Trauma Associated Sleep Disorder: A Proposed Parasomnia Encompassing Disruptive Nocturnal Behaviors, Nightmares, and REM without Atonia in Trauma Survivors

PubMed Central

Mysliwiec, Vincent; O'Reilly, Brian; Polchinski, Jason; Kwon, Herbert P.; Germain, Anne; Roth, Bernard J.

2014-01-01

Study Objectives: To characterize the clinical, polysomnographic and treatment responses of patients with disruptive nocturnal behaviors (DNB) and nightmares following traumatic experiences. Methods: A case series of four young male, active duty U.S. Army Soldiers who presented with DNB and trauma related nightmares. Patients underwent a clinical evaluation in a sleep medicine clinic, attended overnight polysomnogram (PSG) and received treatment. We report pertinent clinical and PSG findings from our patients and review prior literature on sleep disturbances in trauma survivors. Results: DNB ranged from vocalizations, somnambulism to combative behaviors that injured bed partners. Nightmares were replays of the patient's traumatic experiences. All patients had REM without atonia during polysomnography; one patient had DNB and a nightmare captured during REM sleep. Prazosin improved DNB and nightmares in all patients. Conclusions: We propose Trauma associated Sleep Disorder (TSD) as a unique sleep disorder encompassing the clinical features, PSG findings, and treatment responses of patients with DNB, nightmares, and REM without atonia after trauma. Citation: Mysliwiec V, O'Reilly B, Polchinski J, Kwon HP, Germain A, Roth BJ. Trauma associated sleep disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors. J Clin Sleep Med 2014;10(10):1143-1148. PMID:25317096

Non-operative management of isolated liver trauma.

PubMed

Li, Min; Yu, Wen-Kui; Wang, Xin-Bo; Ji, Wu; Li, Jie-Shou; Li, Ning

2014-10-01

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.

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

Trauma in elderly patients evaluated in a hospital emergency department in Konya, Turkey: a retrospective study

PubMed Central

Kara, Hasan; Bayir, Aysegul; Ak, Ahmet; Akinci, Murat; Tufekci, Necmettin; Degirmenci, Selim; Azap, Melih

2014-01-01

Purpose Trauma is a common cause of admission to the hospital emergency department. The purpose of this study was to evaluate the cause of admission, clinical characteristics, and outcomes of patients aged ≥65 years admitted to an emergency department in Turkey because of blunt trauma. Materials and methods Medical records were retrospectively reviewed for 568 patients (314 women and 254 men) aged ≥65 years who were admitted to an emergency department of a tertiary care hospital. Results Trauma was caused by low-energy fall in 379 patients (67%), traffic accident in 79 patients (14%), high-energy fall in 69 patients (12%), and other causes in 41 patients (7%). The most frequent sites of injury were the lower extremity, thorax, upper extremity, and head. The femur was the most frequent fracture site. After evaluation in the emergency department, 377 patients (66%) were hospitalized. There were 31 patients (5%) who died. Risk of hospitalization after trauma was significantly associated with trauma to the lower extremity, thorax, and spine; fractures of the femur and rib; and intracranial injury. Conclusion Emergency department admission after trauma in patients aged ≥65 years is common after low-energy falls, and most injuries occur to the extremities. It is important to focus on prevention of falls to decrease the frequency of trauma in the elderly. PMID:24376346

[Firework-related eye trauma from 2005 to 2013].

PubMed

Unterlauft, J D; Wiedemann, P; Meier, P

2014-09-01

Fireworks combusted during New Year's Eve festivities can cause different eye traumas which often need complex reconstructive surgery. It was our aim to systematically analyse these eye trauma cases which were treated at our clinic during the last eight years. Age, gender, side, trauma mechanism, treatment methods and outcome were analysed for all eye trauma cases caused by fireworks during the New Year's Eve celebrations from 2006 to 2013. For statistical analysis all trauma cases were divided into two groups of major and non-major eye trauma. The total number of patients treated was 122 (28 women, 94 men, mean age 26.2±13.0 years) with 137 traumatised eyes (77 right, 60 left). 24.6% of patients were ≤18 years of age. 76.2% were bystanders. 50 eyes from 46 patients (37.7%) suffered from major eye trauma. 26 patients (21.3%) were hospitalised. 8 eyes (5.8%) suffered from a penetrating injury or globe rupture and underwent primary reconstructive surgery. Further 16 eyes (11.7%) suffered from major eye trauma without open globe injury. In the aftermath 11 eyes (8.0%) went blind (visual acuity<1/50). Gender, side and role of the patient were not significantly different between the two groups. Mean age was significantly higher in the major eye trauma group (p=0.01). Young male bystanders have a high risk for suffering from eye trauma caused by fireworks. However older patients suffer from major eye trauma more often. More education and prophylaxis of eye trauma caused by fireworks is desirable. Georg Thieme Verlag KG Stuttgart · New York.

