Douglas L.; Fagan, Shawn P.; McDonald-Smith, Grace P.; Alexander, Andrew K.; Gamelli, Richard L.; Gibran, Nicole S.; Finnerty, Celeste C.; Jeschke, Marc G.; Arnoldo, Brett; Wispelwey, Bram; Mindrinos, Michael N.; Xiao, Wenzhong; Honari, Shari E.; Mason, Philip H.; Schoenfeld, David A.; Herndon, David N.; Tompkins, Ronald G.

2014-01-01

Objective To determine and compare outcomes with accepted benchmarks in burn care at six academic burn centers. Background Since the 1960s, U.S. morbidity and mortality rates have declined tremendously for burn patients, likely related to improvements in surgical and critical care treatment. We describe the baseline patient characteristics and well-defined outcomes for major burn injuries. Methods We followed 300 adults and 241 children from 2003–2009 through hospitalization using standard operating procedures developed at study onset. We created an extensive database on patient and injury characteristics, anatomic and physiological derangement, clinical treatment, and outcomes. These data were compared with existing benchmarks in burn care. Results Study patients were critically injured as demonstrated by mean %TBSA (41.2±18.3 for adults and 57.8±18.2 for children) and presence of inhalation injury in 38% of the adults and 54.8% of the children. Mortality in adults was 14.1% for those less than 55 years old and 38.5% for those age ≥55 years. Mortality in patients less than 17 years old was 7.9%. Overall, the multiple organ failure rate was 27%. When controlling for age and %TBSA, presence of inhalation injury was not significant. Conclusions This study provides the current benchmark for major burn patients. Mortality rates, notwithstanding significant % TBSA and presence of inhalation injury, have significantly declined compared to previous benchmarks. Modern day surgical and medically intensive management has markedly improved to the point where we can expect patients less than 55 years old with severe burn injuries and inhalation injury to survive these devastating conditions. PMID:24722222

Effects of severity of traumatic brain injury and brain reserve on cognitive-control related brain activation.

PubMed

Scheibel, Randall S; Newsome, Mary R; Troyanskaya, Maya; Steinberg, Joel L; Goldstein, Felicia C; Mao, Hui; Levin, Harvey S

2009-09-01

Functional magnetic resonance imaging (fMRI) has revealed more extensive cognitive-control related brain activation following traumatic brain injury (TBI), but little is known about how activation varies with TBI severity. Thirty patients with moderate to severe TBI and 10 with orthopedic injury (OI) underwent fMRI at 3 months post-injury using a stimulus response compatibility task. Regression analyses indicated that lower total Glasgow Coma Scale (GCS) and GCS verbal component scores were associated with higher levels of brain activation. Brain-injured patients were also divided into three groups based upon their total GCS score (3-4, 5-8, or 9-15), and patients with a total GCS score of 8 or less produced increased, diffuse activation that included structures thought to mediate visual attention and cognitive control. The cingulate gyrus and thalamus were among the areas showing greatest increases, and this is consistent with vulnerability of these midline structures in severe, diffuse TBI. Better task performance was associated with higher activation, and there were differences in the over-activation pattern that varied with TBI severity, including greater reliance upon left-lateralized brain structures in patients with the most severe injuries. These findings suggest that over-activation is at least partially effective for improving performance and may be compensatory.

Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®)

PubMed Central

2014-01-01

Background Blunt thoracic trauma is one of the critical injury mechanisms in multiply injured trauma victims. Although these patients present a plethora of potential structural damages to vital organs, it remains debated which injuries actually influence outcome and thereby should be addressed initially. Hence, the aim of this study was to identify the influence of critical structural damages on mortality. Methods All patients in the database of the TraumaRegister DGU® (TR-DGU) from 2002–2011 with AIS Chest ≥ 2, blunt trauma, age of 16 or older and an ISS ≥ 16 were analyzed. Outcome parameters were in-hospital mortality as well as ventilation time in patients surviving the initial 14 days after trauma. Results 22613 Patients were included (mean ISS 30.5 ± 12.6; 74.7% male; Mean Age 46.1 ± 197 years; mortality 17.5%; mean duration of ventilation 7.3 ± 11.5; mean ICU stay 11.7 ± 14.1 days). Only a limited number of specific injuries had a significant impact on survival. Major thoracic vessel injuries (AIS ≥5), bilateral lung contusion, bilateral flail chest, structural heart injury (AIS ≥3) significantly influence mortality in study patients. Several extrathoracic factors (age, blood transfusion, systolic blood pressure and extrathoracic severe injuries) were also predictive of increased mortality. Most injuries of the thoracic wall had no or only a moderate effect on the duration of ventilation. Injuries to the lung (laceration, contusion or pneumothoraces) had a moderate prolonging effect. Cardiac injuries and severe injuries to the thoracic vessels induced a substantially prolonged ventilation interval. Conclusions We demonstrate quantitatively the influence of specific structural damages of the chest on critical outcome parameters. While most injuries of the chest wall have no or only limited impact in the study collective, injuries to the lung overall show adverse outcome. Injuries to the heart or thoracic vessels have a devastating prognosis following blunt chest trauma. PMID:25204466

Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®).

PubMed

Huber, Stephan; Biberthaler, Peter; Delhey, Patrick; Trentzsch, Heiko; Winter, Hauke; van Griensven, Martijn; Lefering, Rolf; Huber-Wagner, Stefan

2014-09-03

Blunt thoracic trauma is one of the critical injury mechanisms in multiply injured trauma victims. Although these patients present a plethora of potential structural damages to vital organs, it remains debated which injuries actually influence outcome and thereby should be addressed initially. Hence, the aim of this study was to identify the influence of critical structural damages on mortality. All patients in the database of the TraumaRegister DGU® (TR-DGU) from 2002-2011 with AIS Chest ≥ 2, blunt trauma, age of 16 or older and an ISS ≥ 16 were analyzed. Outcome parameters were in-hospital mortality as well as ventilation time in patients surviving the initial 14 days after trauma. 22613 Patients were included (mean ISS 30.5 ± 12.6; 74.7% male; Mean Age 46.1 ± 197 years; mortality 17.5%; mean duration of ventilation 7.3 ± 11.5; mean ICU stay 11.7 ± 14.1 days). Only a limited number of specific injuries had a significant impact on survival. Major thoracic vessel injuries (AIS ≥5), bilateral lung contusion, bilateral flail chest, structural heart injury (AIS ≥3) significantly influence mortality in study patients. Several extrathoracic factors (age, blood transfusion, systolic blood pressure and extrathoracic severe injuries) were also predictive of increased mortality. Most injuries of the thoracic wall had no or only a moderate effect on the duration of ventilation. Injuries to the lung (laceration, contusion or pneumothoraces) had a moderate prolonging effect. Cardiac injuries and severe injuries to the thoracic vessels induced a substantially prolonged ventilation interval. We demonstrate quantitatively the influence of specific structural damages of the chest on critical outcome parameters. While most injuries of the chest wall have no or only limited impact in the study collective, injuries to the lung overall show adverse outcome. Injuries to the heart or thoracic vessels have a devastating prognosis following blunt chest trauma.

Rehabilitation of acute and subacute low back and neck pain in the work-injured patient.

PubMed

Hartigan, C; Miller, L; Liewehr, S C

1996-10-01

In spite of the favorable natural history and the nonserious nature of the problem of much work-related low back and neck pain, conventional rehabilitation methods have failed to reduce work disability. Recently, rehabilitation goals have shifted from exclusively reducing or eradicating pain to improving patients' work and activity tolerance, avoiding illness behaviors, and preventing deconditioning and chronicity. Rehabilitation programs must incorporate strategies that have been proved to improve outcome in randomized, controlled trials. Treatment should be based on duration of symptoms, severity of impairment, and patient response. Consideration must be given to physical and psychological therapeutic milieu. Acute patients should be educated that pain is a normal part of recovery, and that activity maintenance improves outcome. Therapy should focus on restoring or maintaining flexibility, strength, and level of fitness while maintaining maximum productivity. Some acute patients may wish to change health habits and may undergo several sessions of general and low back conditioning training with the development of a health-club or home maintenance regimen. Patients failing to respond favorably to acute treatment and other subacute patients should participate in quota-based graded exercise regimens, with behavioral management. Quantification of function for flexibility, trunk strength, lifting capacity, and cardiovascular fitness is recommended to document progress and guide treatment. "Wellness" is stressed. Incorporating direct return-to-work advice into the treatment plan is important, as is direct communication with the employer throughout treatment. Patients should be cleared for full-duty return to work at treatment end in most circumstances. Successfully managed patients will feel confident about abilities for work and general activities. Intensive management of subacute patients may require 4 to 6 weeks and 12 to 18 comprehensive rehabilitation sessions. Once such comprehensive treatment has been provided, patients may be deemed at a medical endpoint, and further "chronic" rehabilitation treatment should not be necessary. The rehabilitation principles discussed here for work-injured low back and neck pain patients may be used to treat other industrial injuries as long as medical clearance is given for applying the treatment model. Specific time frames for recovery and expected performance for specific diagnoses need to be developed.

Principles for managing penetrating craniocerebral injuries caused by firearm missiles.

PubMed

Zhang, X; Yi, S Y; Liu, W P; Zhang, Z W; Wang, L G; Li, A M

1996-07-01

Penetrating craniocerebral firearm injuries remain one of the most lethal causes of all trauma and are common both in war or peace time. Data were reviewed for 4140 severely head-injured patients (Glasgow Coma Scale (GCS) scores 3-8) treated at Xi-Jing Hospital between 1973 and 1993; 51 of these patients had acute penetrating craniocerebral injuries caused by firearm missiles. These patients consisted of 46 males (90.2%) and 5 females (9.8%) ranging in age from 3 months to 48 years (median 22.4 years). The lesion types included 2 tangential wounds, 37 tubular wounds and 12 through-and-through wounds. All cases were urgent with the patients in severe and unstable states. After emergency treatment and operation, 5 cases died (9.8%). Follow up studies at three months showed that 23 cases (45.1%) had made a good recovery. Moderate disability, severe disability and vegetative states in this series were 29.4%, 13.7% and 2.0% respectively. Long term follow up studies indicated that 32 were able to resume their occupation. The principles for managing penetrating craniocerebral firearm injuries and suggestions for operation are discussed.

Early nutritional support in severe traumatic patients.

PubMed

Chuntrasakul, C; Siltharm, S; Chinswangwatanakul, V; Pongprasobchai, T; Chockvivatanavanit, S; Bunnak, A

1996-01-01

Multiple trauma is associated with altered metabolism, wasting of the lean body mass and compromised wound healing. Nutritional support is one way to improve the condition of these critically ill patients. We performed a prospective randomized study on the effect of early nutritional support in severely injured patients admitted to the Division of Traumatic Surgery, Siriraj Hospital between June 1992 and January 1994. Thirty-eight severe traumatic patients with ISS between 20-40 were randomly divided into control and study group. The 17 patients in the control group were treated in the conventional method with administration of hypo caloric intravenous regimen and supplement with oral diet as soon as the bowel function was returned. The 21 patients of the study group were fed either by enteral or parenteral feeding or both with an appropriate caloric and protein requirement as soon as hemodynamic status was stabilized. We found the study group had a lower mortality rate, a lower complication rate, a shorter period of ICU stay, and an earlier weaning from the ventilator than the control group. The study group also lost less weight than the control group. Nitrogen balance in the study group was significantly lower than the control group.

Injuries and helmet use related to non-motorized wheeled activities among pediatric patients.

PubMed

Lindsay, H; Brussoni, M

2014-07-01

Patients presenting to emergency departments (ED) for injuries resulting from recreational activities represent a unique source of information on important directions for injury prevention efforts. We describe the epidemiology of non-motorized wheeled activity-related injury in pediatric patients presenting to Canadian EDs as well as patients' helmet use. Data for the years 2004 to 2009 were abstracted from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), a national ED injury surveillance program in fifteen hospitals. Most of the 28 618 children aged 1 to 16 years injured during non-motorized wheeled activities were injured while cycling, followed by skateboarding. Most injuries occurred among boys. Children injured on scooters tended to be younger whereas skateboarders were the oldest. On average, the number of all injuries decreased by 6% over the time period. Falls were the most common mechanism of injury; 8.3% of patients had head injuries, which were seen more often among cyclists than other wheeled-activity users. Helmet use was greatest among cyclists (62.2%) and lowest among skateboarders (32.9%). Injured patients presenting to EDs in jurisdictions with legislation mandating helmet use had 2.12 greater odds of helmet use and 0.86 lesser odds of head injury compared with those presenting in jurisdictions without helmet laws. These results provide further evidence that legislation mandating helmet use may be an effective way of reducing injury among all wheeled-activity users. The small number of patients who presented with helmet use and protective gear (59.4% overall) suggests that this remains an area for intervention.

Quantitative evaluation of the viscoelastic properties of the ankle joint complex in patients suffering from ankle sprain by the anterior drawer test.

PubMed

Lin, Che-Yu; Shau, Yio-Wha; Wang, Chung-Li; Chai, Huei-Ming; Kang, Jiunn-Horng

2013-06-01

Biological tissues such as ligaments exhibit viscoelastic behaviours. Injury to the ligament may induce changes of these viscoelastic properties, and these changes could serve as biomarkers to detect the injury. In the present study, a novel instrument was developed to non-invasive quantify the viscoelastic properties of the ankle in vivo by the anterior drawer test. The purpose of the study was to investigate the reliability of the instrument and to compare the viscoelastic properties of the ankle between patients suffering from ankle sprain and controls. Eight patients and eight controls participated in the present study. The reliability test was performed on three randomly chosen subjects. In patient and control test, both ankles of each subject were tested to evaluate the viscoelastic properties of the ankle. The viscosity index was defined for quantitatively evaluating the viscosity of the ankle. Greater viscosity index was associated with lower viscosity. Injured and uninjured ankles of patient and both ankles of controls were compared. The instrument exhibited excellent test-retest reliability (r > 0.9). Injured ankles exhibited significantly less viscosity than uninjured ankles, since injured ankles of patients had significantly higher viscosity index (8,148 ± 5,266) compared with uninjured ankles of patients (948 ± 617; p = 0.008) and controls (1,326 ± 613; p < 0.001). The study revealed that the viscoelastic properties of the ankle can serve as sensitive and useful clinical biomarkers to differentiate between injured and uninjured ankles. The method may provide a clinical examination for objectively evaluating lateral ankle ligament injuries.

Identifying protective and risk factors for injurious falls in patients hospitalized for acute care: a retrospective case-control study.

PubMed

Aryee, Emmanuel; James, Spencer L; Hunt, Guenola M; Ryder, Hilary F

2017-11-07

Admitted patients who fall and injure themselves during an acute hospitalization incur increased costs, morbidity, and mortality, but little research has been conducted on identifying inpatients at high risk to injure themselves in a fall. Falls risk assessment tools have been unsuccessful due to their low positive predictive value when applied broadly to entire hospital populations. We aimed to identify variables associated with the risk of or protection against injurious fall in the inpatient setting. We also aimed to test the variables in the ABCs mnemonic (Age > 85, Bones-orthopedic conditions, anti-Coagulation and recent surgery) for correlation with injurious fall. We performed a retrospective case-control study at an academic tertiary care center comparing admitted patients with injurious fall to admitted patients without fall. We collected data on the demographics, medical and fall history, outcomes, and discharge disposition of injured fallers and control patients. We performed multivariate analysis of potential risk factors for injurious fall with logistic regression to calculate adjusted odds ratios. We identified 117 injured fallers and 320 controls. There were no differences in age, anti-coagulation use or fragility fractures between cases and controls. In multivariate analysis, recent surgery (OR 0.46, p = 0.003) was protective; joint replacement (OR 5.58, P = 0.002), psychotropic agents (OR 2.23, p = 0.001), the male sex (OR 2.08, p = 0.003) and history of fall (OR 2.08, p = 0.02) were significantly associated with injurious fall. In this study, the variables in the ABCs parameters were among the variables not useful for identifying inpatients at risk of injuring themselves in a fall, while other non-ABCs variables demonstrated a significant association with injurious fall. Recent surgery was a protective factor, and practices around the care of surgical patients could be extrapolated to reduce the in-hospital fall rates.

Pattern of law enforcement-related injuries in the United States.

PubMed

Chang, David C; Williams, Mallory; Sangji, Naveen F; Britt, L D; Rogers, Selwyn O

2016-06-01

The pattern of law enforcement-related injuries of police and civilians in the United States is unknown. Data were aggregated from the Federal Bureau of Investigations, the Bureau of Justice Statistics, the Centers for Disease Control (CDC) Web-based Injury Statistics Query and Reporting System, and the Nationwide Inpatient Sample (NIS) from 2003 to 2011. Law enforcement-related injuries in the CDC Web-based Injury Statistics Query and Reporting System and the NIS were identified using E-codes 970-976, which are meant to identify "injuries inflicted by the police or other law-enforcing agents, including military on duty, in the course of arresting or attempting to arrest lawbreakers, suppressing disturbances, maintaining order, and other legal action." The CDC reported a total of 715,118 nonfatal injuries and 3,156 fatal injuries from 2003 to 2011. In contrast, for the same period, the NIS identified a total of 3,958 patients, ranging from 348 to 572 per year. Among the injured, 1,548 (48.0%) were white, 866 were black (26.8%), and 605 were Hispanic (18.8%); 1,011 patients (25.5%) were injured by firearms, while 2,304 (58.2%) experienced blows or manhandling. Firearm-injured hospitalized patients are more likely to be male, black or Hispanics, and in the age group of 18 years to 39 years. The majority of law enforcement-related injuries are among white or black young men. Hispanic patients are more likely to be injured by a firearm than struck. When injured by firearm, white and black patients are more likely to die compared with Hispanic patients. Unfortunately, data about these injuries are scattered across multiple data systems. A uniform national system to aggregate these data sources is needed to better understand the scope of the problem, for both law enforcement personnel and civilians. Epidemiologic study, level III.

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon

PubMed Central

Pharaon, Shad K; Schoch, Shawn; Marchand, Lucas; Mirza, Amer

2018-01-01

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization. PMID:29766123

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon.

PubMed

Pharaon, Shad K; Schoch, Shawn; Marchand, Lucas; Mirza, Amer; Mayberry, John

2018-01-01

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization.

Ozone injury and infection of potato leaves by Botrytis cinerea

DOE Office of Scientific and Technical Information (OSTI.GOV)

Manning, W.J.; Feder, W.A.; Perkins, I.

1969-09-01

Symptoms of ozone injury were observed on older leaves of potato cultivars Norland and Katahdin under experimental conditions. This symptom expression closely resembled flecks observed on potato leaves also blighted by Botrytis cinerea in the field. Inoculation of ozone-injured and noninjured potato leaves with B. cinerea showed that infection was more rapid and disease development more severe on ozone-injured leaves. Infection was frequently observed to originate in ozone-injured leaf areas. Ozone injury, under experimental conditions, appeared to increase the susceptibility of potato leaves to infection by B. cinerea. 6 references.

Tulsa Oklahoma Oktoberfest Tent Collapse Report

PubMed Central

Deal, Kelly E.; Synovitz, Carolyn K.; Goodloe, Jeffrey M.; King, Brandi; Stewart, Charles E.

2012-01-01

Background. On October 17, 2007, a severe weather event collapsed two large tents and several smaller tents causing 23 injuries requiring evacuation to emergency departments in Tulsa, OK. Methods. This paper is a retrospective analysis of the regional health system's response to this event. Data from the Tulsa Fire Department, The Emergency Medical Services Authority (EMSA), receiving hospitals and coordinating services were reviewed and analyzed. EMS patient care reports were reviewed and analyzed using triage designators assigned in the field, injury severity scores, and critical mortality. Results. EMT's and paramedics from Tulsa Fire Department and EMSA provided care at the scene under unified incident command. Of the 23 patients transported by EMS, four were hospitalized, one with critical spinal injury and one with critical head injury. One patient is still in ongoing rehabilitation. Discussion. Analysis of the 2007 Tulsa Oktoberfest mass casualty incident revealed rapid police/fire/EMS response despite challenges of operations at dark under severe weather conditions and the need to treat a significant number of injured victims. There were no fatalities. Of the patients transported by EMS, a minority sustained critical injuries, with most sustaining injuries amenable to discharge after emergency department care. PMID:22649732

Relationship between viscosity of the ankle joint complex and functional ankle instability for inversion ankle sprain patients.

PubMed

Lin, Che-Yu; Kang, Jiunn-Horng; Wang, Chung-Li; Shau, Yio-Wha

2015-03-01

Measurement of viscosity of the ankle joint complex is a novel method to assess mechanical ankle instability. In order to further investigate the clinical significance of the method, this study intended to investigate the relationship between ankle viscosity and severity of functional ankle instability. Cross-sectional study. 15 participants with unilateral inversion ankle sprain and 15 controls were recruited. Their ankles were further classified into stable and unstable ankles. Ankle viscosity was measured by an instrumental anterior drawer test. Severity of functional ankle instability was measured by the Cumberland Ankle Instability Tool. Unstable ankles were compared with stable ankles. Injured ankles were compared with uninjured ankles of both groups. The spearman's rank correlation coefficient was applied to determine the relationship between ankle viscosity and severity of functional ankle instability in unstable ankles. There was a moderate relationship between ankle viscosity and severity of functional ankle instability (r=-0.64, p<0.0001). Unstable ankles exhibited significantly lower viscosity (p<0.005) and more severe functional ankle instability (p<0.0001) than stable ankles. Injured ankles exhibited significantly lower viscosity and more severe functional ankle instability than uninjured ankles (p<0.0001). There was a moderate relationship between ankle viscosity and severity of functional ankle instability. This finding suggested that, severity of functional ankle instability may be partially attributed to mechanical insufficiencies such as the degenerative changes in ankle viscosity following the inversion ankle sprain. In clinical application, measurement of ankle viscosity could be a useful tool to evaluate severity of chronic ankle instability. Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Risky behaviors associated with pediatric pedestrians and bicyclists struck by motor vehicles.

PubMed

Glass, Nina E; Frangos, Spiros G; Simon, Ronald J; Bholat, Omar S; Todd, S Rob; Wilson, Chad; Jacko, Sally; Slaughter, Dekeya; Foltin, George; Levine, Deborah A

2014-06-01

Road safety constitutes a crisis with important health and economic impacts. In 2010, 11,000 pedestrians and 3500 bicyclists were injured by motor vehicles in New York City (NYC). Motor vehicle injuries represent the second leading cause of injury-related deaths in NYC children aged 5 to 14 years. To better target injury prevention strategies, we evaluated demographics, behaviors, environmental factors, injuries, and outcomes of pediatric pedestrians and bicyclists struck by motor vehicles in NYC. Pediatric data were extracted from a prospectively collected database of pedestrians and bicyclists struck by motor vehicles and treated at a level I regional trauma center between December 2008 and June 2011. Patients, guardians, and first responders were interviewed and medical records were reviewed. Institutional review board approval was granted and verbal consent was obtained. Of the 1457 patients, 168 (12%) were younger than 18 years. Compared with injured adults, children were more likely to be in male sex (69% vs 53%), to have minor injuries (83% vs 73% for injury severity scores of <9), and to be discharged without admission (69% vs 67%). Midblock crossings were more common in children pedestrians than in adults (37% vs 19%), often despite supervision (48%). Electronic device use among teenagers aged 13 to 17 years was nearly 3 times that of adults (28% vs 11%). Risky behaviors are common among pediatric pedestrians and bicyclists injured by motor vehicles. Road safety education and prevention strategies must stress compliance with traffic laws, readdress the importance of supervision, and reinforce avoidance of common distractors including electronic devices.

The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center.

PubMed

Johnson, Jeremy J; Garwe, Tabitha; Raines, Alexander R; Thurman, Joseph B; Carter, Sandra; Bender, Jeffrey S; Albrecht, Roxie M

2013-03-01

Diagnostic laparoscopy (DL) has decreased the rate of nontherapeutic laparotomy for patients suffering from penetrating injuries. We evaluated whether DL similarly lowers the rate of nontherapeutic laparotomy for patients with blunt injuries. All patients undergoing DL over a 10-year period (ie, 2001-2010) in a single level 1 trauma center were classified by the mechanism of injury. Demographic and perioperative data were compared using the Student t and Fisher exact tests. There were 131 patients included, 22 of whom sustained blunt injuries. Patients suffering from blunt injuries were more severely injured (Injury Severity Score 18.0 vs 7.3, P = .0001). The most common indication for DL after blunt injury was a computed tomographic scan concerning for bowel injury (59.1%). The rate of nontherapeutic laparotomy for patients sustaining penetrating vs blunt injury was 1.8% and nil, respectively. DL, when coupled with computed tomographic findings, is an effective tool for the initial management of patients with blunt injuries. Copyright © 2013 Elsevier Inc. All rights reserved.

Direct, indirect, and intangible costs after severe trauma up to occupational reintegration - an empirical analysis of 113 seriously injured patients.

PubMed

Anders, Benjamin; Ommen, Oliver; Pfaff, Holger; Lüngen, Markus; Lefering, Rolf; Thüm, Sonja; Janssen, Christian

2013-01-01

Although seriously injured patients account for a high medical as well as socioeconomic burden of disease in the German health care system, there are only very few data describing the costs that arise between the days of accident and occupational reintegration. With this study, a comprehensive cost model is developed that describes the direct, indirect and intangible costs of an accident and their relationship with socioeconomic background of the patients. This study included 113 patients who each had at least two injuries and a total Abbreviated Injury Scale (AIS) greater than or equal to five. We calculated the direct, indirect and intangible costs that arose between the day of the accident and occupational reintegration. Direct costs were the treatment costs at hospitals and rehabilitation centers. Indirect costs were calculated using the human capital approach on the basis of the work days lost due to injury, including sickness allowance benefits. Intangible costs were assessed using the Short Form Survey (SF-36) and represented in non-monetary form. Following univariate analysis, a bivariate analysis of the above costs and the patients' sociodemographic and socioeconomic characteristics was performed. At an average Injury Severity Score (ISS) of 19.2, the average direct cost per patient were €35,661. An average of 185.2 work days were lost, resulting in indirect costs of €17,205. The resulting total costs per patient were €50,431. A bivariate analysis showed that the costs for hospital treatment were 58% higher in patients who graduated from lower secondary school [Hauptschule] (ISS 19.5) than in patients with qualification for university admission [Abitur] (ISS 19.4). The direct costs of treating trauma patients at the hospital appear to be lower in patients with a higher level of education than in the comparison group with a lower educational level. Because of missing data, the calculated indirect costs can merely represent a general trend, so that the bivariate analysis can only be seen as a starting point for further studies.

Forgiveness, coping, and terrorism: do tendency to forgive and coping strategies associate with the level of posttraumatic symptoms of injured victims of terror attacks?

PubMed

Weinberg, Michael; Gil, Sharon; Gilbar, Ora

2014-07-01

The study examined the tendency to forgive (self, others, and situations) and coping strategies (problem-focused, emotion-focused, and avoidance) among terror attack victims as associated with posttraumatic stress disorder (PTSD) symptom severity. The sample included 108 terror victims who had been injured in terror attacks (mean age 46.23, standard deviation = 11.61; 58.3% male). Participants agreed to undergo assessments of their PTSD symptoms, coping strategies, and tendency to forgive. A nested structural equation model design showed that tendency to forgive is positively associated with problem-focused coping and negatively associated with avoidance coping. Additionally, tendency to forgive and problem-focused coping are associated with decreased PTSD symptom severity, whereas emotion-focused coping is associated with elevated PTSD symptom severity. Tendency to forgive and coping strategies are significantly associated with each other and with severity of PTSD symptoms among individuals injured in terror attacks. Theoretical and clinical implications of the findings are discussed. © 2013 Wiley Periodicals, Inc.

The injury epidemiology of cyclists based on a road trauma registry.

PubMed

Amoros, Emmanuelle; Chiron, Mireille; Thélot, Bertrand; Laumon, Bernard

2011-08-17

Bicycle use has increased in some of France's major cities, mainly as a means of transport. Bicycle crashes need to be studied, preferably by type of cycling. Here we conduct a descriptive analysis. A road trauma registry has been in use in France since 1996, in a large county around Lyon (the Rhône, population 1.6 million). It covers outpatients, inpatients and fatalities. All injuries are coded using the Abbreviated Injury Scale (AIS). Proxies were used to identify three types of cycling: learning = children (0-10 years old); sports cycling = teenagers and adults injured outside towns; cycling as means of transport = teenagers and adults injured in towns. The study is based on 13,684 cyclist casualties (1996-2008). The percentage of cyclists injured in a collision with a motor vehicle was 8% among children, 17% among teenagers and adults injured outside towns, and 31% among those injured in towns. The percentage of serious casualties (MAIS 3+) was 4.5% among children, 10.9% among adults injured outside towns and 7.2% among those injured in towns. Collisions with motor-vehicles lead to more internal injuries than bicycle-only crashes. The description indicates that cyclist type is associated with different crash and injury patterns. In particular, cyclists injured in towns (where cycling is increasing) are generally less severely injured than those injured outside towns for both types of crash (bicycle-only crashes and collisions with a motor vehicle). This is probably due to lower speeds in towns, for both cyclists and motor vehicles.

The injury epidemiology of cyclists based on a road trauma registry

PubMed Central

2011-01-01

Background Bicycle use has increased in some of France's major cities, mainly as a means of transport. Bicycle crashes need to be studied, preferably by type of cycling. Here we conduct a descriptive analysis. Method A road trauma registry has been in use in France since 1996, in a large county around Lyon (the Rhône, population 1.6 million). It covers outpatients, inpatients and fatalities. All injuries are coded using the Abbreviated Injury Scale (AIS). Proxies were used to identify three types of cycling: learning = children (0-10 years old); sports cycling = teenagers and adults injured outside towns; cycling as means of transport = teenagers and adults injured in towns. The study is based on 13,684 cyclist casualties (1996-2008). Results The percentage of cyclists injured in a collision with a motor vehicle was 8% among children, 17% among teenagers and adults injured outside towns, and 31% among those injured in towns. The percentage of serious casualties (MAIS 3+) was 4.5% among children, 10.9% among adults injured outside towns and 7.2% among those injured in towns. Collisions with motor-vehicles lead to more internal injuries than bicycle-only crashes. Conclusion The description indicates that cyclist type is associated with different crash and injury patterns. In particular, cyclists injured in towns (where cycling is increasing) are generally less severely injured than those injured outside towns for both types of crash (bicycle-only crashes and collisions with a motor vehicle). This is probably due to lower speeds in towns, for both cyclists and motor vehicles. PMID:21849071

Neuroendocrine abnormalities in patients with traumatic brain injury

NASA Technical Reports Server (NTRS)

Yuan, X. Q.; Wade, C. E.

1991-01-01

This article provides an overview of hypothalamic and pituitary alterations in brain trauma, including the incidence of hypothalamic-pituitary damage, injury mechanisms, features of the hypothalamic-pituitary defects, and major hypothalamic-pituitary disturbances in brain trauma. While hypothalamic-pituitary lesions have been commonly described at postmortem examination, only a limited number of clinical cases of traumatic hypothalamic-pituitary dysfunction have been reported, probably because head injury of sufficient severity to cause hypothalamic and pituitary damage usually leads to early death. With the improvement in rescue measures, an increasing number of severely head-injured patients with hypothalamic-pituitary dysfunction will survive to be seen by clinicians. Patterns of endocrine abnormalities following brain trauma vary depending on whether the injury site is in the hypothalamus, the anterior or posterior pituitary, or the upper or lower portion of the pituitary stalk. Injury predominantly to the hypothalamus can produce dissociated ACTH-cortisol levels with no response to insulin-induced hypoglycemia and a limited or failed metopirone test, hypothyroxinemia with a preserved thyroid-stimulating hormone response to thyrotropin-releasing hormone, low gonadotropin levels with a normal response to gonadotropin-releasing hormone, a variable growth hormone (GH) level with a paradoxical rise in GH after glucose loading, hyperprolactinemia, the syndrome of inappropriate ADH secretion (SIADH), temporary or permanent diabetes insipidus (DI), disturbed glucose metabolism, and loss of body temperature control. Severe damage to the lower pituitary stalk or anterior lobe can cause low basal levels of all anterior pituitary hormones and eliminate responses to their releasing factors. Only a few cases showed typical features of hypothalamic or pituitary dysfunction. Most severe injuries are sufficient to damage both structures and produce a mixed endocrine picture. Increased intracranial pressure, which releases vasopressin by altering normal hypothalamic anatomy, may represent a unique type of stress to neuroendocrine systems and may contribute to adrenal secretion by a mechanism that requires intact brainstem function. Endocrine function should be monitored in brain-injured patients with basilar skull fractures and protracted posttraumatic amnesia, and patients with SIADH or DI should be closely monitored for other endocrine abnormalities.

Trauma systems and the costs of trauma care.

PubMed Central

Goldfarb, M G; Bazzoli, G J; Coffey, R M

1996-01-01

OBJECTIVE. This study examines the cost of providing trauma services in trauma centers organized by publicly administered trauma systems, compared to hospitals not part of a formal trauma system. DATA SOURCES AND STUDY SETTING. Secondary administrative discharge abstracts for a national sample of severely injured trauma patients in 44 trauma centers and 60 matched control hospitals for the year 1987 were used. STUDY DESIGN. Retrospective univariate and multivariate analyses were conducted to examine the impact of formal trauma systems and trauma center designation on the costs of treating trauma patients. Key dependent variables included length of stay, charge per day per patient, and charge per hospital stay. Key impact variables were type of trauma system and level of trauma designation. Control variables included patient, hospital, and community characteristics. DATA COLLECTION/EXTRACTION METHODS. Data were selected for hospitals based on (1) a large national hospital discharge database, the Hospital Cost and Utilization Project, 1980-1987 (HCUP-2) and (2) a special survey of trauma systems and trauma designation undertaken by the Hospital Research and Educational Trust of the American Hospital Association. PRINCIPAL FINDINGS. The results show that publicly designated Level I trauma centers, which are the focal point of most trauma systems, have the highest charge per case, the highest average charge per day, and similar or longer average lengths of stay than other hospitals. These findings persist after controlling for patient injury and health status, and for demographic characteristics and hospital and community characteristics. CONCLUSIONS. Prior research shows that severely injured trauma patients have greater chances of survival when treated in specialized trauma centers. However, findings here should be of concern to the many states developing trauma systems since the high costs of Level I centers support limiting the number of centers designated at this level and/or reconsidering the requirements placed on these centers. PMID:8617611

The experience of emotional wellbeing for patients with physical injury: A qualitative follow-up study.

PubMed

Wiseman, Taneal; Foster, Kim; Curtis, Kate

2016-09-01

Traumatic physical injury is abrupt, painful, debilitating, costly and life-altering. The experience of emotional wellbeing following traumatic physical injury has not been well investigated, and the role of health services and how services can support the emotional recovery of injured patients has not been well understood. This has impacted on care provision and contributed to a lack of evidence-informed guidance for clinicians to support patients' emotional wellbeing. To explore the patient experience of emotional wellbeing following injury and to understand how injured patients manage their emotional wellbeing. The study comprises the follow-up qualitative phase of a mixed-methods explanatory sequential study. Semi-structured interviews were conducted with a purposive sample of 14 participants admitted to hospital following physical injury. Participants were purposely selected where they had reported high levels of depression, anxiety and stress on the DASS-21 at 3 and 6-months after injury. The qualitative data were analysed using thematic analysis. Three main themes were identified: experiencing the many impacts of injury; facing the emotional journey following injury; and being supported and managing the impacts of injury. Key findings were the extreme negative emotional responses experienced many months after the injury; a strong physical link between the emotional and physical aspects of health; participant reluctance to seek emotional support; a lack of emotional support provision by the health service and a subsequent need for individual and group support in order to develop resilience in the injured person. Finally, male participants who reported extreme emotional responses after injury, including suicidality, were less likely to seek help for their symptoms. Injured patients can experience substantial negative emotional responses following injury. The lack of support provided by health services to injured patients identified highlights the importance of in-hospital screening for emotional wellbeing and follow-up post-discharge, and a support network for patients to reduce the negative impacts of injury on their mental health. There is a need for anticipatory guidance frameworks for clinicians. Copyright © 2016 Elsevier Ltd. All rights reserved.

Parent vs burn-injured child self-report: contributions to a better understanding of anxiety levels.

PubMed

Rimmer, R B; Bay, R C; Sadler, I J; Alam, N B; Foster, K N; Caruso, D M

2014-01-01

Anxiety disorders are the most commonly reported form of mental health problem among youth, but they often go undiagnosed and untreated. This study examined the relationship between burn-injured youths' self-reported anxiety levels, as compared with their parent's perceptions of their child's emotional well-being. Burn-injured children were invited to voluntarily complete the Child Version of the 41-item survey, Screen for Child Anxiety Related Disorders, which consists of five anxiety subscales as well as a Total Anxiety Score. Parents were invited to complete the Parent Version. Sixty-three parent-child dyads, with girls (57%) and boys (43%), completed surveys. Mothers (73%) fathers (16%), and other caregivers (11%) participated. Youth mean age was 12.63 years and 60% reported visible burn scars. Matched-pairs t-tests were used to compare parent and child reports. Significantly lower mean scores were found between Screen for Child Anxiety Related Disorders Total Anxiety Score--Parent mean score of 10.52 vs the Youth mean score 21.06 (P<.001), as well as on all subscales including; panic disorder/somatic symptoms (P<.001), generalized anxiety disorder (P=.004), social anxiety disorder (separation anxiety (P<.001), and school avoidance (P<0.001). Results indicate that parents may be severely underestimating the psychological well-being of burn-injured youth. Findings emphasize the importance of a comprehensive approach in assessment for anxiety, involving the collection of feedback from both child and parent. Asking children for input into their psychological well-being is important. This study reinforces the need for a course of ongoing patient and parent education.

Improvement of the knee center of rotation during walking after opening wedge high tibial osteotomy.

PubMed

Kim, Kyungsoo; Feng, Jun; Nha, Kyung Wook; Park, Won Man; Kim, Yoon Hyuk

2015-06-01

Accurate measurement of the center of rotation of the knee joint is indispensable for prediction of joint kinematics and kinetics in musculoskeletal models. However, no study has yet identified the knee center of rotations during several daily activities before and after high tibial osteotomy surgery, which is one surgical option for treating knee osteoarthritis. In this study, an estimation method for determining the knee joint center of rotation was developed by applying the optimal common shape technique and symmetrical axis of rotation approach techniques to motion-capture data and validated for typical activities (walking, squatting, climbing up stairs, walking down stairs) of 10 normal subjects. The locations of knee joint center of rotations for injured and contralateral knees of eight subjects with osteoarthritis, both before and after high tibial osteotomy surgery, were then calculated during walking. It was shown that high tibial osteotomy surgery improved the knee joint center of rotation since the center of rotations for the injured knee after high tibial osteotomy surgery were significantly closer to those of the normal healthy population. The difference between the injured and contralateral knees was also generally reduced after surgery, demonstrating increased symmetry. These results indicate that symmetry in both knees can be recovered in many cases after high tibial osteotomy surgery. Moreover, the recovery of center of rotation in the injured knee was prior to that of symmetry. This study has the potential to provide fundamental information that can be applied to understand abnormal kinematics in patients, diagnose knee joint disease, and design a novel implants for knee joint surgeries. © IMechE 2015.

Lessons learned from cross-border medical response to the terrorist bombings in Tabba and Ras-el-Satan, Egypt, on 07 October 2004.

PubMed

Leiba, Adi; Blumenfeld, Amir; Hourvitz, Ariel; Weiss, Gali; Peres, Michal; Laor, Dani; Schwartz, Dagan; Arad, Jacob; Goldberg, Avishay; Levi, Yeheskel; Bar-Dayan, Yaron

2005-01-01

Large-scale, terrorist attacks can happen in peripheral areas, which are located close to a country's borders and far from its main medical facilities and involve multi-national casualties and responders. The objective of this study was to analyze the terrorist suicide bombings that occurred on 07 October 2004, near the Israeli-Egyptian border, as representative of such a complex scenario. Data from formal debriefings after the event were processed in order to learn about victim outcomes, resource utilization, critical events, and time course of the emergency response. A total of 185 injured survivors were repatriated: four were severely wounded, 13 were moderately injured, and 168 were mildly injured. Thirty-eight people died. A forward medical team landed at the border town's airport, which provided reinforcement in the field and in the local hospital. Israeli and Egyptian search and rescue teams collaborated at the destruction site. One-hundred sixty-eight injured patients arrived at the small border hospital that rapidly organized itself for the mass-casualty incident, operating as an evacuation "staging hospital". Twenty-three casualties secondarily were distributed to two major trauma centers in the south and the center of Israel, respectively, either by ambulance or by helicopter. Large-scale, terrorist attacks at a peripheral border zone can be handled by international collaboration, reinforcement of medical teams at the site itself and at the peripheral neighboring hospital, rapid rearrangement of an "evacuation hospital", and efficient transport to trauma centers by ambulances, helicopters, and other aircraft.

Reassuring and reducing anxiety in seriously injured patients: a study of accident and emergency interventions.

PubMed

Jay, R

1996-07-01

This paper is an account of a qualitative study of significantly injured patients' experience in the Accident and Emergency department (A&E) and explores the question 'What A&E nursing interventions are effective in providing reassurance and reducing anxiety in patients with significant trauma?' A review of the limited literature available indicates that when a seriously injured patient is admitted to the A&E department, the medical and nursing staff often respond urgently to the physiological crisis without adequate consideration of psychological needs. The research design used a version of the Critical Incident Technique to interview 7 patients who had sustained serious injuries a few days previously. The findings indicate that central to the delivery of emergency care is the individual's transition from their normal independent existence through pre-hospital trauma and into the isolating experience of fear, dependence and the resuscitation room. Different methods of coping were required to meet their needs and regain some control. Methods such as touch, company and information became paramount as did the need to trust the people seen to be in control of their new environment.

Characteristics of Patients Injured in Road Traffic Accidents According to the New Injury Severity Score

PubMed Central

Lee, Jung Soo; Kim, Yeo Hyung; Yun, Jae Sung; Jung, Sang Eun; Chae, Choong Sik

2016-01-01

Objective To investigate the clinical characteristics of patients involved in road traffic accidents according to the New Injury Severity Score (NISS). Methods In this study, medical records of 1,048 patients admitted at three hospitals located in different regions between January and December 2014 were retrospectively reviewed. Only patients who received inpatient treatments covered by automobile insurance during the period were included. Accidents were classified as pedestrian, driver, passenger, motorcycle, or bicycle; and the severity of injury was assessed by the NISS. Results The proportion of pedestrian traffic accident (TA) was the highest, followed by driver, passenger, motorcycle and bicycle TA. The mean NISS was significantly higher in pedestrian and motorcycle TAs and lower in passenger TA. Analysis of differences in mean hospital length of stay (HLS) according to NISS injury severity revealed 4.97±4.86 days in the minor injury group, 8.91±5.93 days in the moderate injury group, 15.46±11.16 days in the serious injury group, 24.73±17.03 days in the severe injury group, and 30.86±34.03 days in the critical injury group (p<0.05). Conclusion The study results indicated that higher NISS correlated to longer HLS, fewer home discharges, and increasing mortality. Specialized hospitals for TA patient rehabilitation are necessary to reduce disabilities in TA patients. PMID:27152279

Local vs general anaesthesia in the development of neurosensory disturbances after mandibular third molars extraction: A retrospective study of 534 cases.