[The radiologist physician in major trauma evaluation].

PubMed

Motta-Ramírez, Gaspar Alberto

2016-01-01

Trauma is the most common cause of death in young adults. A multidisciplinary trauma team consists of at least a surgical team, an anesthesiology team, radiologic team, and an emergency department team. Recognize the integration of multidisciplinary medical team in managing the trauma patient and which must include the radiologist physician responsible for the institutional approach to the systematization of the trauma patient regarding any radiological and imaging study with emphasis on the FAST (del inglés, Focused Assessment with Sonography in Trauma)/USTA, Whole body computed tomography. Ultrasound is a cross-sectional method available for use in patients with major trauma. Whole-body multidetector computed tomography became the imaging modality of choice in the late 1990s. In patients with major trauma, examination FAST often is the initial imaging examination, extended to extraabdominal regions. Patients who have multitrauma from blunt mechanisms often require multiple diagnostic examinations, including Computed Tomography imaging of the torso as well as abdominopelvic Computed Tomography angiography. Multiphasic Whole-body trauma imaging is feasible, helps detect clinically relevant vascular injuries, and results in diagnostic image quality in the majority of patients. Computed Tomography has gained importance in the early diagnostic phase of trauma care in the emergency room. With a single continuous acquisition, whole-body computed tomography angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis.

Abdominal injuries in a low trauma volume hospital - a descriptive study from northern Sweden

PubMed Central

2014-01-01

Background Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and radiologic findings, and delay definite treatment. Here, we determined the incidence, diagnosis, and treatment of traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative management of patients with these injuries in a low trauma volume hospital. Methods This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147 abdominal injuries from an isolated abdominal trauma (n = 70 patients) or during multiple trauma (n = 40 patients). Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009. Results The median New Injury Severity Score was 9 (range: 1–57) for 147 abdominal injuries. Most patients (94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with CT < 60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was performed for 28 patients, either immediately (n = 17) as result of operative management or later (n = 11), due to non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days. Conclusions Non-operative management of patients with abdominal injuries, except for hollow viscus injuries, was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of trauma care at low trauma volume hospitals. PMID:25124882

Changes in urine composition after trauma facilitate bacterial growth

PubMed Central

2012-01-01

Background Critically ill patients including trauma patients are at high risk of urinary tract infection (UTI). The composition of urine in trauma patients may be modified due to inflammation, systemic stress, rhabdomyolysis, life support treatment and/or urinary catheter insertion. Methods Prospective, single-centre, observational study conducted in patients with severe trauma and without a history of UTIs or recent antibiotic treatment. The 24-hour urine samples were collected on the first and the fifth days and the growth of Escherichia coli in urine from patients and healthy volunteers was compared. Biochemical and hormonal modifications in urine that could potentially influence bacterial growth were explored. Results Growth of E. coli in urine from trauma patients was significantly higher on days 1 and 5 than in urine of healthy volunteers. Several significant modifications of urine composition could explain these findings. On days 1 and 5, trauma patients had an increase in glycosuria, in urine iron concentration, and in the concentrations of several amino acids compared to healthy volunteers. On day 1, the urinary osmotic pressure was significantly lower than for healthy volunteers. Conclusion We showed that urine of trauma patients facilitated growth of E. coli when compared to urine from healthy volunteers. This effect was present in the first 24 hours and until at least the fifth day after trauma. This phenomenon may be involved in the pathophysiology of UTIs in trauma patients. Further studies are required to define the exact causes of such modifications. PMID:23194649

Transparent and Open Discussion of Errors Does Not Increase Malpractice Risk in Trauma Patients

PubMed Central

Stewart, Ronald M.; Corneille, Michael G.; Johnston, Joe; Geoghegan, Kathy; Myers, John G.; Dent, Daniel L.; McFarland, Marilyn; Alley, Joshua; Pruitt, Basil A.; Cohn, Stephen M.

2006-01-01

Objective: We set out to determine if there is an increased medical malpractice lawsuit rate when trauma patient cases are presented at an open, multidisciplinary morbidity and mortality conference (M&M). Introduction: Patient safety proponents emphasize the importance of transparency with respect to medical errors. In contrast, the tort system focuses on blame and punishment, which encourages secrecy. Our question: Can the goals of the patient safety movement be met without placing care providers and healthcare institutions at unacceptably high malpractice risk? Methods: The trauma registry, a risk management database, along with the written minutes of the trauma morbidity and mortality conference (M&M) were used to determine the number and incidence of malpractice suits filed following full discussion at an open M&M conference at an academic level I trauma center. Results: A total of 20,749 trauma patients were admitted. A total of 412 patients were discussed at M&M conference and a total of seven lawsuits were filed. Six of the patients were not discussed at M&M prior to the lawsuit being filed. One patient was discussed at M&M prior to the lawsuit being filed. The incidence of lawsuit was calculated in three groups: all trauma patients, all trauma patients with complications, and all patients presented at trauma M&M conference. The ratio of lawsuits filed to patients admitted and incidence in the three groups is as follows: All Patients, 7 lawsuits/20,479 patients (4.25 lawsuits/100,000 patients/year); M&M Presentation, 1 lawsuit/421 patients (29.6 lawsuits/100,000 patients/year); All Trauma Complications, 7 lawsuits/6,225 patients (14 lawsuits/100,000 patients/year). Patients with a complication were more likely to sue (P < 0.01); otherwise, there were no statistical differences between groups. Conclusions: A transparent discussion of errors, complications, and deaths does not appear to lead to an increased risk of lawsuit. PMID:16632999