PubMed

Costantinides, F; Biasotto, M; Maglione, M; Di Lenarda, R

2016-11-01

The choice of the anaesthetic modality is one of the primary steps during planning of third molar surgery. The aim of the present study was to compare the risk of developing neurological injures of the inferior alveolar nerve (IAN) and lingual nerve (LN) in patients treated for wisdom teeth removal under general anaesthesia (GA) with a group treated under local anaesthesia (LA). This is an observational retrospective, unicentric study; between September 2013 and September 2014, 534 patients underwent third molar surgery, 194 (36,3%) under GA and 340 (63,7%) under LA by the same oral surgeon. Difference in the incidence of IAN and LN injures between groups have been statistically analyzed with Fisher exact test and estimated odd ratio for development of such complications has been calculated. In GA patients the incidence of IAN and LN injures was 4.6% and 2.1%, respectively while in the LA group it was and 0.3% and 0%, respectively. A significant difference in IAN and LN involvement between groups was observed (IAN lesion: Fisher exact test, p<0.001; LN lesions: Fisher exact test, p<0.05). The estimated odd ratio for development of IAN injures after GA was 16.49 (95% CI: 2.07-131.19) and was not calculable for LN injures because no cases were observed in the LA group. Since GA is a perioperative variable that seems to significantly increase the risk of developing IAN and LN lesions, when treating patients that request GA, they must be adequately informed that an higher incidence of post-surgical sensory disturbances is expected.

Local vs general anaesthesia in the development of neurosensory disturbances after mandibular third molars extraction: A retrospective study of 534 cases

PubMed Central

Biasotto, Matteo; Maglione, Michele; Di Lenarda, Roberto

2016-01-01

Background The choice of the anaesthetic modality is one of the primary steps during planning of third molar surgery. The aim of the present study was to compare the risk of developing neurological injures of the inferior alveolar nerve (IAN) and lingual nerve (LN) in patients treated for wisdom teeth removal under general anaesthesia (GA) with a group treated under local anaesthesia (LA). Material and Methods This is an observational retrospective, unicentric study; between September 2013 and September 2014, 534 patients underwent third molar surgery, 194 (36,3%) under GA and 340 (63,7%) under LA by the same oral surgeon. Differences in the incidence of IAN and LN injures between groups have been statistically analyzed with Fisher exact test and estimated odd ratio for development of such complications has been calculated. Results In GA patients the incidence of IAN and LN injures was 4.6% and 2.1%, respectively while in the LA group it was and 0.3% and 0%, respectively. A significant difference in IAN and LN involvement between groups was observed (IAN lesion: Fisher exact test, p<0.001; LN lesions: Fisher exact test, p<0.05). The estimated odd ratio for development of IAN injures after GA was 16.49 (95% CI: 2.07-131.19) and was not calculable for LN injures because no cases were observed in the LA group. Conclusions Since GA is a perioperative variable that seems to significantly increase the risk of developing IAN and LN lesions, when treating patients that request GA, they must be adequately informed that an higher incidence of post-surgical sensory disturbances is expected. Key words:Third molars, general anaesthesia, local anaesthesia, inferior alveolar nerve, lingual nerve. PMID:27694783

The -260 C-->T promoter polymorphism of the lipopolysaccharide receptor CD14 and severe sepsis in trauma patients.

PubMed

Heesen, Michael; Bloemeke, Brunhilde; Schade, Ulrich; Obertacke, Udo; Majetschak, Matthias

2002-08-01

CD14, expressed on the cell surface of monocytes and hepatic Kupffer cells, interacts with Gram-positive and Gram-negative bacteria. Upon CD14 stimulation, these cells respond with the enhanced release of cytokines involved in the pathophysiology of sepsis. The purpose of this study was to evaluate whether the genotype distribution of the -260 C-->T promoter polymorphism of the CD14 gene is associated with the development of severe sepsis in trauma patients. Fifty-eight severely injured blunt trauma patients with an injury severity score of 16 or more and without pre-existing chronic diseases. Genotyping for the single nucleotide exchange polymorphism of the CD14 gene was performed by means of a real-time polymerase chain reaction with fluorescence-labeled hybridization probes. Diagnosis of severe sepsis was based on the criteria of the ACCP/SCCM criteria. Fourteen out of the 58 patients (24.6%) developed a trauma-related severe sepsis. The overall allele frequency was 0.58 for the C allele and 0.42 for the T allele. The genotype distribution (TT 0.19, CT 0.47 and CC 0.35) did not differ significantly from a previously reported control group of healthy blood donors. There was no significant difference of the genotype distribution or allele frequency between trauma patients with severe sepsis and patients with an uncomplicated clinical course. This pilot study suggests that the CD14 -260 polymorphism is not associated with an increased risk of severe sepsis in trauma patients.

Evaluation of Subchondral Bone Marrow Lipids of Acute Anterior Cruciate Ligament (ACL)-Injured Patients at 3 T

PubMed Central

Wang, Ligong; Salibi, Nouha; Chang, Gregory; Bencardino, Jenny T.; Babb, James S.; Rokito, Andrew; Jazrawi, Laith; Sherman, Orrin; Regatte, Ravinder R.

2014-01-01

Rationale and Objectives The objectives of this study were to investigate the changes in compartment-specific subchondral bone marrow lipids of femoral–tibial bone in acute anterior cruciate ligament (ACL)-injured patients compared to that of healthy volunteers and patients with osteoarthritis (OA) (Kellgren–Lawrence [KL] grade 2–3). Materials and Methods A total of 55 subjects were recruited in the study and subdivided into three subgroups: 17 healthy controls (4 females, 13 males; mean age = 41 ± 16, age range 24–78 years), 17 patients with acute ACL injury (3 females, 14 males; mean age = 30 ± 11, age range 18–61 years), and 21 patients with KL2–3 OA (12 females, 9 males; mean age = 65 ± 12, age range 44–89 years). Routine clinical proton density–weighted fast spin echo images in sagittal (without fat saturation), axial, and coronal (fat saturation) planes were acquired on a 3 T clinical scanner for cartilage morphology using Whole-Organ Magnetic Resonance Imaging Score grading. A voxel of 10 × 10 × 10 mm3 was positioned in the medial and lateral compartments of the tibia and femur for proton magnetic resonance spectroscopy measurements using the single voxel stimulated echo acquisition mode pulse sequence. All proton magnetic resonance data were processed with Java-based magnetic resonance user interface. Wilcoxon rank sum test and mixed model two-way analysis of variance were performed to determine significant differences between different compartments and examine the effect of ACL injury, OA grade and compartment, and their interactions. Results The index of unsaturation in lateral tibial compartment in ACL-injured patients was significantly higher (P < .05) than all compartments except lateral femoral in patients with KL2–3 OA. Significantly lower values (P < .05) were also identified in saturated lipids at 2.03 ppm in all compartments in ACL-injured patients than those of all compartments in patients with KL2–3 OA. Conclusions The preliminary results suggest that the indices of unsaturation in the lateral tibial compartment and the peaks of saturated lipids at 1.3 and 2.03 ppm in medial tibial compartment may be clinically useful to characterize subchondral bone marrow among healthy controls, acute ACL-injured patients, and patients with OA. PMID:24717549

Evaluation of subchondral bone marrow lipids of acute anterior cruciate ligament (ACL)-injured patients at 3 T.

PubMed

Wang, Ligong; Salibi, Nouha; Chang, Gregory; Bencardino, Jenny T; Babb, James S; Rokito, Andrew; Jazrawi, Laith; Sherman, Orrin; Regatte, Ravinder R

2014-06-01

The objectives of this study were to investigate the changes in compartment-specific subchondral bone marrow lipids of femoral-tibial bone in acute anterior cruciate ligament (ACL)-injured patients compared to that of healthy volunteers and patients with osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 2-3). A total of 55 subjects were recruited in the study and subdivided into three subgroups: 17 healthy controls (4 females, 13 males; mean age = 41 ± 16, age range 24-78 years), 17 patients with acute ACL injury (3 females, 14 males; mean age = 30 ± 11, age range 18-61 years), and 21 patients with KL2-3 OA (12 females, 9 males; mean age = 65 ± 12, age range 44-89 years). Routine clinical proton density-weighted fast spin echo images in sagittal (without fat saturation), axial, and coronal (fat saturation) planes were acquired on a 3 T clinical scanner for cartilage morphology using Whole-Organ Magnetic Resonance Imaging Score grading. A voxel of 10 × 10 × 10 mm(3) was positioned in the medial and lateral compartments of the tibia and femur for proton magnetic resonance spectroscopy measurements using the single voxel stimulated echo acquisition mode pulse sequence. All proton magnetic resonance data were processed with Java-based magnetic resonance user interface. Wilcoxon rank sum test and mixed model two-way analysis of variance were performed to determine significant differences between different compartments and examine the effect of ACL injury, OA grade and compartment, and their interactions. The index of unsaturation in lateral tibial compartment in ACL-injured patients was significantly higher (P < .05) than all compartments except lateral femoral in patients with KL2-3 OA. Significantly lower values (P < .05) were also identified in saturated lipids at 2.03 ppm in all compartments in ACL-injured patients than those of all compartments in patients with KL2-3 OA. The preliminary results suggest that the indices of unsaturation in the lateral tibial compartment and the peaks of saturated lipids at 1.3 and 2.03 ppm in medial tibial compartment may be clinically useful to characterize subchondral bone marrow among healthy controls, acute ACL-injured patients, and patients with OA. Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.

The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients.

PubMed

Helling, Thomas S; Nelson, Paul W; Shook, John W; Lainhart, Kathy; Kintigh, Denise

2003-07-01

The presence of a surgeon at the initial assessment and care of the trauma patient has been the focal point of trauma center designation. However, for Level I verification, the American College of Surgeons Committee on Trauma currently does not require the presence of an attending trauma surgeon in the hospital (IH), provided senior surgical residents are immediately available. Likewise, the state of Missouri does not mandate an IH presence of the attending trauma surgeon but requires senior (postgraduate year 4 or 5) level surgical residents to immediately respond, with a 20-minute response time mandated for the attending surgeon if IH or out of the hospital (OH). Nevertheless, some claim that IH coverage by attending surgeons provides better care for seriously injured patients. This retrospective study assessed patient care parameters over the past 10 years on critically injured patients to detect any difference in outcome whether the surgeon was IH or OH at the time of the trauma team activation (cardiopulmonary instability, Glasgow Coma Scale [GCS] score < 9, penetrating truncal injury). Patients were subcategorized into blunt/penetrating, shock (systolic blood pressure < 90 mm Hg) on arrival, GCS score < 9, Injury Severity Score (ISS) > 15, or ISS > 25. Response was examined from 8 am to 6 pm weekdays (IH) or 6 pm to 8 am weekdays and all weekends (OH). Patient care parameters examined were mortality, complications, time in the emergency department, time to the operating room, time to computed tomographic scanning, intensive care unit length of stay (LOS), and hospital LOS. For all patients (n = 766), there was no significant difference in any parameters except intensive care unit LOS (IH, 4.90 +/- 7.96 days; OH, 3.58 +/- 7.69 days; p < 0.05). For blunt trauma (n = 369), emergency department time was shorter (99.71 +/- 88.26 minutes vs. 126.51 +/- 96.68 minutes, p < 0.01) and hospital LOS was shorter (8.04 +/- 1.02 days vs. 11.08 +/- 1.15 days, p < 0.05) for OH response. For penetrating trauma (n = 377), shock (n = 187), GCS score < 9 (n = 248), ISS > 15 (n = 363), and ISS > 25 (n = 230), there were no statistically significant differences in any patient care parameter between IH and OH response. For those in most need of urgent operation-penetrating injuries and shock-there were no differences in time to operating room or mortality for OH or IH response. As long as initial assessment and care is provided by senior level IH surgical residents and as long as the attending surgeon responds in a defined period of time (if OH) to guide critical decision-making, the IH presence of an attending surgeon has not been shown in this retrospective study to improve care of the critically injured patient.

Facial trauma.

PubMed

Peeters, N; Lemkens, P; Leach, R; Gemels B; Schepers, S; Lemmens, W

Facial trauma. Patients with facial trauma must be assessed in a systematic way so as to avoid missing any injury. Severe and disfiguring facial injuries can be distracting. However, clinicians must first focus on the basics of trauma care, following the Advanced Trauma Life Support (ATLS) system of care. Maxillofacial trauma occurs in a significant number of severely injured patients. Life- and sight-threatening injuries must be excluded during the primary and secondary surveys. Special attention must be paid to sight-threatening injuries in stabilized patients through early referral to an appropriate specialist or the early initiation of emergency care treatment. The gold standard for the radiographic evaluation of facial injuries is computed tomography (CT) imaging. Nasal fractures are the most frequent isolated facial fractures. Isolated nasal fractures are principally diagnosed through history and clinical examination. Closed reduction is the most frequently performed treatment for isolated nasal fractures, with a fractured nasal septum as a predictor of failure. Ear, nose and throat surgeons, maxillofacial surgeons and ophthalmologists must all develop an adequate treatment plan for patients with complex maxillofacial trauma.

Measurement of self-esteem in repeat assault victims.

PubMed Central

Conti, C. T.; Moncure, M.; Hines, J.; Clack, Z.; Smith, T.; Simpkins, C. O.

1998-01-01

Background characterization of assault-related injuries have demonstrated that lifestyle, substance abuse, education, employment, mental illness, and high-risk behavior contribute to low self-esteem in repeat assault victims. Recurrent-assault patients have never been studied with respect to self-esteem. This study evaluated self-esteem and assault-related injury in 28 consecutive male assault patients (11 first-assault and 17 recurrent-assault patients) and 19 controls with no previous assault history. Study participants were administered the Walmyr Assessment Scales Index of Self-Esteem (WASISE) as part of a three-item survey to determine the relationship between self-esteem and assault-related injury. No demographic differences were found between the groups. The mean (+/- standard error) WASISE score for recurrent-assault patients (34.9 +/- 3.4) was significantly higher than mean scores for no-assault and first-time assault-injured patients (14.7 +/- 1.4 and 15.0 +/- 2.3, respectively). The recurrent-assault patients had a lower mean education level than both no-assault and first-time assault-injured patients (2.1 +/- 0.26 and 1.9 +/- 0.57, respectively). Eighteen (2%) first-time assault-injured and 11 (7%) recurrent-assault patients were employed. These data suggest that self-esteem, education, and employment history need to be considered when evaluating and developing interventions for repeat-assault patients. PMID:9549981

Direct, indirect, and intangible costs after severe trauma up to occupational reintegration – an empirical analysis of 113 seriously injured patients

PubMed Central

Anders, Benjamin; Ommen, Oliver; Pfaff, Holger; Lüngen, Markus; Lefering, Rolf; Thüm, Sonja; Janssen, Christian

2013-01-01

Aim: Although seriously injured patients account for a high medical as well as socioeconomic burden of disease in the German health care system, there are only very few data describing the costs that arise between the days of accident and occupational reintegration. With this study, a comprehensive cost model is developed that describes the direct, indirect and intangible costs of an accident and their relationship with socioeconomic background of the patients. Methods: This study included 113 patients who each had at least two injuries and a total Abbreviated Injury Scale (AIS) greater than or equal to five. We calculated the direct, indirect and intangible costs that arose between the day of the accident and occupational reintegration. Direct costs were the treatment costs at hospitals and rehabilitation centers. Indirect costs were calculated using the human capital approach on the basis of the work days lost due to injury, including sickness allowance benefits. Intangible costs were assessed using the Short Form Survey (SF-36) and represented in non-monetary form. Following univariate analysis, a bivariate analysis of the above costs and the patients’ sociodemographic and socioeconomic characteristics was performed. Results: At an average Injury Severity Score (ISS) of 19.2, the average direct cost per patient were €35,661. An average of 185.2 work days were lost, resulting in indirect costs of €17,205. The resulting total costs per patient were €50,431. A bivariate analysis showed that the costs for hospital treatment were 58% higher in patients who graduated from lower secondary school [Hauptschule] (ISS 19.5) than in patients with qualification for university admission [Abitur] (ISS 19.4). Conclusions: The direct costs of treating trauma patients at the hospital appear to be lower in patients with a higher level of education than in the comparison group with a lower educational level. Because of missing data, the calculated indirect costs can merely represent a general trend, so that the bivariate analysis can only be seen as a starting point for further studies. PMID:23798979

Registry based trauma outcome: perspective of a developing country.

PubMed

Zafar, H; Rehmani, R; Raja, A J; Ali, A; Ahmed, M

2002-09-01

To report trauma outcome from a developing country based on the Trauma and Injury Severity Scoring (TRISS) method and compare the outcome with the registry data from Major Trauma Outcome Study (MTOS). Registry based audit of all trauma patients over two years. Emergency room of a teaching university hospital. 279 injured patients meeting trauma team activation criteria including all deaths in the emergency room. TRISS methodology to compare expected and observed outcome. W, M, and Z statistics and comparison with MTOS data. 279 patients meeting the trauma triage criteria presented to the emergency room, 235 (84.2%) were men and 44 (15.8%) women. Blunt injury accounted for 204 (73.1%) and penetrating for 75 (26.9%) patients. Seventy two patients had injury severity score of more than 15. Only 18 (6.4%) patients were transported in an ambulance. A total of 142 (50.9%) patients were transferred from other hospitals with a mean prehospital delay of 7.1 hours. M statistic of our study subset was 0.97, indicating a good match between our patients and MTOS cohort. There were 18 deaths with only one unexpected survivor. The expected number of deaths based on MTOS dataset should have been 12. Present injury severity instruments using MTOS coefficients do not accurately correlate with observed survival rates in a developing country.

Prevalence of nonsuicidal self-injury and its risk and protective factors among adolescents in Taiwan.

PubMed

Lin, Min-Pei; You, Jianing; Ren, Yaxuan; Wu, Jo Yung-Wei; Hu, Wei-Hsuan; Yen, Cheng-Fang; Zhang, Xu

2017-09-01

The present study aimed to investigate the prevalence of nonsuicidal self-injury (NSSI) in a large representative sample of secondary school students and identified the psychosocial risk and protective factors. Using a cross-sectional design, 2170 participants were recruited from senior high schools throughout Taiwan using both stratified and cluster sampling. The one-year prevalence of NSSI was found to be 20.1%. Results suggested that compared to non-injurers, episodic self-injurers reported higher levels of neuroticism and openness, while repetitive self-injurers reported higher levels of neuroticism, openness, avoidance/emotion-focused coping, and virtual social support, and lower levels of self-esteem and cognitive reconstruction/problem-focused coping. Compared to episodic self-injurers, repetitive self-injurers reported a higher level of avoidance/ emotion-focused coping. Additionally, compared to non-injurers, mild self-injurers reported higher levels of neuroticism and openness, while severe self-injurers reported higher levels of neuroticism, openness, avoidance/emotion-focused coping, and virtual social support, and lower levels of self-esteem and cognitive reconstruction/problem-focused coping. Our study found that NSSI is fairly prevalent among secondary school students in Taiwan. Psychosocial risk factors, especially maladaptive coping strategies, should be given special attention when examining adolescents with NSSI. Regarding protective factors, enhancing self-esteem should be the focus of formulating effective intervention strategies for NSSI. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.

Suicide bombing attacks: Can external signs predict internal injuries?

PubMed

Almogy, Gidon; Mintz, Yoav; Zamir, Gideon; Bdolah-Abram, Tali; Elazary, Ram; Dotan, Livnat; Faruga, Mohammed; Rivkind, Avraham I

2006-04-01

To report the distribution and types of injuries in victims of suicide bombing attacks and to identify external signs that would guide triage and initial management. There is a need for information on the degree to which external injuries indicate internal injuries requiring emergency triage. The medical charts and the trauma registry database of all patients who were admitted to the Hadassah Hospital in Jerusalem from August 2001 to August 2004 following a suicide bombing attack were reviewed and analyzed for injury characteristics, number of body areas injured, presence of blast lung injury (BLI), and need for therapeutic laparotomy. Logistic analysis was performed to identify predictors of BLI and intra-abdominal injury. The study population consisted of 154 patients who were injured as a result of 17 attacks. Twenty-eight patients suffered from BLI (18.2%) and 13 patients (8.4%) underwent therapeutic laparotomy. Patients with penetrating head injury and those with > or =4 body areas injured were significantly more likely to suffer from BLI (odds ratio, 3.47 and 4.12, respectively, P < 0.05). Patients with penetrating torso injury and those with > or =4 body areas injured were significantly more likely to suffer from intra-abdominal injury (odds ratio, 22.27 and 4.89, respectively, P < 0.05). Easily recognizable external signs of trauma can be used to predict the occurrence of BLI and intra-abdominal injury. The importance of these signs needs to be incorporated into triage protocols and used to direct victims to the appropriate level of care both from the scene and in the hospital.

Modified Multivisceral Transplant After Acute Abdominal Trauma.

PubMed

Nikeghbalian, Saman; Alaa Eldin, Ahmed; Aliakbarian, Mohsen; Kazemi, Kourosh; Shamsaeefar, Alireza; Gholami, Siavash; Malekhosseini, Seyed Ali

2016-04-01

A 50-year-old man sustained blunt abdominal trauma in a motor vehicle accident. He underwent exploratory laparotomy on the day of trauma, and severe bleeding from the base of the small bowel mesentery was controlled by mass ligation and through-and-through suturing. After transfer to our center, repeat exploratory laparotomy showed ischemic small intestine, ischemic right colon, and severe pancreatic trauma. The severely injured organs were excised including the entire small bowel, pancreas, spleen, stomach, and right hemicolon. The next day, a modified multivisceral transplant was performed including stomach, pancreaticoduodenal complex, and small bowel transplant. Postoperative complications included an intra-abdominal collection that was drained percutaneously with ultrasonographic guidance and severe rejection that was treated with anti-thymocyte globulin. In summary, for select patients who have severe abdominal trauma may be treated with acute multivisceral transplant.

Establishing components of high-quality injury care: Focus groups with patients and patient families.

PubMed

Gagliardi, Anna R; Boyd, Jamie M; Evans, David; Gerein, Lynn; Nathens, Avery; Stelfox, Henry Thomas

2014-11-01

Each year, injuries affect 700 million people worldwide, more than 5 million people die of injuries, and 68,000 survivors remain permanently impaired. Half of all critically injured patients do not receive recommended care, and medical errors are common. Little is known about the aspects of injury care that are important to patients and their families. The purpose of this study was to explore the views of patients and families affected by injury on desired components of injury care in the hospital setting. With the use of a grounded theory approach, this qualitative study involved focus groups with injured patients, family members of survivors, and bereaved family members from four Canadian trauma (injury care) centers. Thirty-eight participants included injured patients (n = 16), family members of survivors (n = 13), and bereaved family members (n = 9) across four trauma (injury care) centers in different jurisdictions. Participants articulated numerous themes reflecting important components of injury care organized across three domains as follows: clinical care (staff availability, professionalism, physical comfort, adverse events), holistic care (patient wellness, respect for patient and family, family access to patient, family wellness, hospital facilities, supportive care), and communication and information (among staff, with or from staff, content, delivery, and timing). Bereaved family members commented on decision making and end-of-life processes. Subthemes were revealed in most of these themes. Trends by site or type of participant were not identified. The framework of patient- and family-derived components of quality injury care could be used by health care managers and policy makers to guide quality improvement efforts. Further research is needed to extend and validate these components among injured patients and families elsewhere. Translating these components into quality indicators and blending those with measures that reflect a provider perspective may offer a comprehensive means of assessing injury care.

Effective Factors in Severity of Traffic Accident-Related Traumas; an Epidemiologic Study Based on the Haddon Matrix

PubMed Central

Masoumi, Kambiz; Forouzan, Arash; Barzegari, Hassan; Asgari Darian, Ali; Rahim, Fakher; Zohrevandi, Behzad; Nabi, Somayeh

2016-01-01

Introduction: Traffic accidents are the 8th cause of mortality in different countries and are expected to rise to the 3rd rank by 2020. Based on the Haddon matrix numerous factors such as environment, host, and agent can affect the severity of traffic-related traumas. Therefore, the present study aimed to evaluate the effective factors in severity of these traumas based on Haddon matrix. Methods: In the present 1-month cross-sectional study, all the patients injured in traffic accidents, who were referred to the ED of Imam Khomeini and Golestan Hospitals, Ahvaz, Iran, during March 2013 were evaluated. Based on the Haddon matrix, effective factors in accident occurrence were defined in 3 groups of host, agent, and environment. Demographic data of the patients and data regarding Haddon risk factors were extracted and analyzed using SPSS version 20. Results: 700 injured people with the mean age of 29.66 ± 12.64 years (3-82) were evaluated (92.4% male). Trauma mechanism was car-pedestrian in 308 (44%) of the cases and car-motorcycle in 175 (25%). 610 (87.1%) cases were traffic accidents and 371 (53%) occurred in the time between 2 pm and 8 pm. Violation of speed limit was the most common violation with 570 (81.4%) cases, followed by violation of right-of-way in 57 (8.1%) patients. 59.9% of the severe and critical injuries had occurred on road accidents, while 61.3% of the injuries caused by traffic accidents were mild to moderate (p < 0.001). The most common mechanisms of trauma for critical injuries were rollover (72.5%), motorcycle-pedestrian (23.8%), and car-motorcycle (13.14%) accidents (p < 0.001). Conclusion: Based on the results of the present study, the most important effective factors in severity of traffic accident-related traumas were age over 50, not using safety tools, and undertaking among host-related factors; insufficient environment safety, road accidents and time between 2 pm and 8 pm among environmental factors; and finally, rollover, car-pedestrian, and motorcycle-pedestrian accidents among the agent factors PMID:27274517

Management of return-to-work programs for workers with musculoskeletal disorders: a qualitative study in three Canadian provinces.

PubMed

Baril, R; Clarke, J; Friesen, M; Stock, S; Cole, D

2003-12-01

In this qualitative research project, researchers in three Canadian provinces explored the perceptions of many different actors involved in return-to-work (RTW) programs for injured workers, studying their views on successful RTW strategies and barriers to/facilitators of the RTW process, then analyzing the underlying dynamics driving their different experiences. Each research team recruited actors in a variety of different workplaces and key informants in the RTW system, and used a combination of in-depth, semi-structured interviews and focus groups to collect data, which were coded using an open coding system. Analysis took a social constructionist perspective. The roles and mandates of the different groups of actors (injured workers; other workplace actors; actors outside the workplace), while sometimes complementary, could also differ, leading to tension and conflict. Characteristics of injured workers described as influencing RTW success included personal and sociodemographic factors, beliefs and attitudes, and motivation. Human resources managers and health care professionals tended to attribute workers' motivation to their individual characteristics, whereas injured workers, worker representatives and health and safety managers described workplace culture and the degree to which workers' well-being was considered as having a strong influence on workers' motivation. Some supervisors experienced role conflict when responsible for both production quotas and RTW programs, but difficulties were alleviated by innovations such as consideration of RTW program responsibilities in the determination of production quotas and in performance evaluations. RTW program success seemed related to labor-management relations and top management commitment to Health and Safety. Non-workplace issues included confusion stemming from the compensation system itself, communication difficulties with some treating physicians, and role conflict on the part of physicians wishing to advocate for patients whose problems were non-compensable. Several common themes emerged from the experiences related by the wide range of actors including the importance of trust, respect, communication and labor relations in the failure or success of RTW programs for injured workers.

Relationship between etiology and covert cognition in the minimally conscious state

PubMed Central

Chennu, S.; Chatelle, C.; Fernández-Espejo, D.; Bekinschtein, T.A.; Pickard, J.D.; Laureys, S.; Owen, A.M.

2012-01-01

Objectives: Functional neuroimaging has shown that the absence of externally observable signs of consciousness and cognition in severely brain-injured patients does not necessarily indicate the true absence of such abilities. However, relative to traumatic brain injury, nontraumatic injury is known to be associated with a reduced likelihood of regaining overtly measurable levels of consciousness. We investigated the relationships between etiology and both overt and covert cognitive abilities in a group of patients in the minimally conscious state (MCS). Methods: Twenty-three MCS patients (15 traumatic and 8 nontraumatic) completed a motor imagery EEG task in which they were required to imagine movements of their right-hand and toes to command. When successfully performed, these imagined movements appear as distinct sensorimotor modulations, which can be used to determine the presence of reliable command-following. The utility of this task has been demonstrated previously in a group of vegetative state patients. Results: Consistent and robust responses to command were observed in the EEG of 22% of the MCS patients (5 of 23). Etiology had a significant impact on the ability to successfully complete this task, with 33% of traumatic patients (5 of 15) returning positive EEG outcomes compared with none of the nontraumatic patients (0 of 8). Conclusions: The overt behavioral signs of awareness (measured with the Coma Recovery Scale–Revised) exhibited by nontraumatic MCS patients appear to be an accurate reflection of their covert cognitive abilities. In contrast, one-third of a group of traumatically injured patients in the MCS possess a range of high-level cognitive faculties that are not evident from their overt behavior. Neurology®2012;78:816–822 PMID:22377810

Impact of the severity of trauma on early retirement.

PubMed

Kuhlman, Michael Bilde; Lohse, Nicolai; Sørensen, Anne Marie; Larsen, Claus Falck; Christensen, Karl Bang; Steinmetz, Jacob

2014-03-01

To assess the association between Injury Severity Score (ISS) and subsequent risk of early retirement. Observational cohort study with follow-up based on prospectively collected data. Hospital-based data were linked to national register data on pension reception and vital status. Level-one urban trauma centre. Patients aged 18-64 years entering the trauma centre in Copenhagen during 1999-2007 who were alive after three days were followed until early retirement, death or emigration. Primary outcome was early retirement, defined as receiving disability pension (unintentional) or voluntary early retirement pension (intentional) before the regular age of retirement (65 years). Relative risk of early retirement according to ISS (low, ISS 1-15 vs. high, ISS 16-75) was assessed using Cox proportional hazards regression, adjusted for age and gender. Of all 6687 patients admitted to the trauma centre, a total of 1722 trauma patients were included and followed for a median of 6.2 years (interquartile range (IQR) 3.7-9.1). Of these, 1305 (75.8%) were males, median age was 35.0 years (IQR 25.4-46.5), and median ISS was 16 (IQR 9-25). Three hundred and twenty-two patients retired during follow-up. Patients with high ISS, compared to patients with low ISS, had an increased risk of early retirement, adjusted hazard ratio 2.60 (95% confidence interval (CI) 2.05-3.30; p<0.001). Relative increase in retirement risk was 1.04 (95% CI 1.03-1.05) per ISS point and 1.03 (95% CI 1.03-1.04) per year older. Gender was not found to be a significant risk factor (p=0.69). Five-year absolute risks of early retirement were 9.9% (95% CI 7.8-12.0%) for the low ISS group and 24.6% (95% CI 21.6-27.5%) for the high ISS group. The risk of early retirement is 2.6 times higher in severely injured patients (ISS 16-75) than the risk in low to moderately injured patients (ISS 1-15) and they have a high absolute 5-year risk as well. Early, targeted interventions to assist with return to work might be able to reduce this risk. Copyright © 2013 Elsevier Ltd. All rights reserved.

The effect of resident duty hour restriction on trauma center outcomes in teaching hospitals in the state of Pennsylvania.

PubMed

Helling, Thomas S; Kaswan, Sumesh; Boccardo, Justin; Bost, James E

2010-09-01

Resident duty hour restriction was instituted to improve patient safety, but actual impact on patient care is unclear. We sought to determine the effect of duty hour restriction on trauma outcomes in Level I trauma centers (TCs; surgery residency programs) versus Level II TCs (those with no surgery residency programs) within the state of Pennsylvania, using noninferiority as our hypothesis testing. Outcomes (mortality and length of stay [LOS]) were compared in Level II TCs without surgery residencies (n = 7) with Level I TCs (with surgery residencies; n = 14) PRE80 (2001-2003) and POST80 (2004-2007). The subcategories of critically injured patients, Injury Severity Score (ISS) >15, ISS >25, Trauma and Injury Severity Score (TRISS) ≤ 50, Abbreviated Injury Scale (AIS) head/chest/abdomen score >3, age >65 years, mechanism, and shock, functioned as outcome predictors. There was a decrease in mortality overall PRE80 to POST80 for Level I and II TCs. There was a decrease in mortality in Level I TCs POST80 in ISS >15 (16.5% vs. 14.8%, p = 0.0001), AIS (head) score >3 (20.8% vs. 17.8%, p < 0.0001), age >65 years (12.2% vs. 10.7%, p = 0.0013), and blunt mechanism (5.2% vs. 4.6%, p = 0.0004). LOS was reduced in ISS >15, AIS (head) score >3, age >65 years, and penetrating mechanism in Level I TCs POST80. A similar but more profound decrease was also seen in Level II TCs PRE80 and POST80 (ISS >15, 25; AIS (head) score; shock; blunt mechanism; and TRISS ≤ 50). Testing for inhomogeneity identified less-severely injured patients at Level II TCs POST80 compared with Level I TCs in certain subcategories (ISS >15, 25; AIS (head) score; shock; blunt mechanism; and TRISS ≤ 50) regarding mortality and LOS (TRISS >50%). Decreases in mortality and LOS during the study periods were likely not related to resident work hour restriction but rather to overall improvement in outcomes seen at Level II (no residents) and Level I (residents) TCs. Resident work hour restrictions had no discernible effect on patient care (noninferiority).

Drawing the Curtain Back on Injured Commercial Bicyclists.

PubMed

Heyer, Jessica H; Sethi, Monica; Wall, Stephen P; Ayoung-Chee, Patricia; Slaughter, Dekeya; Jacko, Sally; DiMaggio, Charles J; Frangos, Spiros G

2015-10-01

We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City's (NYC's) central business district. Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses. Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723). Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs.

Verbal Rehearsal and Memory in Children with Closed Head Injury: A Quantitative and Qualitative Analysis.

ERIC Educational Resources Information Center

Harris, Jessica R.

1996-01-01

Nine closed head injured (CHI) children (mean age 11 years) with post-onset intervals of 7 months to 8 years were given an overt free recall task. Quantitative analysis suggested inefficient passive rehearsal strategy by severely injured subjects. Qualitative analysis revealed differences between CHI children and controls in rehearsal strategies,…

[Air rescue: current significance and practical issues].

PubMed

Schellhaaß, A; Popp, E

2014-12-01

Germany has a nationwide and powerful helicopter emergency medical services system (HEMS), which executes primary rescue missions and interhospital transfer of intensive care patients. In recent years the range of HEMS missions has become modified due to demographic changes and structural changes in the healthcare system. Furthermore, the number of HEMS missions is steadily increasing. If reasonably used air rescue contributes to desired reductions in overall preclinical time. Moreover, it facilitates prompt transport of patients to a hospital suitable for definitive medical care and treatment can be initiated earlier which is a particular advantage for severely injured and critically ill patients. Because of complex challenges during air rescue missions the qualifications of the HEMS personnel have to be considerably higher in comparison with ground based emergency medical services.

[Demographic features and difficulties in rehabilitation in patients referred to hand rehabilitation unit for phalangeal fractures].

PubMed

Sahin, Füsun; Yücel, Serap Dalgiç; Yilmaz, Figen; Ergöz, Ernur; Kuran, Banu

2006-01-01

We evaluated demographic and occupational features of patients with phalangeal fractures of the hand, etiologies and types of injuries, and the results of rehabilitation. The study included 91 fingers of 62 patients (54 males, 8 females; mean age 28+/-13 years; range 4 to 59 years) who were referred to our hand rehabilitation unit for phalangeal fractures. Demographic features, the cause and localization of injury, the type of surgery, time from surgery to rehabilitation, and the follow-up period were determined. At the end of rehabilitation, range of motion (ROM) of the phalangeal joint and total ROM of the injured fingers were assessed using the Strickland-Glogovac rating system. A great majority of injuries were caused by work accidents, followed by sport injuries and falls occurring in students. Sixty patients (96.8%) were right-handed. The fractures occurred in the dominant hand in 29 patients (46.8%). The majority of patients (n=45) were primary school graduates. The most common mechanism of injury was accidents related to heavy work machinery (n=18). The most commonly injured finger and the phalanx were the third finger (n=25, 27.5%) and the proximal phalanx (n=59, 56.7%), respectively. Only 27 patients (43.6%) had a sufficient follow-up with a mean of 79.7+/-46.6 days (range 30 to 254 days). Following rehabilitation, the mean ROM and the total ROM were 45.0+/-22.9 degrees and 63.3+/-16.1 degrees for the injured joint and the thumb, and 31.3+/-22.5 degrees and 122+/-60.3 degrees for the injured joint and the other fingers, respectively. Our data provide important insight into appropriate treatment and rehabilitation of phalangeal fractures, in particular, shortcomings in the treatment and follow-up.

Balanced versus chloride-rich solutions for fluid resuscitation in brain-injured patients: a randomised double-blind pilot study

PubMed Central

2013-01-01

Introduction We sought to investigate whether the use of balanced solutions reduces the incidence of hyperchloraemic acidosis without increasing the risk for intracranial hypertension in patients with severe brain injury. Methods We conducted a single-centre, two-arm, randomised, double-blind, pilot controlled trial in Nantes, France. Patients with severe traumatic brain injury (Glasgow Coma Scale score ≤8) or subarachnoid haemorrhage (World Federation of Neurosurgical Society grade III or higher) who were mechanically ventilated were randomised within the first 12 hours after brain injury to receive either isotonic balanced solutions (crystalloid and hydroxyethyl starch; balanced group) or isotonic sodium chloride solutions (crystalloid and hydroxyethyl starch; saline group) for 48 hours. The primary endpoint was the occurrence of hyperchloraemic metabolic acidosis within 48 hours. Results Forty-two patients were included, of whom one patient in each group was excluded (one consent withdrawn and one use of forbidden therapy). Nineteen patients (95%) in the saline group and thirteen (65%) in the balanced group presented with hyperchloraemic acidosis within the first 48 hours (hazard ratio = 0.28, 95% confidence interval [CI] = 0.11 to 0.70; P = 0.006). In the saline group, pH (P = .004) and strong ion deficit (P = 0.047) were lower and chloraemia was higher (P = 0.002) than in the balanced group. Intracranial pressure was not different between the study groups (mean difference 4 mmHg [-1;8]; P = 0.088). Seven patients (35%) in the saline group and eight (40%) in the balanced group developed intracranial hypertension (P = 0.744). Three patients (14%) in the saline group and five (25%) in the balanced group died (P = 0.387). Conclusions This study provides evidence that balanced solutions reduce the incidence of hyperchloraemic acidosis in brain-injured patients compared to saline solutions. Even if the study was not powered sufficiently for this endpoint, intracranial pressure did not appear different between groups. Trial registration EudraCT 2008-004153-15 and NCT00847977 The work in this trial was performed at Nantes University Hospital in Nantes, France. PMID:23601796

Sexual counseling with spinal cord-injured clients.

PubMed

Miller, D K

1975-01-01

Spinal cord-injured clients have many fears and misapprehension about their sexual functioning. Common beliefs include: (a) disabled men cannot sexually satisfy able-bodied women; and (b) cord-injured persons cannot have sexual intercourse. Such misapprehensions can be helped by the counselor's willingness to discuss sexual issues openly. Clients need a clear and accurate picture of the facts, as well as encouragement and support to help them rediscover their sexuality. Spinal cord injury does not mean sexual incapacity. Given a knowing and patient partner, most clients can enjoy a satisfying sex life.

Developing and implementing a plan for large-scale burn disaster response in New Jersey.

PubMed

Conlon, Kathe M; Ruhren, Chris; Johansen, Sandra; Dimler, Margaret; Frischman, Barbara; Gehringer, Eileen; Houng, Abraham; Marano, Michael; Petrone, Sylvia J; Mansour, E Hani

2014-01-01

For the first time in modern history burn centers must face the reality of having to potentially care for a staggering number of injured patients. Factors such as staffing, patient acuity and bed availability compel medical professionals to regularly examine various aspects of their respective healthcare delivery systems, especially with regards to how these systems should function for mass casualty response. The majority of burn care in New Jersey is provided by one designated burn treatment facility. A planning group was formed to identify additional hospital support systems capable of providing short-term patient care during a disaster. Focus was on three key areas: identifying actual versus potential nonburn center resources, ascertaining the number and level of burn expertise at these facilities, and assessing the capacities of any available resources and personnel. Retrospective review of discharge data highlighted which of the more than seventy New Jersey hospitals besides The Burn Center were treating and releasing burn injures. In a disaster The Burn Center designates these hospitals as Tier Facilities to serve as additional resources until patients may be transferred to other recognized regional and national burn centers. Triage is conducted in accordance with the American Burn Association Benefit-to-Ratio Triage grid, matching patient acuity with each hospital's tier designation. A secondary triage, conducted 24 hours after the initial incident, identifies which patients require transport for more specialized burn care. Twenty-seven burn centers from Maine through Maryland and the District of Columbia, who have joined together as a Consortium, agree to support one another for optimal patient distribution and management in accordance with accepted national standards of care. State Medical Coordination Centers equipped to coordinate and track transport of large numbers of injured personnel are able to facilitate this collaborative, multiagency response throughout the northeast region. Burn centers share many issues common to emergency preparedness. Paramount among them is an ability to provide quality burn care for the greatest number of patients at a time when staff and resources will be severely limited. It is incumbent upon burn centers to explore opportunities extending beyond individual state and regional resources in order for centers to continually maintain this standard of care, particularly in a disaster.

Chest injuries related to surfing.

PubMed

Sano, Atsushi; Yotsumoto, Takuma

2015-09-01

Surfing is a popular sport in coastal areas, which can be associated with chest injuries. Between 2008 and 2013, 6 patients were referred to our hospital with chest injuries sustained during surfing. Clinical data were collected from their medical records and analyzed retrospectively. Patient age ranged from 35 to 52 years. Five of the 6 patients were male. Four patients were injured in August, and the other two were injured in September and October. Rib fractures were observed in 3 of the 6 patients. The other 3 patients were diagnosed with chest contusions only. Hemothorax occurred in one patient. No lacerations were observed in any of the 6 patients. Chest injuries associated with surfing are usually blunt chest injuries; however, they may occasionally be life-threatening. © The Author(s) 2015.

[Pancreaticoduodenectomy in the management of pancreatic and duodenal injuries].

PubMed

Içöz, Gökhan; Tunçyürek, Pars; Kiliç, Murat; Ilkgül, Ozer; Tercan, Mustafa; Yilmaz, Mustafa

2002-04-01

Patients who have undergone pancreaticoduodenectomy because of duodenopancreatic injury are retrospectively evaluated. Eight patients have undergone pancreaticoduodenectomy because of trauma in Ege University School of Medicine Department of Surgery. Six of the injuries were penetrating, and two of them were blunt. Six patients were male and two of them were female with a mean age of 29.2 (between 17 and 63). All patients had complicated duodenopancreatic, and associated grade I and grade II liver injuries. Major vessels were injured in three patients. There were also two colonic, one gastric, and one jejunal injury as a coexisting pathology. Two patients were died because of sepsis. One patient had pancreatic, and one had biliary fistula, both healed spontaneously. Pancreaticoduodenectomy should be practiced as a life-saving procedure in the management of severe duodenopancreatic trauma. Qualified centers with adequate experience have a higher success rate.

Study of 100 patients injured by London underground trains 1981-6.

PubMed Central

Cocks, R A

1987-01-01

One hundred patients who were injured by London underground trains during 1981-6 were studied; 43 of them died. Deliberate self harm was probable in roughly three quarters. Alcohol intoxication was thought to play an important part in a further tenth of cases. Thirteen were psychiatric inpatients at the time of the incident, and a further two had recently been discharged. Early warning of a potential suicide attempt was given during the 24 hours preceding the incident in 15 of the cases. Some of the deaths in the psychiatric patients may have been preventable. PMID:3122889

Study of 100 patients injured by London underground trains 1981-6.

PubMed

Cocks, R A

1987-12-12

One hundred patients who were injured by London underground trains during 1981-6 were studied; 43 of them died. Deliberate self harm was probable in roughly three quarters. Alcohol intoxication was thought to play an important part in a further tenth of cases. Thirteen were psychiatric inpatients at the time of the incident, and a further two had recently been discharged. Early warning of a potential suicide attempt was given during the 24 hours preceding the incident in 15 of the cases. Some of the deaths in the psychiatric patients may have been preventable.

Treatment preference among suicidal and self-injuring women with borderline personality disorder and PTSD.

PubMed

Harned, Melanie S; Tkachuck, Mathew A; Youngberg, Kelly A

2013-07-01

This study examined treatment preferences among suicidal and self-injuring women with borderline personality disorder (BPD) and PTSD. Women (N = 42, M(age) = 34) with BPD, PTSD and recent intentional self-injury were evaluated upon entry into a psychotherapy outcome study. The majority preferred a combined dialectical behavior therapy (DBT) and prolonged exposure (PE) treatment (73.8%), followed by DBT alone (26.2%), and PE alone (0%). Women who preferred the combined treatment were more likely to report a desire to obtain relief from PTSD and to receive specific DBT and PE treatment components as reasons underlying this preference. Few women (21.4%) reported concerns about PE, but those who did were more likely to prefer DBT alone. More severe PTSD re-experiencing symptoms, a childhood index trauma, and less reduction in positive affect after a trauma interview predicted a preference for the combined treatment. These results may help to inform treatment for these complex patients. © 2013 Wiley Periodicals, Inc.

Near Infrared Light Scattering Changes Following Acute Brain Injury

PubMed Central

Highton, David; Tachtsidis, Ilias; Tucker, Alison; Elwell, Clare; Smith, Martin

2018-01-01

Acute brain injury (ABI) is associated with changes in near infrared light absorption reflecting haemodynamic and metabolic status via changes in cerebral oxygenation (haemoglobin oxygenation and cytochrome-c-oxidase oxidation). Light scattering has not been comprehensively investigated following ABI and may be an important confounding factor in the assessment of chromophore concentration changes, and/or a novel non-invasive optical marker of brain tissue morphology, cytostructure, hence metabolic status. The aim of this study is to characterize light scattering following adult ABI. Time resolved spectroscopy was performed as a component of multimodal neuromonitoring in critically ill brain injured patients. The scattering coefficient (μ′s), absorption coefficient and cerebral haemoglobin oxygen saturation (SO2) were derived by fitting the time resolved data. Cerebral infarction was subsequently defined on routine clinical imaging. In total, 21 patients with ABI were studied. Ten patients suffered a unilateral frontal infarction, and mean μ′s was lower over infarcted compared to non-infarcted cortex (injured 6.9/cm, non-injured 8.2/cm p = 0.002). SO2 did not differ significantly between the two sides (injured 69.3 %, non-injured 69.0 % p = 0.7). Cerebral infarction is associated with changes in μ′s which might be a novel marker of cerebral injury and will interfere with quantification of haemoglobin/cytochrome c oxidase concentration. Although further work combining optical and physiological analysis is required to elucidate the significance of these results, μ′s may be uniquely placed as a non-invasive biomarker of cerebral energy failure as well as gross tissue changes. PMID:26782205

Psycho-social and Mental Variables and Post-Traumatic Stress Disorder in Traffic Accident Survivors in Northern Iran

PubMed Central

khodadadi-hassankiadeh, Naema; Dehghan-Nayeri, Nahid; Shahsavari, Hooman; Yousefzadeh-Chabok, Shahrokh; Haghani, Hamid

2017-01-01

Objective: To assess the psycho-social and mental variables associated with post-traumatic stress disorder (PTSD) in a series of Iranian patients. Methods: A total of 528 eligible accident survivors in pre-sampling of a randomized controlled trial targeting PTSD were included in this cross-sectional study. Psycho-social characteristics associated to PTSD were explored in these survivors in an outpatient clinic. They completed the questionnaires via interview between six weeks to six months after accident. Data collection tools were PSS (DSM-V version) for PTSD and BDI-II for depression and a researcher-made questionnaire for psycho-social variables. Results: There was a significant association between PTSD and the following variables; family communication, current depression, return to work, history of death of relatives, witnessed the death, length of amnesia, hospitalization, injured situation, and accident severity. Multivariate logistic regression indicated that some variables were associated with PTSD such as accident severity, (p<0.001), injured situation, (p<0.001), current depression, (p<0.001), RTW (p<0.001), and family communication (p=0.01). Conclusion: Psychiatric nursing prevention efforts is best directed toward motorcycle depressed drivers with severe accident and poor family communication who do not return to work. Thus, routine assessment of PTSD, depression and psycho-social variables after traffic accidents must be taken into account. PMID:28795065

[Application of standardized systems for assessment of prognosis of the traumatic process in patients with penetrating abdominal wounds and hepatic injuries].

PubMed

Hur'iev, S O; Novykov, F M; Shuryhin, O Iu; Ivanov, V I

2011-04-01

There were examined 131 injured persons, suffering penetrating abdominal wounding and hepatic injury. Correlation analysis was done, basing on studying of the results of the injured persons state estimation, using prognostic scales, aiming to prognosticate the traumatic process course.

Predicting Posttraumatic Stress Symptoms Longitudinally in a Representative Sample of Hospitalized Injured Adolescents

ERIC Educational Resources Information Center

Zatzick, Douglas F.; Grossman, David C.; Russo, Joan; Pynoos, Robert; Berliner, Lucy; Jurkovich, Gregory; Sabin, Janice A.; Katon, Wayne; Ghesquiere, Angela; McCauley, Elizabeth; Rivara, Frederick P.

2006-01-01

Objective: Adolescents constitute a high-risk population for traumatic physical injury, yet few longitudinal investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms over time in representative samples. Method: Between July 2002 and August 2003,108 randomly selected injured adolescent patients ages 12 to 18 and…

An Injury Severity-, Time Sensitivity-, and Predictability-Based Advanced Automatic Crash Notification Algorithm Improves Motor Vehicle Crash Occupant Triage.

PubMed

Stitzel, Joel D; Weaver, Ashley A; Talton, Jennifer W; Barnard, Ryan T; Schoell, Samantha L; Doud, Andrea N; Martin, R Shayn; Meredith, J Wayne

2016-06-01

Advanced Automatic Crash Notification algorithms use vehicle telemetry measurements to predict risk of serious motor vehicle crash injury. The objective of the study was to develop an Advanced Automatic Crash Notification algorithm to reduce response time, increase triage efficiency, and improve patient outcomes by minimizing undertriage (<5%) and overtriage (<50%), as recommended by the American College of Surgeons. A list of injuries associated with a patient's need for Level I/II trauma center treatment known as the Target Injury List was determined using an approach based on 3 facets of injury: severity, time sensitivity, and predictability. Multivariable logistic regression was used to predict an occupant's risk of sustaining an injury on the Target Injury List based on crash severity and restraint factors for occupants in the National Automotive Sampling System - Crashworthiness Data System 2000-2011. The Advanced Automatic Crash Notification algorithm was optimized and evaluated to minimize triage rates, per American College of Surgeons recommendations. The following rates were achieved: <50% overtriage and <5% undertriage in side impacts and 6% to 16% undertriage in other crash modes. Nationwide implementation of our algorithm is estimated to improve triage decisions for 44% of undertriaged and 38% of overtriaged occupants. Annually, this translates to more appropriate care for >2,700 seriously injured occupants and reduces unnecessary use of trauma center resources for >162,000 minimally injured occupants. The algorithm could be incorporated into vehicles to inform emergency personnel of recommended motor vehicle crash triage decisions. Lower under- and overtriage was achieved, and nationwide implementation of the algorithm would yield improved triage decision making for an estimated 165,000 occupants annually. Copyright © 2016. Published by Elsevier Inc.

Abdominal injuries in communal crises: The Jos experience

PubMed Central

Ojo, Emmanuel Olorundare; Ozoilo, Kenneth N.; Sule, Augustine Z.; Ugwu, Benjamin T.; Misauno, Michael A.; Ismaila, Bashiru O.; Peter, Solomon D.; Adejumo, Adeyinka A.

2016-01-01

Background: Abdominal injuries contribute significantly to battlefield trauma morbidity and mortality. This study sought to determine the incidence, demographics, clinical features, spectrum, severity, management, and outcome of abdominal trauma during a civilian conflict. Materials and Methods: A prospective analysis of patients treated for abdominal trauma during the Jos civil crises between December 2010 and May 2012 at the Jos University Teaching Hospital. Results: A total of 109 victims of communal conflicts with abdominal injuries were managed during the study period with 89 (81.7%) males and 20 (18.3%) females representing about 12.2% of the total 897 combat related injuries. The peak age incidence was between 21 and 40 years (range: 3–71 years). The most frequently injured intra-abdominal organs were the small intestine 69 (63.3%), colon 48 (44%), and liver 41 (37.6%). Forty-four (40.4%) patients had extra-abdominal injuries involving the chest in 17 (15.6%), musculoskeletal 12 (11%), and the head in 9 (8.3%). The most prevalent weapon injuries were gunshot 76 (69.7%), explosives 12 (11%), stab injuries 11 (10.1%), and blunt abdominal trauma 10 (9.2%). The injury severity score varied from 8 to 52 (mean: 20.8) with a fatality rate of 11 (10.1%) and morbidity rate of 29 (26.6%). Presence of irreversible shock, 3 or more injured intra-abdominal organs, severe head injuries, and delayed presentation were the main factors associated with mortality. Conclusion: Abdominal trauma is major life-threatening injuries during conflicts. Substantial mortality occurred with loss of nearly one in every 10 hospitalized victims despite aggressive emergency room resuscitation. The resources expenditure, propensity for death and expediency of timing reinforce the need for early access to the wounded in a concerted trauma care systems. PMID:26957819

Developing a cumulative anatomic scoring system for military perineal and pelvic blast injuries.

PubMed

Mossadegh, Somayyeh; Midwinter, M; Parker, P

2013-03-01

Improvised explosive device (IED) yields in Afghanistan have increased resulting in more proximal injuries. The injury severity score (ISS) is an anatomic aggregate score of the three most severely injured anatomical areas but does not accurately predict severity in IED related pelvi-perineal trauma patients. A scoring system based on abbreviated injury score (AIS) was developed to reflect the severity of these injuries in order to better understand risk factors, develop a tool for future audit and improve performance. Using standard AIS descriptors, injury scales were constructed for the pelvis (1, minor to 6, maximal). The perineum was divided into anterior and posterior zones as relevant to injury patterns and blast direction with each soft tissue structure being allocated a score from its own severity scale. A cumulative score, from 1 to 36 for soft tissue, or a maximum of 42 if a pelvic fracture was involved, was created for all structures injured in the anterior and posterior zones. Using this new scoring system, 77% of patients survived with a pelvi-perineal trauma score (PPTS) below 5. There was a significant increase in mortality, number of pelvic fractures and amputations with increase in score when comparing the first group (score 1-5) to the second group (score 6-10). For scores between 6 and 16 survival was 42% and 22% for scores between 17 and 21. In our cohort of 62 survivors, 1 patient with an IED related pelvi-perineal injury had a 'theoretically un-survivable' maximal ISS of 75 and survived, whereas there were no survivors with a PPTS greater than 22 but this group had no-one with an ISS of 75 suggesting ISS is not an accurate reflection of the true severity of pelvi-perineal blast injury. This scoring system is the initial part of a more complex logistic regression model that will contribute towards a unique trauma scoring system to aid surgical teams in predicting fluid requirements and operative timelines. In austere environments, it may also help to prevent futile resuscitations. Better correlation between measurement of severity and outcome would aid performance improvement monitoring. In the longer term it will also allow benchmarking of current survival rates and comparisons in the future.

Bone scan as a screening test for missed fractures in severely injured patients.

PubMed

Lee, K-J; Jung, K; Kim, J; Kwon, J

2014-12-01

In many cases, patients with severe blunt trauma have multiple fractures throughout the body. These fractures are not often detectable by history or physical examination, and their diagnosis can be delayed or even missed. Thus, screening test fractures of the whole body is required after initial management. We performed this study to evaluate the reliability of bone scans for detecting missed fractures in patients with multiple severe traumas and we analyzed the causes of missed fractures by using bone scan. A bone scan is useful as a screening test for fractures of the entire body of severe trauma patients who are passed the acute phase. We reviewed the electronic medical records of severe trauma patients who underwent a bone scan from September 2009 to December 2010. Demographic and medical data were compared and statistically analyzed to determine whether missed fractures were detected after bone scan in the two groups. A total of 382 patients who had an injury severity score [ISS] greater than 16 points with multiple traumas visited the emergency room. One hundred and thirty-one patients underwent bone scan and 81 patients were identified with missed fractures by bone scan. The most frequent location for missed fractures was the rib area (55 cases, 41.98%), followed by the extremities (42 cases, 32.06%). The missed fractures that required surgery or splint were most common in extremities (11 cases). In univariate analysis, higher ISS scores and mechanism of injury were related with the probability that missed fractures would be found with a bone scan. The ISS score was statistically significant in multivariate analysis. Bone scan is an effective method of detecting missed fractures among patients with multiple severe traumas. Level IV, retrospective study. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Glasgow Coma Scale score, mortality, and functional outcome in head-injured patients.

PubMed

Udekwu, Pascal; Kromhout-Schiro, Sharon; Vaslef, Steven; Baker, Christopher; Oller, Dale

2004-05-01

Preresuscitation Glasgow Coma Scale (P-GCS) score is frequently obtained in injured patients and incorporated into mortality prediction. Data on functional outcome in head injury is sparse. A large group of patients with head injuries was analyzed to assess relationships between P-GCS score, mortality, and functional outcome as measured by the Functional Independence Measure (FIM). Records for patients with International Classification of Diseases, Ninth Revision diagnosis codes indicating head injury in a statewide trauma registry between 1994 and 2002 were selected. P-GCS score, mortality, and FIM score at hospital discharge were integrated and analyzed. Of 138,750 patients, 22,924 patients were used for the mortality study and 7,150 patients for the FIM study. A good correlation exists between P-GCS score and FIM, as determined by rank correlation coefficients, whereas mortality falls steeply between a P-GCS score of 3 and a P-GCS score of 7 followed by a shallow fall. Although P-GCS score is related to mortality in head-injured patients, its relationship is nonlinear, which casts doubt on its use as a continuous measure or an equivalent set of categorical measures incorporated into outcome prediction models. The average FIM scores indicate substantial likelihood of good outcomes in survivors with low P-GCS scores, further complicating the use of the P-GCS score in the prediction of poor outcome at the time of initial patient evaluation. Although the P-GCS score is related to functional outcome as measured by the FIM score and mortality in head injury, current mortality prediction models may need to be modified to account for the nonlinear relationship between P-GCS score and mortality. The P-GCS score is not a good clinical tool for outcome prediction in individual head-injured patients, given the variability in mortality rates and functional outcomes at all scores.

Legal Preparedness

PubMed Central

Courtney, Brooke; Hodge, James G.; Toner, Eric S.; Roxland, Beth E.; Penn, Matthew S.; Devereaux, Asha V.; Dichter, Jeffrey R.; Kissoon, Niranjan; Christian, Michael D.; Powell, Tia

2015-01-01

BACKGROUND Significant legal challenges arise when health-care resources become scarce and population-based approaches to care are implemented during severe disasters and pandemics. Recent emergencies highlight the serious legal, economic, and health impacts that can be associated with responding in austere conditions and the critical importance of comprehensive, collaborative health response system planning. This article discusses legal suggestions developed by the American College of Chest Physicians (CHEST) Task Force for Mass Critical Care to support planning and response efforts for mass casualty incidents involving critically ill or injured patients. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS Following the CHEST Guidelines Oversight Committee’s methodology, the Legal Panel developed 35 key questions for which specific literature searches were then conducted. The literature in this field is not suitable to provide support for evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process resulting in seven final suggestions. RESULTS Acceptance is widespread for the health-care community’s duty to appropriately plan for and respond to severe disasters and pandemics. Hospitals, public health entities, and clinicians have an obligation to develop comprehensive, vetted plans for mass casualty incidents involving critically ill or injured patients. Such plans should address processes for evacuation and limited appeals and reviews of care decisions. To legitimize responses, deter independent actions, and trigger liability protections, mass critical care (MCC) plans should be formally activated when facilities and practitioners shift to providing MCC. Adherence to official MCC plans should contribute to protecting hospitals and practitioners who act in good faith from liability. Finally, to address anticipated staffing shortages during severe and prolonged disasters and pandemics, governments should develop approaches to formally expand the availability of qualified health-care workers, such as through using official foreign medical teams. CONCLUSIONS As a fundamental element of health-care and public health emergency planning and preparedness, the law underlies critical aspects of disaster and pandemic responses. Effective responses require comprehensive advance planning efforts that include assessments of complex legal issues and authorities. Recent disasters have shown that although law is a critical response tool, it can also be used to hold health-care stakeholders who fail to appropriately plan for or respond to disasters and pandemics accountable for resulting patient or staff harm. Claims of liability from harms allegedly suffered during disasters and pandemics cannot be avoided altogether. However, appropriate planning and legal protections can help facilitate sound, consistent decision-making and support response participation among health-care entities and practitioners. PMID:25144203

[Multicentre study on risk factors of injuries in car crashes].

PubMed

Panzino, F; Pizà Oliveras, A; Pociello Almiñana, N; García García, J J; Luaces Cubells, C; Pou Fernández, J

2009-07-01

Traffic accidents are the main cause of death in children between 2 and 14 years in developed countries. We analysed their clinical repercussions, epidemiological characteristics, use and suitability of Child Restraint Systems (CRS) and its correlation with the type of injuries in children less than 12 years old. Multicentre descriptive prospective study. The following data was collected: personal details of the victims and the type of accident, use and suitability of the CRS, classification of injuries according to location and severity, need for hospitalisation, medical treatment received, use of Emergency Services and final destination of the injured. A total of 366 patients were studied, with a sex ratio of 1:1 and a mean age of 6 years. Of these, 69.7% had some injury (slight 92.3%). A total of 81.1% affected the head and neck, and 77.9% used some type of CRS (suitable only in 55.7%). CRS were used more in >6 year olds (27.1%-P<0.001). Driving long distances (odds ratio 6.7) and not using a suitable CRS (odds ratio 3.7) were associated with the severity of the injuries. The age of the patients and the position within the automobile were not related. All the patients with a Glasgow less than 8 and all the deceased were using an unsuitable CRS. The hospitalization rate was 8.7% and the mortality rate at 24h was 0.8%. An important percentage of the injured children do not use suitable child restraint systems. Non-use of a CRS or its inadequate use is a risk factor of morbidity in the traffic accidents in childhood.

Iron as a possible aggravating factor for osteopathy in itai-itai disease, a disease associated with chronic cadmium intoxication

DOE Office of Scientific and Technical Information (OSTI.GOV)

Noda, M.; Yasuda, M.; Kitagawa, M.

1991-03-01

Itai-itai disease is thought to be the result of chronic cadmium (Cd) intoxication. We examined 23 autopsy cases of itai-itai disease and 18 cases of sudden death as controls. Urine and blood samples from 10 patients were collected before they died and revealed the presence of severe anemia and renal tubular injuries. Undecalcified sections of iliac bone were stained with Aluminon reagent, and ammonium salt of aurintricarboxylic acid, and Prussian blue reagent in all cases of itai-itai disease. These two reagents reacted at the same mineralization fronts. X-ray microanalysis revealed the presence of iron at mineralization fronts in itai-itai disease.more » Five patients showed evidence of hemosiderosis in the liver, spleen, and pancreas, probably as a result of post transfusion iron overload. Renal calculi and calcified aortic walls were also stained with Prussian blue reagent in several patients. Neither ferritin nor transferrin were visualized at mineralization fronts in itai-itai disease by immunohistochemical staining. These results suggest that iron is bound to calcium or to calcium phosphate by a physicochemical reaction. A marked osteomalacia was observed in 10 cases of itai-itai disease by histomorphometry. Regression analyses of data from cases of itai-itai disease suggested that an Aluminon-positive metal inhibited mineralization and that renal tubules were injured. Since bone Cd levels were increased in itai-itai disease, it is likely that renal tubules were injured by exposure to Cd. Therefore, stainable bone iron is another possible aggravating factor for osteopathy in itai-itai disease, and a synergistic effect between iron and Cd on mineralization is proposed.« less

Trampolines revisited: a review of 114 pediatric recreational trampoline injuries.

PubMed

Woodward, G A; Furnival, R; Schunk, J E

1992-05-01

A search of the medical literature failed to reveal any articles that discuss pediatric injuries acquired on privately owned recreational trampolines. This study was undertaken to quantify and qualify pediatric injuries from recreational trampoline use. A group of 114 patients who presented to the Emergency Department at Primary Children's Medical Center in Salt Lake City, Utah, with injuries directly related to use of a trampoline are discussed. There was a 1.2:1 male-female ratio. The average age was 8.0 years. Forty-eight percent of the patients were injured on their family's trampoline, with the remainder injured on a friend's, neighbor's, relative's, or gymnasium's equipment. The majority of injuries involved group use of the trampoline and the youngest person in a group was most often the injured participant. Extremity injuries were seen in 55% of the patient and head or neck injuries in 37%. Seventy-five percent of the patients required radiographs, 23% hospitalization, and 17% operative intervention. The history of the trampoline and medical literature discussions concerning injuries and safety are reviewed.

Changes in blood transfusion practices in the UK role 3 medical treatment facility in Afghanistan, 2008-2011.

PubMed

Jansen, J O; Morrison, J J; Midwinter, M J; Doughty, H

2014-06-01

To document blood component usage in the UK medical treatment facility, Afghanistan, over a period of 4 years; and to examine the relationship with transfusion capability, injury pattern and survival. Haemostatic resuscitation is now firmly established in military medical practice, despite the challenges of providing such therapy in austere settings. Retrospective study of blood component use in service personnel admitted for trauma. Data were extracted from the UK Joint Theatre Trauma Registry. A total of 2618 patients were identified. Survival increased from 76 to 84% despite no change in injury severity. The proportion of patients receiving blood components increased from 13 to 32% per annum; 417 casualties received massive transfusion (≥10 units of RCC), the proportion increasing from 40 to 62%. Use of all blood components increased significantly in severely injured casualties, to a median (IQR) of 16 (9-25) units of red cell concentrate (P = 0·006), 15 (8-24) of plasma (P = 0·002), 2 (0-5) of platelets (P < 0·001) and 1 (0-3) of cryoprecipitate (P < 0·001). Cryoprecipitate (P = 0·009) and platelet use (P = 0·005) also increased in moderately injured casualties. The number of blood components transfused to individual combat casualties increased during the 4-year period, despite no change in injury severity or injury pattern. Survival also increased. Combat casualties requiring massive transfusion have a significantly higher chance of survival than civilian patients. Survival is the product of the entire system of care. However, we propose that the changes in military transfusion practice and capability have contributed to increased combat trauma survival. © 2013 Crown copyright. Transfusion Medicine © 2013 British Blood Transfusion Society. This article is published with the permission of the Controller of HMSO and the Queen's Printer for Scotland.

Intermittent catheterisation with hydrophilic-coated catheters (SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord injured patients: a prospective randomised parallel comparative trial.

PubMed

De Ridder, D J M K; Everaert, K; Fernández, L García; Valero, J V Forner; Durán, A Borau; Abrisqueta, M L Jauregui; Ventura, M G; Sotillo, A Rodriguez

2005-12-01

To compare the performance of SpeediCath hydrophilic-coated catheters versus uncoated polyvinyl chloride (PVC) catheters, in traumatic spinal cord injured patients presenting with functional neurogenic bladder-sphincter disorders. A 1-year, prospective, open, parallel, comparative, randomised, multi centre study included 123 male patients, > or =16 y and injured within the last 6 months. Primary endpoints were occurrence of symptomatic urinary tract infection (UTI) and hematuria. Secondary endpoints were development of urethral strictures and convenience of use. The main hypothesis was that coated catheters cause fewer complications in terms of symptomatic UTIs and hematuria. 57 out of 123 patients completed the 12-month study. Fewer patients using the SpeediCath hydrophilic-coated catheter (64%) experienced 1 or more UTIs compared to the uncoated PVC catheter group (82%) (p = 0.02). Thus, twice as many patients in the SpeediCath group were free of UTI. There was no significant difference in the number of patients experiencing bleeding episodes (38/55 SpeediCath; 32/59 PVC) and no overall difference in the occurrence of hematuria, leukocyturia and bacteriuria. The results indicate that there is a beneficial effect regarding UTI when using hydrophilic-coated catheters.

Prone position for the prevention of lung infection.

PubMed

Beuret, P

2002-04-01

Pulmonary infection is frequent in brain injured patients. It has been identified as an independent predictor of unfavorable neurological outcome, calling for attempts of prevention. We recently evaluated intermittent prone positioning for the prevention of ventilator-associated pneumonia (VAP) in comatose brain injured patients, in a randomized study. 25 patients were included in the prone position (PP) group: they were positioned on prone four hours once daily until they could get up to sit in an armchair; 26 patients were included in the supine position (SP) group. The main characteristics of the patients from the two groups were similar at randomization. The primary end-point was the incidence of lung worsening, defined by an increase in the Lung Injury Score by at least one point since the time of randomization. The incidence of lung worsening was lower in the PP group (12%) than in the SP group (50%) (p=0.003). The incidence of VAP was 38.4% in the SP group and 20% in the PP group (p=0.14). There was no serious complication attributable to prone positioning. In conclusion, the beneficial effect of prone positioning for prevention of lung infection in brain injured patients is not well established. However, in those patients, prone positioning is able to avoid the worsening of pulmonary function, especially in oxygenation.

Quality of life following road traffic injury: A systematic literature review.

PubMed

Rissanen, Ritva; Berg, Hans-Yngve; Hasselberg, Marie

2017-11-01

To assess and provide a systematic overview of current knowledge about the relationship between quality of life (QoL) and road traffic injury, and to appraise how QoL is affected by road traffic injury. A systematic review of the literature published since 1990 on QoL after a road traffic injury, including adult and paediatric populations, from three databases (Pubmed, PsychInfo and SafetyLit) was undertaken. The methodological quality was assessed according to the Newcastle-Ottawa Quality Assessment Scale. Thirty articles were included and assessed for quality. The QoL scores of those injured were similar to population norms at the first assessment, followed by a drop at the second assessment. An increase of QoL from the second to third assessment was reported, but participants never reached the population norms at the last follow-up (range six weeks to two years), with an exception of those claiming compensation and those with lower extremity fractures. Age, gender, socioeconomic status, injury severity, injury type and post-traumatic stress disorder were associated with reduced QoL. Available literature regarding QoL among injured in road traffic crashes is heterogeneous with regard to aims and tools used for assessment. Our review confirmed that independent of measure, the overall QoL was significantly reduced after a road traffic injury compared to the general population norms. Persons who are older, of female gender, lower socioeconomic status, diagnosed with post-traumatic stress disorder, with more severe injuries or injuries to the lower limbs are more vulnerable to loss of QoL following road traffic injury compared to other patient groups injured in road traffic crashes. Copyright © 2017 Elsevier Ltd. All rights reserved.

Retrograde nail for tibiotalocalcaneal arthrodesis as a limb salvage procedure for open distal tibia and talus fractures with severe bone loss.

PubMed

Ochman, Sabine; Evers, Julia; Raschke, Michael J; Vordemvenne, Thomas

2012-01-01

The treatment of complex fractures of the distal tibia, ankle, and talus with soft tissue damage, bone loss, and nonreconstructable joints for which the optimal timing for reduction and fixation has been missed is challenging. In such cases primary arthrodesis might be a treatment option. We report a series of multi-injured patients with severe soft tissue damage and bone loss, who were treated with a retrograde tibiotalocalcaneal arthrodesis nail as a minimally invasive treatment option for limb salvage. After a median follow-up of 5.4 years, all patients returned to their former profession. The ankle and bone fusion was complete, with moderate functional results and quality of life. Calcaneotibial arthrodesis using a retrograde nail is a good treatment option for nonreconstructable fractures of the ankle joint with severe bone loss and poor soft tissue quality in selected patients with multiple injuries, in particular, those involving both lower extremities, as a salvage procedure. Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Open Repair Versus Thoracic Endovascular Aortic Repair in Multiple-Injured Patients: Observations From a Level-1 Trauma Center

PubMed Central

Brand, Stephan; Breitenbach, Ingo; Bolzen, Philipp; Petri, Maximilian; Krettek, Christian; Teebken, Omke

2015-01-01

Background: Blunt trauma of the thoracic aorta is a rare but potentially life-threatening entity. Intimal tears are a domain of non-operative management, whereas all other types of lesions should be repaired urgently. There is now a clear trend favoring minimally invasive stent grafting over open surgical repair. Objectives: The aim of the present study was to retrospectively evaluate the mortality and morbidity with either treatment option. Therefore, a retrospective observational study was performed to compare two different treatment methods at two different time periods at one trauma center. Patients and Methods: Between 1977 and 2012, all severely injured patients referred to our level 1 trauma center were screened for blunt aortic injuries. We compared baseline characteristics, 30-day and overall mortality, morbidity, duration of intensive care treatment, procedure time, and transfusion of packed red blood between patients who underwent open surgical or stent repair. Results: During the observation period, 45 blunt aortic injuries were recorded. The average Injury Severity Score (ISS) was 41.8 (range 29 - 68). Twenty-five patients underwent Open Repair (OR), and another 20 patients were scheduled to emergency stent grafting. The 30-day mortality in the surgical and stent groups were 5/25 (20%) and 2/20 (10%), respectively. The average time for open surgery was 151 minutes; the mean time for stent grafting was 67 minutes (P = 0.001). Postoperative stay on the intensive care unit was between one and 59 days (median 10) in group one and between four and 50 days in group two (median 26)(P = 0.03). Patients undergoing OR required transfusion of 6.0 units of packed red cells in median; patients undergoing stent grafting required a median of 2.0 units of packed red cells (P < 0.001). In the stent grafting group, 30-day mortality was 10% (2/20). Conclusions: Due to more sophisticated diagnostic tools and surgical approaches, mortality and morbidity of blunt aortic injuries were significantly reduced over the years compared to thoracic endovascular aortic repair and OR over two different time periods. PMID:26848470

Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury.

PubMed

Hernandez, Matthew C; Thiels, Cornelius A; Aho, Johnathon M; Habermann, Elizabeth B; Zielinski, Martin D; Stubbs, James A; Jenkins, Donald H; Zietlow, Scott P

2017-09-01

Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking. We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up. Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001). In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients. Therapeutic, level V.

A pair-matched comparison of return to pivoting sports at 1 year in ACL-injured patients after a nonoperative versus operative treatment course

PubMed Central

Grindem, Hege; Eitzen, Ingrid; Moksnes, Håvard; Snyder-Mackler, Lynn; Risberg, May Arna

2013-01-01

Background The wish to return to level I pivoting sports is a major indication of ACL-reconstruction. Patients usually return to pivoting sports between 6 months and 1 year postoperatively, but no matched study has so far examined 1-year return to sport rates in nonoperatively and operatively treated ACL-injured patients. Hypothesis ACL-injured patients following a nonoperative treatment course, including recommendation of activity modification, will have lower return to pivoting sport rates than operatively treated patients 1 year after baseline testing/surgery, when matched by preinjury sports activity, age and sex. Study Design Pair-matched cohort study Methods Sixty-nine nonoperatively treated ACL-injured patients were pair-matched with 69 operatively treated patients (n=138), based on specific preinjury sport, age and sex. Nonoperatively treated patients were recommended not to return to level I sports. Patients were defined as nonoperatively or operatively treated according to their status at follow-up. The baseline and follow-up testing included registration of sports participation, KT-1000 measurements, 4 hop tests, and patient-reported outcome measures. McNemar’s test and paired t-tests or Wilcoxon’s test were used to compare outcomes of nonoperatively and operatively treated patients. Results No significant baseline differences were found. At 12.9±1.2 months (mean ± standard deviation) after baseline testing (nonoperative) and 12.7±1.2 months after surgery (operative), there was no significant difference in overall return to sport rates (nonoperative: 68.1 %, operative: 68.1 %, p=1.000), or in return to level I sport rates (nonoperative: 54.8 %, operative: 61.9 %, p=0.664). Nonoperatively treated patients who participated in level I sports prior to injury had a significantly lower return to sport rate (54.8 %) than nonoperatively treated patients who participated in level II sports (88.9 %, p=0.003). The nonoperatively treated patients had significantly higher knee joint laxity, but significantly better hop test limb symmetry indexes, KOS-ADLS scores, and IKDC 2000 scores. None of the functional differences were larger than the smallest detectable difference. Conclusion ACL-injured patients following a nonoperative treatment course, including recommendations of activity modifications, and operatively treated patients did not have significantly different rates of returning to pivoting sports after 1 year in this pair-matched cohort study. Clinicians should be aware of a potentially high level of noncompliance to recommendations of activity modifications. While these results show that it is possible for nonoperatively treated patients to return to sport after rehabilitation, future follow-ups are needed to examine whether these patients maintain sports participation over time, and what long-term consequences they may suffer regarding subsequent injuries and knee osteoarthritis. PMID:22962290

Bomb blast imaging: bringing order to chaos.

PubMed

Dick, E A; Ballard, M; Alwan-Walker, H; Kashef, E; Batrick, N; Hettiaratchy, S; Moran, C G

2018-06-01

Blast injuries are complex, severe, and outside of our everyday clinical practice, but every radiologist needs to understand them. By their nature, bomb blasts are unpredictable and affect multiple victims, yet require an immediate, coordinated, and whole-hearted response from all members of the clinical team, including all radiology staff. This article will help you gain the requisite expertise in blast imaging including recognising primary, secondary, and tertiary blast injuries. It will also help you understand the fundamental role that imaging plays during mass casualty attacks and how to avoid radiology becoming a bottleneck to the forward flow of severely injured patients as they are triaged and treated. Copyright © 2018. Published by Elsevier Ltd.

Poststroke Seizures and Epilepsy: Clinical Studies and Animal Models

PubMed Central

Kelly, Kevin M.

2002-01-01

Poststroke seizures and epilepsy have been described in numerous clinical studies for many years. Most studies are retrospective in design, include relatively small numbers of patients, have limited periods of follow-up, and report a diversity of findings. Well-designed clinical trials and population studies in the recent past addressed several critical clinical issues and generated important findings regarding the occurrence of poststroke seizures and epilepsy. In contrast, the pathophysiologic events of injured brain that establish poststroke epileptogenesis are not well understood, and animal modeling has had limited development. Reviews of several important clinical studies and animal models that hold promise for a better understanding of poststroke epileptogenesis are presented. PMID:15309107

Injury, disability and quality of life after the 2009 earthquake in Padang, Indonesia: a prospective cohort study of adult survivors

PubMed Central

Sudaryo, Mondastri K.; Besral; Endarti, Ajeng Tias; Rivany, Ronnie; Phalkey, Revati; Marx, Michael; Guha-Sapir, Debarati

2012-01-01

Background On 30 September 2009, a 7.6 magnitude earthquake severely hit the coast of Padang city in West Sumatra, Indonesia leaving about 1,117 people dead and injuring another 3,515. Health consequences such as physical injury, co-morbidity, disability and quality of life over time are seldom reported among survivors after earthquakes. Objectives To investigate the associations between injury, disability and quality of life amongst adult survivors in Padang city after the 2009 earthquake. Design/Methods A prospective cohort study was conducted to compare adult injured (184) and adult non-injured (93) subjects over a 6-month period. Data on physical injury, co-morbidities, disability and quality of life were collected through interviews and measured quantitatively in three phases, i.e. at baseline, end of 3 and 6 months. Results Disability scores were consistently and significantly higher among injured subjects compared to non-injured, even when adjusted for co-morbidities (i.e. acute symptoms and chronic diseases). The highest disability score amongst injured subjects was attributed to ‘feeling discomfort/pain’. Quality of life attribute (QLA) scores, were significantly lower amongst injured people as compared to those non-injured even when adjusted for co-morbidities. The lowest QLA item score amongst the injured was ‘pain, depression and anxiety’. Significant and consistent negative correlations were found between disability and QLA scores in both the injured and non-injured groups. Conclusion Physical injury is significantly correlated with both higher disability and lower quality of life, while disability has significant negative correlation with quality of life. The findings suggest that, through disability, injury may contribute to decreased quality of life. It is therefore recommended to promptly and adequately treat injuries after disasters to prevent any potential for disability and hence restore quality of life. PMID:22629236

Point-of-Care Ultrasound: A Trend in Health Care.

PubMed

Buerger, Anita M; Clark, Kevin R

2017-11-01

To discuss the current and growing use of point-of-care (POC) ultrasound in the management and care of patients. Several electronic research databases were searched to find articles that emphasized the use of POC ultrasound by health care providers who manage and treat critically ill or injured patients. Thirty-five relevant peer-reviewed journal articles were selected for this literature review. Common themes identified in the literature included the use of POC ultrasound in emergency medicine, military medicine, and remote care; comparison of POC ultrasound to other medical imaging modalities; investigation of the education and training required for nonimaging health care professionals who perform POC ultrasound in their practices; and discussion of the financial implications and limitations of POC ultrasound. POC ultrasound provides clinicians with real-time information to better manage and treat critically ill or injured patients in emergency medicine, military medicine, and remote care. In addition to providing immediate bedside diagnostic information, use of POC ultrasound has increased because of concerns regarding radiation protection. Finally, the expansion of POC ultrasound to other specialty areas requires nonimaging health care professionals to perform bedside ultrasound examinations and interpret the resulting images. Because POC ultrasound is user-dependent, adequate training is essential for all who perform and interpret the examinations. Research involving POC ultrasound will continue as innovations and confidence in ultrasound applications advance. Future research should continue to examine the broad use of POC ultrasound in patient care and management. ©2017 American Society of Radiologic Technologists.

Skateboards: Are they really perilous? A retrospective study from a district hospital

PubMed Central

Rethnam, Ulfin; Yesupalan, Rajam Sheeja; Sinha, Amit

2008-01-01

Background Skateboarding has been a popular sport among teenagers even with its attendant associated risks. The literature is packed with articles regarding the perils of skateboards. Is the skateboard as dangerous as has been portrayed? Methods This was a retrospective study conducted over a 5 year period. All skateboard related injuries seen in the Orthopaedic unit were identified and data collated on patient demographics, mechanism & location of injury, annual incidence, type of injury, treatment needed including hospitalisation. Results We encountered 50 patients with skateboard related injuries. Most patients were males and under the age of 15. The annual incidence has remained low at about 10. The upper limb was predominantly involved with most injuries being fractures. Most injuries occurred during summer. The commonest treatment modality was plaster immobilisation. The distal radius was the commonest bone to be fractured. There were no head & neck injuries, open fractures or injuries requiring surgical intervention. Conclusion Despite its negative image among the medical fraternity, the skateboard does not appear to be a dangerous sport with a low incidence and injuries encountered being not severe. Skateboarding should be restricted to supervised skateboard parks and skateboarders should wear protective gear. These measures would reduce the number of skateboarders injured in motor vehicle collisions, reduce the personal injuries among skateboarders, and reduce the number of pedestrians injured in collisions with skateboarders. PMID:18710512

[Intensive care within the context of military long-distance transport].

PubMed

Hossfeld, B; Rohowsky, B; Rödig, E; Lampl, L

2004-05-01

Due to the changed task spectrum of the German Federal Armed Forces with participation in international deployments for UN and NATO the concept of Aeromedical Evacuation (MedEvac) gained a new quality for the Air Force as well as for the Medical Corps. The transport of mostly severely injured or critically ill patients requires both, medical equipment which has to be permanently adapted to the national standard, and qualified intensive-care-personnel. At present, the aircrafts used for such deployments are four C-160 Transall, one CL-601 Challenger and two Airbus A310, which, if necessary, can be equipped with one or more intensive-care "patient transportation units" (PTU). Contrary to the two other aircrafts, the CL-601 Challenger is only equipped for the intensive-care transport of one individual patient. The PTU corresponds to the technical equipment of the intensive care unit of a level-1-trauma centre and ensures an intensive-care therapy on highest level also during longer transportation. The work with this equipment, the characteristics of the long-distance air transport and the special situation of the military deployment causes special demands on the qualifications of the assigned personnel. Primarily planned for the repatriation of injured or ill soldiers, in the mean time, this concept is also essential for the medevac of civilian victims after mass casualties worldwide.

Impairment of leaf photosynthesis after insect herbivory or mechanical injury on common milkweed, Asclepias syriaca.

PubMed

Delaney, K J; Haile, F J; Peterson, R K D; Higley, L G

2008-10-01

Insect herbivory has variable consequences on plant physiology, growth, and reproduction. In some plants, herbivory reduces photosynthetic rate (Pn) activity on remaining tissue of injured leaves. We sought to better understand the influence of leaf injury on Pn of common milkweed, Asclepias syriaca (Asclepiadaceae), leaves. Initially, we tested whether Pn reductions occurred after insect herbivory or mechanical injury. We also (1) examined the duration of photosynthetic recovery, (2) compared mechanical injury with insect herbivory, (3) studied the relationship between leaf Pn with leaf injury intensity, and (4) considered uninjured leaf compensatory Pn responses neighboring an injured leaf. Leaf Pn was significantly reduced on mechanically injured or insect-fed leaves in all reported experiments except one, so some factor(s) (cardiac glycoside induction, reproductive investment, and water stress) likely interacts with leaf injury to influence whether Pn impairment occurs. Milkweed tussock moth larval herbivory, Euchaetes egle L. (Arctiidae), impaired leaf Pn more severely than mechanical injury in one experiment. Duration of Pn impairment lasted > 5 d to indicate high leaf Pn sensitivity to injury, but Pn recovery occurred within 13 d in one experiment. The degree of Pn reduction was more severe from E. egle herbivory than similar levels of mechanical tissue removal. Negative linear relationships characterized leaf Pn with percentage tissue loss from single E. egle-fed leaves and mechanically injured leaves and suggested that the signal to trigger leaf Pn impairment on remaining tissue of an injured leaf was amplified by additional tissue loss. Finally, neighboring uninjured leaves to an E. egle-fed leaf had a small (approximately 10%) degree of compensatory Pn to partly offset tissue loss and injured leaf Pn impairment.

Distal axotomy enhances retrograde presynaptic excitability onto injured pyramidal neurons via trans-synaptic signaling.

PubMed

Nagendran, Tharkika; Larsen, Rylan S; Bigler, Rebecca L; Frost, Shawn B; Philpot, Benjamin D; Nudo, Randolph J; Taylor, Anne Marion

2017-09-20

Injury of CNS nerve tracts remodels circuitry through dendritic spine loss and hyper-excitability, thus influencing recovery. Due to the complexity of the CNS, a mechanistic understanding of injury-induced synaptic remodeling remains unclear. Using microfluidic chambers to separate and injure distal axons, we show that axotomy causes retrograde dendritic spine loss at directly injured pyramidal neurons followed by retrograde presynaptic hyper-excitability. These remodeling events require activity at the site of injury, axon-to-soma signaling, and transcription. Similarly, directly injured corticospinal neurons in vivo also exhibit a specific increase in spiking following axon injury. Axotomy-induced hyper-excitability of cultured neurons coincides with elimination of inhibitory inputs onto injured neurons, including those formed onto dendritic spines. Netrin-1 downregulation occurs following axon injury and exogenous netrin-1 applied after injury normalizes spine density, presynaptic excitability, and inhibitory inputs at injured neurons. Our findings show that intrinsic signaling within damaged neurons regulates synaptic remodeling and involves netrin-1 signaling.Spinal cord injury can induce synaptic reorganization and remodeling in the brain. Here the authors study how severed distal axons signal back to the cell body to induce hyperexcitability, loss of inhibition and enhanced presynaptic release through netrin-1.

Damage control: Concept and implementation.

PubMed

Malgras, B; Prunet, B; Lesaffre, X; Boddaert, G; Travers, S; Cungi, P-J; Hornez, E; Barbier, O; Lefort, H; Beaume, S; Bignand, M; Cotte, J; Esnault, P; Daban, J-L; Bordes, J; Meaudre, E; Tourtier, J-P; Gaujoux, S; Bonnet, S

2017-12-01

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Lethal obesity associated with sodium valproate in a brain-injured patient.

PubMed

Black, Deborah N; Althoff, Robert R; Daye, Kathleen; Pelletier, Corinne A

2005-06-01

A 34-year-old man developed posttraumatic epilepsy and a disinhibited orbitofrontal syndrome following severe head trauma at age 22. After an 11-year prison term marked by repeated impulsive aggression, he was transferred to a state psychiatric hospital. Replacement of phenytoin by valproic acid resulted in a 100-lb weight gain, exacerbation of sleep apnea, and right heart failure. Despite replacement of valproate with topiramate, he died of a cardiorespiratory arrest during a seizure. This case illustrates the potential risks associated with valproate therapy in the obese brain-damaged population.

Association between the Number of Injuries Sustained and 12-Month Disability Outcomes: Evidence from the Injury-VIBES Study

PubMed Central

Gabbe, Belinda J.; Simpson, Pam M.; Lyons, Ronan A.; Ameratunga, Shanthi; Harrison, James E.; Derrett, Sarah; Polinder, Suzanne; Davie, Gabrielle; Rivara, Frederick P.

2014-01-01

Objective To determine associations between the number of injuries sustained and three measures of disability 12-months post-injury for hospitalised patients. Methods Data from 27,840 adult (18+ years) participants, hospitalised for injury, were extracted for analysis from the Validating and Improving injury Burden Estimates (Injury-VIBES) Study. Modified Poisson and linear regression analyses were used to estimate relative risks and mean differences, respectively, for a range of outcomes (Glasgow Outcome Scale-Extended, GOS-E; EQ-5D and 12-item Short Form health survey physical and mental component summary scores, PCS-12 and MCS-12) according to the number of injuries sustained, adjusted for age, sex and contributing study. Findings More than half (54%) of patients had an injury to more than one ICD-10 body region and 62% had sustained more than one Global Burden of Disease injury type. The adjusted relative risk of a poor functional recovery (GOS-E<7) and of reporting problems on each of the items of the EQ-5D increased by 5–10% for each additional injury type, or body region, injured. Adjusted mean PCS-12 and MCS-12 scores worsened with each additional injury type, or body region, injured by 1.3–1.5 points and 0.5 points, respectively. Conclusions Consistent and strong relationships exist between the number of injury types and body regions injured and 12-month functional and health status outcomes. Existing composite measures of anatomical injury severity such as the NISS or ISS, which use up to three diagnoses only, may be insufficient for characterising or accounting for multiple injuries in disability studies. Future studies should consider the impact of multiple injuries to avoid under-estimation of injury burden. PMID:25501651

What is the role of brain mechanisms underlying arousal in recovery of motor function after structural brain injuries?

PubMed Central

Schiff, Nicholas D.

2013-01-01

Purpose of review Standard neurorehabilitation approaches have limited impact on motor recovery in patients with severe injuries. Consideration of the contributions of impaired arousal offers a novel approach to understand and enhance recovery. Recent findings Animal and human neuroimaging studies are elucidating the neuroanatomical bases of arousal and of arousal regulation, the process by which the cerebrum mobilizes resources. Studies of patients with disorders of consciousness have revealed that recovery of these processes is associated with marked improvements in motor performance. Recent studies have also demonstrated that patients with less severe brain injuries also have impaired arousal, manifesting as diminished sustained attention, fatigue and apathy. In these less severely injured patients it is difficult to connect disorders of arousal with motor recovery due to a lack of measures of arousal independent of motor function. Summary Arousal impairment is common after brain injury and likely plays a significant role in recovery of motor function. A more detailed understanding of this connection will help to develop new therapeutic strategies applicable for a wide range of patients. This requires new tools that continuously and objectively measure arousal in patients with brain injury, to correlate with detailed measures of motor performance and recovery. PMID:22002078

Ocular injuries sustained by survivors of the Oklahoma City bombing.

PubMed

Mines, M; Thach, A; Mallonee, S; Hildebrand, L; Shariat, S

2000-05-01

The purpose of this study is to provide a review of the ocular injuries sustained by survivors of the April 19, 1995, bombing of the Alfred P. Murrah Federal Building in Oklahoma City. Retrospective, noncomparative case series. The authors retrospectively evaluated data collected on all surviving persons receiving ocular injuries during the bombing and on all at-risk occupants of the federal building and four adjacent buildings. Injury data from survivors were collected from multiple sources to include hospital medical records, a physician survey, emergency medical services run reports, written survivor accounts, building occupant survey, telephone interviews, and mail surveys. The types of ocular injuries, the associated systemic injuries, and the location of the injured at the time of the blast were evaluated. Fifty-five (8%) of the 684 injured bombing survivors sustained an ocular injury. Persons injured in the Murrah building were more than three times more likely to sustain an ocular injury than other injured persons. Seventy-one percent of ocular injuries occurred within 300 feet of the point of detonation. The most common serious ocular injuries included lid/brow lacerations (20 patients, 23 eyes), open globe injuries (12 eyes), orbital fractures (6 eyes), and retinal detachment (5 eyes). A retained intraocular foreign body accounted for only two of the injuries (4%). Glass accounted for nearly two thirds of the ocular injuries. Blasts involving explosions inflict severe ocular injury, mostly as a result of secondary blast effects from glass, debris, etc. Eye injuries in bombings can probably be prevented by increasing the distance from and orientation away from windows (i.e., by facing desks away from windows). Use of such products as laminated glass, toughened window glazing, and Mylar curtains may reduce glass projectiles in the blast vicinity.

Treating work-injured patients in Europe. The Italian experience.

PubMed

Giannini, Sandro; Ceccarelli, Francesco

2002-06-01

According with to International Labor Office, the European Union gave the directions to improve the life of workers not only by regulating care, but also safety and return to work. Each European country is conforming to this. In Italy, INAIL, an independent body under the control of the Department of Labor and the Ministry of Health, covers the workers for occupational accidents and is funded by an insurance premium, obligatory paid by the employer. INAIL has the medicolegal task of assessment of injuries, supply of prostheses, physical therapy, and various compensation according to the degree of disability and the type of work. The specific treatment of the injured workers is carried out by the SSN, which is in charge of the outpatient treatment and hospitalization; however, INAIL contributes to the costs according to agreements made with each region. Although on one hand the injured worker is fully protected by the regulations, on the other hand, he or she is obliged to abide to the laws of security and to undergo treatment offered. In returning to work, certain factors are taken into account, such as percentage of disability, type of work, and discomfort that disability produces in carrying out work. Should the type or severity of the disability not allow complete return to work, support is given to assess and integrate the reduced working ability of the injured worker with regards to the workplace, even by adapting the latter to solve structural and environmental problems. INAIL, in accordance with the European Council, is committed to the total care of the worker and not only worker meaning "work force." In fact, health care and economic aid are integrated with the safety and rehabilitation of the worker and his or her return to family, social, and working life.

[Treatment management of a multiply injured patient with HIV infection].

PubMed

Mand, C; Giannadakis, K; Schnabel, M; Stiletto, R

2007-11-01

In orthopaedic surgery and emergency medicine, patients of the age groups with a HIV risk represent the largest part of the entire population. As necessary steps have to be taken immediately at the scene of an accident and in the emergency room, contact with HIV-positive blood is often unavoidable, so that there is an increased risk of transmission for doctors and personnel. Due to the immunological state, the HIV patient is exposed to considerable post-operative complications such as wound infection, pneumonia and even sepsis. With the case of a 35-year-old HIV-positive patient who was multiply injured in a traffic accident, we want to present an interesting example of the problems that occur in the treatment of this patient group.

Bone mass in the calcaneus after heavy loaded eccentric calf-muscle training in recreational athletes with chronic achilles tendinosis.

PubMed

Alfredson, H; Nordström, P; Pietilä, T; Lorentzon, R

1999-05-01

In an ongoing prospective study of 14 recreational athletes (12 males and 2 females, mean age 44.2 +/- 7.1 years) with unilateral chronic Achilles tendinosis, we investigated the effect of treatment with heavy-loaded eccentric calf-muscle training. Pain during activity (recorded on a VAS scale) and isokinetic concentric and eccentric calf-muscle strength (peak torque at 90 degrees /second and 225 degrees /second) on the injured and noninjured side were evaluated. In this group of patients, we examined areal bone mineral density (BMD) of the calcaneus after 9 months (range 6-14 months) of training. BMD of the injured side (subjected to heavy-loaded eccentric training) was compared with BMD of the noninjured side. Before onset of heavy-loaded eccentric training, all patients had Achilles tendon pain which prohibited running activity, and significantly lower concentric and eccentric plantar flexion peak torque on the injured compared with the noninjured side. The training program consisted of 12 weeks of daily, heavy-loaded, eccentric calf-muscle training; thereafter the training was continued for 2-3 days/week. The clinical results were excellent-all 14 patients were back at their preinjury level with full running activity at the 3 month follow-up. The concentric and eccentric plantar flexion peak torque had increased significantly and did not significantly differ from the noninjured side at the 3 and 9 month follow-up. There were no significant side-to-side differences in BMD of the calcaneus. There was no significant relationship between BMD of the calcaneus and calf-muscle strength. As a comparison group, we used 10 recreational athletes (5 males and 5 females) mean age 40.9 years (range 26-55 years), who were selected for surgical treatment of chronic Achilles tendinosis localized at the 2-6 cm level. Their duration of symptoms and severity of disease were the same as in the experimental group. There were no significant side-to-side differences in BMD of the calcaneus preoperatively, but 12 months postoperatively BMD of the calcaneus was 16.4% lower at the injured side compared with the noninjured side. Heavy-loaded eccentric calf-muscle training resulted in a fast recovery in all patients, equaled the side-to-side differences in muscle strength, and was not associated with side-to-side differences in BMD of the calcaneus. In this group of middle-aged recreational athletes, BMD of the calcaneus was not related to calf-muscle strength.

Immunological control of methicillin-resistant Staphylococcus aureus (MRSA) infection in an immunodeficient murine model of thermal injuries

PubMed Central

Katakura, T; Yoshida, T; Kobayashi, M; Herndon, D N; Suzuki, F

2005-01-01

Staphylococcus aureus, especially methicillin-resistant S. aureus (MRSA), is a major cause of sepsis in patients who are immunosuppressed by their burns. In this study, an immunological regulation of MRSA infection was attempted in a mouse model of thermal injury. SCIDbg mice were resistant to MRSA infection, while SCIDbgMN mice (SCIDbg mice depleted of neutrophils and macrophages (Mφ)) were susceptible to the same infection. Also, thermally injured SCIDbg mice were shown to be susceptible to MRSA infection. On the other hand, the resistance of SCIDbgMN mice to the infection was completely recovered after an inoculation with Mφ from normal mice. However, anti-MRSA resistance was not shown in SCIDbgMN mice inoculated with Mφ from thermally injured mice. Mφ from MRSA-infected thermally injured mice were identified as alternatively activated Mφ, and Mφ from MRSA-infected unburned mice were characterized as classically activated Mφ. Mφ from thermally injured SCIDbg mice previously treated with 2-carboxyethylgermanium sesquioxide (Ge-132) protected SCIDbgMN mice against MRSA infection. Ge-132 has been described as an inhibitor of alternatively activated Mφ generation. These results suggest that MRSA infection in thermally injured patients is controlled immunologically through the induction of anti-MRSA effector cells and elimination of burn-associated alternatively activated Mφ, which are cells that inhibit the generation of classically activated Mφ. PMID:16297152

Audit filters for improving processes of care and clinical outcomes in trauma systems.

PubMed

Evans, Christopher; Howes, Daniel; Pickett, William; Dagnone, Luigi

2009-10-07

Traumatic injuries represent a considerable public health burden with significant personal and societal costs. The care of the severely injured patient in a trauma system progresses along a continuum that includes numerous interventions being provided by a multidisciplinary group of healthcare personnel. Despite the recent emphasis on quality of care in medicine, there has been little research to direct trauma clinicians and administrators on how optimally to monitor and improve upon the quality of care delivered within a trauma system. Audit filters are one mechanism for improving quality of care and are defined as specific clinical processes or outcomes of care that, when they occur, represent unfavorable deviations from an established norm and which prompt review and feedback. Although audit filters are widely utilized for performance improvement in trauma systems they have not been subjected to systematic review of their effectiveness. To determine the effectiveness of using audit filters for improving processes of care and clinical outcomes in trauma systems. Our search strategy included an electronic search of the Cochrane Injuries Group Specialized Register, the Cochrane EPOC Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 4), MEDLINE, PubMed, EMBASE, CINAHL, and ISI Web of Science: (SCI-EXPANDED and CPCI-S). We handsearched the Journal of Trauma, Injury, Annals of Emergency Medicine, Academic Emergency Medicine, and Injury Prevention. We searched two clinical trial registries: 1) The World Health Organization International Clinical Trials Registry Platform and, 2) Clinical Trials.gov. We also contacted content experts for further articles. The most recent electronic search was completed in December 2008 and the handsearch was completed up to February 2009. We searched for randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time series studies that used audit filters as an intervention for improving processes of care, morbidity, or mortality for severely injured patients. Two authors independently screened the search results, applied inclusion criteria, and extracted data. There were no studies identified that met the inclusion criteria for this review. We were unable to identify any studies of sufficient methodological quality to draw conclusions regarding the effectiveness of audit filters as a performance improvement intervention in trauma systems. Future research using rigorous study designs should focus on the relative effectiveness of audit filters in comparison to alternative quality improvement strategies at improving processes of care, functional outcomes, and mortality for injured patients.

Validation of fluorescent-labeled microspheres for measurement of relative blood flow in severely injured lungs

NASA Technical Reports Server (NTRS)

Hubler, M.; Souders, J. E.; Shade, E. D.; Hlastala, M. P.; Polissar, N. L.; Glenny, R. W.

1999-01-01

The aim of the study was to validate a nonradioactive method for relative blood flow measurements in severely injured lungs that avoids labor-intensive tissue processing. The use of fluorescent-labeled microspheres was compared with the standard radiolabeled-microsphere method. In seven sheep, lung injury was established by using oleic acid. Five pairs of radio- and fluorescent-labeled microspheres were injected before and after established lung injury. Across all animals, 175 pieces were selected randomly. The radioactivity of each piece was determined by using a scintillation counter. The fluorescent dye was extracted from each piece with a solvent without digestion or filtering. The fluorescence was determined with an automated fluorescent spectrophotometer. Perfusion was calculated for each piece from both the radioactivity and fluorescence and volume normalized. Correlations between flow determined by the two methods were in the range from 0.987 +/- 0.007 (SD) to 0.991 +/- 0.002 (SD) after 9 days of soaking. Thus the fluorescent microsphere technique is a valuable tool for investigating regional perfusion in severely injured lungs and can replace radioactivity.

Cognitive and behavioural post-traumatic impairments: what is the specificity of a brain injury ? A study within the ESPARR cohort.

PubMed

Nash, S; Luauté, J; Bar, J Y; Sancho, P O; Hours, M; Chossegros, L; Tournier, C; Charnay, P; Mazaux, J M; Boisson, D

2014-12-01

The variety and extent of impairments occurring after traumatic brain injury vary according to the nature and severity of the lesions. In order to better understand their interactions and long-term outcome, we have studied and compared the cognitive and neurobehavioral profile one year post onset of patients with and without traumatic brain injury in a cohort of motor vehicle accident victims. The study population is composed of 207 seriously injured persons from the ESPARR cohort. This cohort, which has been followed up in time, consists in 1168 motor vehicle accident victims (aged 16 years or more) with injuries with all degrees of severity. Inclusion criteria were: living in Rhone county, victim of a traffic accident having involved at least one wheel-conducted vehicle and having occurred in Rhone county, alive at the time of arrival in hospital and having presented in one of the different ER facilities of the county. The cohort's representativeness regarding social and geographic criteria and the specificities of the accidents were ensured by the specific targeting of recruitment. Deficits and impairments were assessed one year after the accident using the Neurobehavioral Rating Scale - Revised and the Trail-Making Test. Within our seriously injured group, based on the Glasgow Score, the presence of neurological deficits, aggravation of neurological condition in the first 72hours and/or abnormal cerebral imaging, we identified three categories: (i) moderate/severe traumatic brain injury (n=48), (ii) mild traumatic brain injury (n=89), and (iii) severely injured but without traumatic brain injury (n=70). The most frequently observed symptoms were anxiety, irritability, memory and attention impairments, depressive mood and emotional lability. While depressive mood and irritability were observed with similar frequency in all three groups, memory and attention impairments, anxiety and reduced initiative were more specific to traumatic brain injury whereas executive disorders were associated with moderate/severe traumatic brain injury. The presence and the initial severity of a traumatic brain injury condition the nature and frequency of residual effects after one year. Some impairments such as irritability, which is generally associated with traumatic brain injury, do not appear to be specific to this population, nor does depressive mood. Substantial interactions between cognitive, affective and neurobehavioral disorders have been highlighted. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Hepatitis A complicated with acute renal failure and high hepatocyte growth factor: A case report.

PubMed

Oe, Shinji; Shibata, Michihiko; Miyagawa, Koichiro; Honma, Yuichi; Hiura, Masaaki; Abe, Shintaro; Harada, Masaru

2015-08-28

A 58-year-old man was admitted to our hospital. Laboratory data showed severe liver injury and that the patient was positive for immunoglobulin M anti-hepatitis A virus (HAV) antibodies. He was also complicated with severe renal dysfunction and had an extremely high level of serum hepatocyte growth factor (HGF). Therefore, he was diagnosed with severe acute liver failure with acute renal failure (ARF) caused by HAV infection. Prognosis was expected to be poor because of complications by ARF and high serum HGF. However, liver and renal functions both improved rapidly without intensive treatment, and he was subsequently discharged from our hospital on the 21(st) hospital day. Although complication with ARF and high levels of serum HGF are both important factors predicting poor prognosis in acute liver failure patients, the present case achieved a favorable outcome. Endogenous HGF might play an important role as a regenerative effector in injured livers and kidneys.

Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011.

PubMed

Neblett Fanfair, Robyn; Benedict, Kaitlin; Bos, John; Bennett, Sarah D; Lo, Yi-Chun; Adebanjo, Tolu; Etienne, Kizee; Deak, Eszter; Derado, Gordana; Shieh, Wun-Ju; Drew, Clifton; Zaki, Sherif; Sugerman, David; Gade, Lalitha; Thompson, Elizabeth H; Sutton, Deanna A; Engelthaler, David M; Schupp, James M; Brandt, Mary E; Harris, Julie R; Lockhart, Shawn R; Turabelidze, George; Park, Benjamin J

2012-12-06

Mucormycosis is a fungal infection caused by environmentally acquired molds. We investigated a cluster of cases of cutaneous mucormycosis among persons injured during the May 22, 2011, tornado in Joplin, Missouri. We defined a case as a soft-tissue infection in a person injured during the tornado, with evidence of a mucormycete on culture or immunohistochemical testing plus DNA sequencing. We conducted a case-control study by reviewing medical records and conducting interviews with case patients and hospitalized controls. DNA sequencing and whole-genome sequencing were performed on clinical specimens to identify species and assess strain-level differences, respectively. A total of 13 case patients were identified, 5 of whom (38%) died. The patients had a median of 5 wounds (range, 1 to 7); 11 patients (85%) had at least one fracture, 9 (69%) had blunt trauma, and 5 (38%) had penetrating trauma. All case patients had been located in the zone that sustained the most severe damage during the tornado. On multivariate analysis, infection was associated with penetrating trauma (adjusted odds ratio for case patients vs. controls, 8.8; 95% confidence interval [CI], 1.1 to 69.2) and an increased number of wounds (adjusted odds ratio, 2.0 for each additional wound; 95% CI, 1.2 to 3.2). Sequencing of the D1-D2 region of the 28S ribosomal DNA yielded Apophysomyces trapeziformis in all 13 case patients. Whole-genome sequencing showed that the apophysomyces isolates were four separate strains. We report a cluster of cases of cutaneous mucormycosis among Joplin tornado survivors that were associated with substantial morbidity and mortality. Increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted.

Resistance Patterns and Clinical Significance of Candida Colonization and Infection in Combat-Related Injured Patients From Iraq and Afghanistan

PubMed Central

Blyth, Dana M.; Mende, Katrin; Weintrob, Amy C.; Beckius, Miriam L.; Zera, Wendy C.; Bradley, William; Lu, Dan; Tribble, David R.; Murray, Clinton K.

2014-01-01

Background  Penetrating wounds with environmental contamination are associated with a range of infectious complications, including fungus. This is the first study to examine the epidemiology, resistance patterns, and outcomes of Candida infections and colonization in United States military patients injured in Iraq and Afghanistan. Methods  Clinical information associated with initial unique and serial Candida isolates collected from patients (June 2009–October 2013) through the Trauma Infectious Disease Outcomes Study (TIDOS) was evaluated. Susceptibilities were performed using Sensititre YeastOne (YO-9) plates and interpreted by Clinical Laboratory and Standards Institute (CLSI) and adjusted-European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. Results  The analysis included 127 patients with 131 unique Candida isolates, of which 102 were Candida albicans and 29 non-albicans Candida spp. Overall, 99% of patients were male with a median age of 23 and an injury severity score of 22. Injuries were primarily due to blasts (77%) and sustained among personnel serving in Afghanistan (89%). There was a median of 7 days from injury to Candida isolation, and 74 isolates were associated with infection. In the multivariate analysis, non-albicans Candida spp were associated with prior antifungal exposure, blood isolates, and wound isolates (P < .01). Nonsusceptibility by CLSI and EUCAST criteria was associated with non-albicans Candida spp (P < .05). Patients with Candida isolation had a 7.1% mortality rate, compared with 1.4% from the overall TIDOS population. Conclusions  Candida isolation from patients with penetrating war injuries may identify a population at higher risk for death. Prospective studies are needed to determine whether targeted antifungals and surgical management will affect this mortality rate. PMID:25734177

Is policy well-targeted to remedy financial strain among caregivers of severely injured U.S. service members?

PubMed

Van Houtven, Courtney Harold; Friedemann-Sánchez, Greta; Clothier, Barbara; Levison, Deborah; Taylor, Brent C; Jensen, Agnes C; Phelan, Sean M; Griffin, Joan M

U.S. military service members have sustained severe injuries since the start of the wars in Iraq and Afghanistan. This paper aims to determine the factors associated with financial strain of their caregivers and establish whether recent federal legislation targets caregivers experiencing financial strain. In our national survey, 62.3% of caregivers depleted assets and/or accumulated debt, and 41% of working caregivers left the labor force. If a severely injured veteran needed intensive help, the primary caregiver faced odds 4.63 times higher of leaving the labor force, and used $27,576 more in assets and/or accumulated debt compared to caregivers of veterans needing little or no assistance.

Protocol compliance and time management in blunt trauma resuscitation.

PubMed

Spanjersberg, W R; Bergs, E A; Mushkudiani, N; Klimek, M; Schipper, I B

2009-01-01

To study advanced trauma life support (ATLS) protocol adherence prospectively in trauma resuscitation and to analyse time management of daily multidisciplinary trauma resuscitation at a level 1 trauma centre, for both moderately and severely injured patients. All victims of severe blunt trauma were consecutively included. Patients with a revised trauma score (RTS) of 12 were resuscitated by a "minor trauma" team and patients with an RTS of less than 12 were resuscitated by a "severe trauma" team. Digital video recordings were used to analyse protocol compliance and time management during initial assessment. From 1 May to 1 September 2003, 193 resuscitations were included. The "minor trauma" team assessed 119 patients, with a mean injury severity score (ISS) of 7 (range 1-45). Overall protocol compliance was 42%, ranging from 0% for thoracic percussion to 93% for thoracic auscultation. The median resuscitation time was 45.9 minutes (range 39.7-55.9). The "severe team" assessed 74 patients, with a mean ISS of 22 (range 1-59). Overall protocol compliance was 53%, ranging from 4% for thoracic percussion to 95% for thoracic auscultation. Resuscitation took 34.8 minutes median (range 21.6-44.1). Results showed the current trauma resuscitation to be ATLS-like, with sometimes very low protocol compliance rates. Timing of secondary survey and radiology and thus time efficiency remains a challenge in all trauma patients. To assess the effect of trauma resuscitation protocols on outcome, protocol adherence needs to be improved.

[Ecological assessment of executive functions in a patient with acquired brain injury].

PubMed

Chevignard, M; Taillefer, C; Picq, C; Pradat-Diehl, P

2008-03-01

Dysexecutive syndrome is one of the most frequent sequel of severe traumatic brain injury. It causes severe disabilities and it is incompletely assessed by the classical "paper and pencil" neuropsychological tests. We developed an ecological assessment conducted in a naturalistic situation, consisting of a cooking task, and we described a classification of errors. This assessment is very sensitive, even to a mild dysexecutive syndrome. To describe the disabilities in activities of daily living of a traumatic brain-injured patient and to demonstrate the sensitivity of an ill-structured ecological assessment. We report a single case study illustrating how the ecological assessment by the cooking task helped better understand and characterize the patient's disabilities. The patient presented severe disabilities in daily life activities, which were well described by his family. His cognitive disorders were mild in the cognitive tests, even those supposed to be more ecological, such as the Six Elements Task or script generation. He exhibited very severe disorders in the cooking task, with a very high number of errors. Moreover, duration of the cooking task was very long; he did not achieve the goal and exhibited dangerous behaviour. The cooking task involves abilities to deal with multitasking, which particularly involve executive functions. The most severe disorders were observed during the patient's interaction with the environment while conducting a complex goal-directed action plan, indicating control disorders. This type of naturalistic assessment provides very useful information to help patients organise their familial, social or professional reintegration.

Drawing the Curtain Back on Injured Commercial Bicyclists

PubMed Central

Heyer, Jessica H.; Sethi, Monica; Wall, Stephen P.; Ayoung-Chee, Patricia; Slaughter, Dekeya; Jacko, Sally; DiMaggio, Charles J.

2015-01-01

Objectives. We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City’s (NYC’s) central business district. Methods. Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses. Results. Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723). Conclusions. Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs. PMID:26270281

Analysis of foot structure in athletes sustaining proximal fifth metatarsal stress fracture.

PubMed

Hetsroni, Iftach; Nyska, Meir; Ben-Sira, David; Mann, Gideon; Segal, Ofer; Maoz, Guy; Ayalon, Moshe

2010-03-01

In the past, several studies provided anecdotal descriptions of high-arched feet in individuals sustaining proximal fifth metatarsal stress fractures. This relationship has never been supported by scientific evidence. Our objective was to examine whether athletes who sustained this injury had an exceptional static foot structure or dynamic loading pattern. Ten injured professional soccer players who regained full professional activity following a unilateral proximal fifth metatarsal stress fracture and ten control soccer players were examined. Independent variables included static evaluation of foot and arch structure, followed by dynamic plantar foot pressure evaluation. Each variable was compared between injured, contra-lateral uninjured, and control feet. Static measurements of foot and arch structure did not reveal differences among the groups. However, plantar pressure evaluation revealed relative unloading of the fourth metatarsal in injured and uninjured limbs of injured athletes compared with control, while the fifth metatarsal revealed pressure reduction only in the injured limbs of injured athletes. Athletes who sustained proximal fifth metatarsal stress fracture were not characterized by an exceptional static foot structure. Dynamically, lateral metatarsal unloading during stance may either play a role in the pathogenesis of the injury, or alternately represent an adaptive process. Footwear fabrication for previously injured athletes should not categorically address cushioning properties designed for high-arch feet, but rather focus on individual dynamic evaluation of forefoot loading, with less attention applied to static foot and arch characteristics.

The effect of contextual auditory stimuli on virtual spatial navigation in patients with focal hemispheric lesions.

PubMed

Cogné, Mélanie; Knebel, Jean-François; Klinger, Evelyne; Bindschaedler, Claire; Rapin, Pierre-André; Joseph, Pierre-Alain; Clarke, Stephanie

2018-01-01

Topographical disorientation is a frequent deficit among patients suffering from brain injury. Spatial navigation can be explored in this population using virtual reality environments, even in the presence of motor or sensory disorders. Furthermore, the positive or negative impact of specific stimuli can be investigated. We studied how auditory stimuli influence the performance of brain-injured patients in a navigational task, using the Virtual Action Planning-Supermarket (VAP-S) with the addition of contextual ("sonar effect" and "name of product") and non-contextual ("periodic randomised noises") auditory stimuli. The study included 22 patients with a first unilateral hemispheric brain lesion and 17 healthy age-matched control subjects. After a software familiarisation, all subjects were tested without auditory stimuli, with a sonar effect or periodic random sounds in a random order, and with the stimulus "name of product". Contextual auditory stimuli improved patient performance more than control group performance. Contextual stimuli benefited most patients with severe executive dysfunction or with severe unilateral neglect. These results indicate that contextual auditory stimuli are useful in the assessment of navigational abilities in brain-damaged patients and that they should be used in rehabilitation paradigms.

A field evaluation of real-life motor vehicle accidents: presence of unrestrained objects and their association with distribution and severity of patient injuries.

PubMed

Staff, Trine; Eken, Torsten; Hansen, Trond Boye; Steen, Petter Andreas; Søvik, Signe

2012-03-01

Moving objects may pose an added threat to car occupants in motor vehicle accidents (MVAs). However, to our knowledge, there have only been two case studies published on the subject. For the present study, accident reports and photo documentation from MVAs were collected on-scene by dedicated paramedics. Emergency medical service personnel on-scene were interviewed as necessary. Potentially harmful unrestrained objects in the involved motor vehicles (MVs) were identified and categorised by type, weight and hardness. Seatback offset by unrestrained objects was noted. The patient injury distribution (Abbreviated Injury Scale (AIS) body regions) and severity (AIS severity scores and New Injury Severity Score (NISS) scores) were retrospectively determined from hospital and autopsy records, and their potential relationship to unrestrained objects was explored. A total of 190 accidents involving 338 MVs and 618 individuals were included. In total, 327 individuals (53%) were injured, and 61 (10%) died. 37 of 61 were not autopsied. The mean NISS was 17 (median 8, interquartile range (IQR) 1-27). Unrestrained objects were reported for 133 motor vehicles (39%) involving 293 individuals. 35% of the unrestrained objects found in the passenger compartment weighed >2 kg. In the boot, 32% of objects weighed >20 kg. Seatback offset associated with unrestrained objects was found for 45 individuals (15%). Unrestrained objects originally located in the boot (heavy luggage, groceries and tyres were the most frequently reported) had moved into the passenger compartment on impact in 27 cases, 24 of which were associated with seatback offset. An in-depth analysis was performed on 24 patients whose injuries were highly likely to be associated with unrestrained objects, as indicated by accident reports and medical documentation. Nineteen (79%) were involved in frontal collisions, and 12 (50%) died on-scene. The mean NISS was 51.7 (median 51, IQR 27-75) in the 17 (71%) patients with seatback offset and 37.2 (median 41, IQR 22.5-50) in the 7 (29%) without seatback offset. Seatback offset was associated with more severe head and thoracic injuries and an increased incidence of abdominal and pelvic injuries. Patients injured by unrestrained objects while sitting in unharmed car seats predominantly suffered head, cervical spine and thoracic injuries. Our results indicate a need for public information campaigns. The development of car backseats that can better sustain hits from heavy objects in the cargo boot is an important area for the motor vehicle production industry to explore. Copyright © 2011 Elsevier Ltd. All rights reserved.

High-velocity gunshot wounds to the head: analysis of 135 patients.

PubMed

Bakir, Abdurrahman; Temiz, Cüneyt; Umur, Sukru; Aydin, Varol; Torun, Fuat

2005-06-01

Head injuries due to high-velocity missiles and shrapnel as a result of military conflicts have become a very important cause of death or severe neurological deficits. Military-type missiles have high velocities and transfer higher amounts of energy to neural tissue, compared to civil-type missiles. This physical phenomenon also causes greater neural tissue destruction. Shrapnel particles derive from blasts and cause less severe injury because of the irregular particle shape and low energy transmission. This study analyzed 135 patients with head trauma, 80 patients (59%) injured by missiles and 55 patients (41%) by shrapnel. Glasgow Coma Scale (GCS) scores at admission were 3 to 7 in 69 patients, 8 to 10 in 29 patients, and 11 to 15 in 37 patients. The most common anatomical localizations were the right frontoparietal region in 42 patients and the left frontoparietal region in 40 patients. One hundred patients (74%) were operated on immediately and 35 patients (26%) were treated conservatively in the intensive care unit. Ten of the 135 patients died (7.4%), seven from missile injury and three from shrapnel injury. In this study, we found that high mortality was associated with low GCS score at admission, presence of multilobar or skull base injuries, and involvement of ventricles. Early and aggressive surgical intervention decreased the mortality.

Toward an Attention-Based Diagnostic Tool for Patients With Locked-in Syndrome.

PubMed

Lesenfants, Damien; Habbal, Dina; Chatelle, Camille; Soddu, Andrea; Laureys, Steven; Noirhomme, Quentin

2018-03-01

Electroencephalography (EEG) has been proposed as a supplemental tool for reducing clinical misdiagnosis in severely brain-injured populations helping to distinguish conscious from unconscious patients. We studied the use of spectral entropy as a measure of focal attention in order to develop a motor-independent, portable, and objective diagnostic tool for patients with locked-in syndrome (LIS), answering the issues of accuracy and training requirement. Data from 20 healthy volunteers, 6 LIS patients, and 10 patients with a vegetative state/unresponsive wakefulness syndrome (VS/UWS) were included. Spectral entropy was computed during a gaze-independent 2-class (attention vs rest) paradigm, and compared with EEG rhythms (delta, theta, alpha, and beta) classification. Spectral entropy classification during the attention-rest paradigm showed 93% and 91% accuracy in healthy volunteers and LIS patients respectively. VS/UWS patients were at chance level. EEG rhythms classification reached a lower accuracy than spectral entropy. Resting-state EEG spectral entropy could not distinguish individual VS/UWS patients from LIS patients. The present study provides evidence that an EEG-based measure of attention could detect command-following in patients with severe motor disabilities. The entropy system could detect a response to command in all healthy subjects and LIS patients, while none of the VS/UWS patients showed a response to command using this system.

Asymmetry in gait pattern following bicondylar tibial plateau fractures-A prospective one-year cohort study.

PubMed

Elsoe, Rasmus; Larsen, Peter

2017-07-01

Despite the high number of studies evaluating outcomes following tibial plateau fractures, the literature lacks studies including the objective assessment of gait pattern. The purpose of the present study was to evaluate asymmetry in gait patterns at 12 months after frame removal following ring fixation of a tibial plateau fracture. The study design was a prospective cohort study. The primary outcome measurement was the gait patterns 12 months after frame removal measured with a pressure-sensitive mat. The mat registers footprints and present gait speed, cadence, as well as temporal and spatial parameters of the gait cycle. Gait patterns were compared to a healthy reference population. Twenty-three patients were included with a mean age of 54.4 years (32-78 years). Patients presented with a shorter step-length of the injured leg compared to the non-injured leg (asymmetry of 11.3%). Analysis of single-support showed shorter support time of the injured leg compared to the non-injured leg (asymmetry of 8.7%). Moreover, analysis of swing-time showed increased swing-time of the injured leg (asymmetry of 8.9%). Compared to a healthy reference population, increased asymmetry in all gait patterns was observed. The association between asymmetry and health-related quality of life (HRQOL) showed moderate associations (single-support: R=0.50, P=0.03; step-length: R=0.43, P=0.07; swing-time: R=0.46, P=0.05). Compared to a healthy reference population, gait asymmetry is common 12 months after frame removal in patients treated with external ring fixation following a tibial plateau fracture of the tibia. Copyright © 2017 Elsevier Ltd. All rights reserved.

[Posttraumatic retroperitoneal hematoma in injured persons with severe closed multiple and combined abdominal trauma].

PubMed

Rylov, A I; Kravets, N S

2001-01-01

The experience of treatment of 69 injured persons with posttraumatic retroperitoneal hematoma suffering severe multiple combined abdominal trauma was analyzed. Application of the classification proposed permits to formulate diagnosis and to choose the tactic of treatment correctly. The intraoperative tactics algorithm was elaborated. It promotes the correct analysis of intraoperative findings and reduction of the diagnostic mistakes frequency as well. In the presence of vast defect, making impossible to suture over the parietal peritoneum, extraperitonization using cerebral dura mater was done. Operative intervention was concluded by drainage with subsequent laserotherapy.

Narrating the self-injured body

PubMed Central

Chandler, Amy

2014-01-01

Illness narratives have traditionally been used as a conceptual tool for exploring experiences of chronic illness or disease. In this paper, I suggest that Frank's typology of illness narratives (chaos, restitution and quest) also offers an illuminating approach to analysing accounts of self-injury, demonstrating the diverse ways in which self-injury is practiced, experienced and narrated. Drawing on 24 narrative interviews with 12 people who had self-injured, I focus on participants’ accounts of their self-injured bodies. The approach is phenomenological, and concerned with talk about the experience of living with and in a body that has been marked by self-injury. Thus, the act of self-injury is not the sole focus, and particular attention is paid to accounts of the bodily aftermath: scars, marks and wounds. Scars left by self-injury can be seen as communicative, and the analysis developed here demonstrates some of the various ways that these marks may be read. Attending to these diverse narratives can contribute to the provision of compassionate, non-judgemental care for patients who have self-injured. Further, highlighting the existence of different ways of narrating the self-injured body may offer an optimistic resource for people who have self-injured. PMID:24812335

Major Transcriptome Changes Accompany the Growth of Pseudomonas aeruginosa in Blood from Patients with Severe Thermal Injuries

PubMed Central

Kruczek, Cassandra; Kottapalli, Kameswara Rao; Dissanaike, Sharmila; Dzvova, Nyaradzo; Griswold, John A.; Colmer-Hamood, Jane A.; Hamood, Abdul N.

2016-01-01

Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen that causes serious infections in immunocompromised hosts including severely burned patients. After multiplying within the burn wound, P. aeruginosa translocate into the bloodstream causing bacterial sepsis frequently leading to organ dysfunction and septic shock. Although the pathogenesis of P. aeruginosa infection of thermally-injured wounds has been extensively analyzed, little is known regarding the ability of P. aeruginosa to adapt and survive within the blood of severely burned patients during systemic infection. To identify such adaptations, transcriptome analyses (RNA-seq) were conducted on P. aeruginosa strain PA14 that was grown in whole blood from a healthy volunteer or three severely burned patients. Compared with growth in blood from healthy volunteers, growth of PA14 in the blood from severely burned patients significantly altered the expression of 2596 genes, with expression of 1060 genes enhanced, while that of 1536 genes was reduced. Genes whose expression was significantly reduced included genes related to quorum sensing, quorum sensing-controlled virulence factors and transport of heme, phosphate, and phosphonate. Genes whose expression was significantly enhanced were related to the type III secretion system, the pyochelin iron-acquisition system, flagellum synthesis, and pyocyanin production. We confirmed changes in expression of many of these genes using qRT-PCR. Although severe burns altered the levels of different blood components in each patient, the growth of PA14 in their blood produced similar changes in the expression of each gene. These results suggest that, in response to changes in the blood of severely burned patients and as part of its survival strategy, P. aeruginosa enhances the expression of certain virulence genes and reduces the expression of others. PMID:26933952

Combat-related acetabular fractures: Outcomes of open versus closed injuries.

PubMed

Purcell, Richard L; Donohue, Michael A; Saxena, Sameer K; Gordon, Wade T; Lewandowski, Louis L

2018-02-01

Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures. Published by Elsevier Ltd.

Effect of a fish oil and arginine-fortified diet in thermally injured patients.

PubMed

Wibbenmeyer, Lucy A; Mitchell, Melanie A; Newel, Ingrid M; Faucher, Lee D; Amelon, Margery J; Ruffin, Timothy O; Lewis, Robert D; Latenser, Barbara A; Kealey, Patrick G

2006-01-01

Burn injury induces a hypercatabolic inflammatory state, predisposing burn patients to malnutrition, poor wound healing, and infectious complications. We conducted this study to determine what effect a diet fortified with fish oil and arginine (FAD) would have on wound healing in a thermally injured population. Twenty-three thermally injured patients were enrolled in this randomized double blind enteral feeding study from July 2002 to August 2004. All study patients received isonitrogenous enteral intragastric feeding within 48 hours of admission. Patients were randomized to our standard diet (STD, ProBalance with Promix, Probalance from Nestlé, Glendale, CA; ProMix R.D., Navaco Laboratories, Phoenix, AZ) or a diet fortified with fish oil and arginine (FAD, Crucial, Nestlé Nutrition Glendale, CA) Diets were advanced as tolerated to meet 100% of estimated needs. The primary endpoint of the study was time to heal the first donor site. There were no statistical differences between the study groups with respect to baseline characteristics. Both diets were well tolerated, and there were no differences in the daily total kilocalories or protein intake per kilogram between the two diet groups throughout the study. Although nonsignificant, the patients in the FAD group showed a slightly faster healing time than those in the STD group (10.8 +/- 2.7 days vs 12.3 +/- 5.2 days, respectively). This trend was further accelerated when those with body surface area burns less than 30% were examined (patients with body surface area burns <30% in the FAD healed in 9.0 +/- 1.7 vs corresponding patients in the standard group who healed in 12.2 +/- 6.2, P = .63). Patients in the FAD group trended to more infections and more adverse complications. The adverse complications were predominantly associated with inhalation injuries. The role of fortified enteral diets in the outcomes of thermally injured patients deserves further study. Such a future study should be conducted in a multicenter trial and involve inhalation injury stratification systems to accurately score and randomize patients for inhalation injury. Finally, the frequency and pattern of infections in patients receiving fortified enteral diets deserves further evaluation.

The effect of brain injury on the inflammatory response following severe trauma.

PubMed

Lustenberger, T; Kern, M; Relja, B; Wutzler, S; Störmann, P; Marzi, I

2016-03-01

The inflammatory response is an important part of the pathophysiology of severe injury and, in particular, of severe traumatic brain injury (TBI). This study evaluates the inflammatory course following major trauma and focuses on the effect of severe TBI on inflammatory markers. This was a retrospective analysis of prospectively collected data in 123 severely injured (ISS ≥16) trauma patients. The study cohort was divided into patients with isolated TBI (Head AIS ≥3, all other AIS <3), polytraumatized patients with severe TBI (Head AIS ≥3; AIS of other body area ≥3; Polytrauma+TBI) and polytraumatized patients without TBI (Head AIS <3; Polytrauma). Levels of inflammatory markers (Interleukin-6 [IL-6], C-reactive Protein [CRP], leukocytes) measured upon arrival and through hospital days 1-3 were compared between the groups. On admission and through hospital day 3, IL-6 levels were significantly different between the 3 groups (admission: isolated TBI vs. Polytrauma+TBI vs. Polytrauma; 94±16 vs. 149±20 vs. 245±50pg/mL; p<0.05). Interleukin-6 levels peaked on hospital day 1 and declined thereafter. C-reactive protein and leukocyte counts were not significantly different between the cohorts on arrival and peaked on hospital day 2 and 1, respectively. In patients with severe TBI, admission IL-6 levels significantly predicted the development of septic complications (ROC analysis, AUC: 0.88, p=0.001, 95% CI: 0.79-0.97) and multiple organ dysfunction (ROC analysis, AUC: 0.83, p=0.001, 95% CI: 0.69-0.96). Severe TBI reduced the inflammatory response following trauma. Significant correlations between admission IL-6 values and the development of MOF, sepsis and the neurological outcome were found in patients with TBI. Copyright © 2015 Elsevier GmbH. All rights reserved.