Management of pericardial fluid in blunt trauma: variability in practice and predictors of operative outcome in patients with computed tomography evidence of pericardial fluid

PubMed Central

Witt, Cordelie E.; Linnau, Ken F.; Maier, Ronald V.; Rivara, Frederick P.; Vavilala, Monica S.; Bulger, Eileen M.; Arbabi, Saman

2017-01-01

Background The objectives of this study were to assess current variability in management preferences for blunt trauma patients with pericardial fluid, and to identify characteristics associated with operative intervention for patients with pericardial fluid on admission computed tomography (CT) scan. Methods This was a mixed-methods study of blunt trauma patients with pericardial fluid. The first portion was a research survey of members of the Eastern Association for the Surgery of Trauma conducted in 2016, in which surgeons were presented with four clinical scenarios of blunt trauma patients with pericardial fluid. The second portion of the study was a retrospective evaluation of all blunt trauma patients ≥14 years treated at our Level I trauma center between 1/1/2010 and 11/1/2015 with pericardial fluid on admission CT scan. Results For the survey portion of our study, 393 surgeons responded (27% response rate). There was significant variability in management preferences for scenarios depicting trace pericardial fluid on CT with concerning hemodynamics, and for scenarios depicting hemopericardium intraoperatively. For the separate retrospective portion of our study, we identified 75 blunt trauma patients with pericardial fluid on admission CT scan. Seven underwent operative management; six of these had hypotension and/or electrocardiogram changes. In multivariable analysis, pericardial fluid amount was a significant predictor of receiving pericardial window (relative risk for one category increase in pericardial fluid amount: 3.99, 95% CI 1.47-10.81) but not of mortality. Conclusions There is significant variability in management preferences for patients with pericardial fluid from blunt trauma, indicating a need for evidence-based research. Our institutional data suggest that patients with minimal to small amounts of pericardial fluid without concerning clinical findings may be observed. Patients with moderate to large amounts of pericardial fluid who are clinically stable with normal hemodynamics may also appear appropriate for observation, although confirmation in larger studies is needed. Patients with hemodynamic instability should undergo operative exploration. Level of Evidence Level IV, Therapeutic/Care Management PMID:28129264

Current concepts in simulation-based trauma education.

PubMed

Cherry, Robert A; Ali, Jameel

2008-11-01

The use of simulation-based technology in trauma education has focused on providing a safe and effective alternative to the more traditional methods that are used to teach technical skills and critical concepts in trauma resuscitation. Trauma team training using simulation-based technology is also being used to develop skills in leadership, team-information sharing, communication, and decision-making. The integration of simulators into medical student curriculum, residency training, and continuing medical education has been strongly recommended by the American College of Surgeons as an innovative means of enhancing patient safety, reducing medical errors, and performing a systematic evaluation of various competencies. Advanced human patient simulators are increasingly being used in trauma as an evaluation tool to assess clinical performance and to teach and reinforce essential knowledge, skills, and abilities. A number of specialty simulators in trauma and critical care have also been designed to meet these educational objectives. Ongoing educational research is still needed to validate long-term retention of knowledge and skills, provide reliable methods to evaluate teaching effectiveness and performance, and to demonstrate improvement in patient safety and overall quality of care.

[Malnutrition in Elderly Trauma Patients - Comparison of Two Assessment Tools].

PubMed

Ihle, C; Bahrs, C; Freude, T; Bickel, M; Spielhaupter, I; Wintermeyer, E; Stollhof, L; Grünwald, L; Ziegler, P; Pscherer, S; Stöckle, U; Nussler, A

2017-04-01

Background: The prevalence of malnutrition in hospitalised patients is reported to be between 16 and 55 % across disciplines. Within hospital care, screening for malnutrition is required. However, in orthopaedics and trauma surgery, there is still no generally accepted recommendation for the methods for such a data survey. In the present study, the following aspects are to be investigated with the help of two established scores: (1) the prevalence of malnutrition in the patient population of geriatric trauma care, and (2) the correlation between methods of data survey. Material and Methods: Between June 2014 and June 2015, a consecutive series of hospitalised trauma patients were studied prospectively with two validated screening instruments to record nutritional status. The study was carried out at a municipal trauma surgery hospital, which is a first level interregional trauma centre as well as a university hospital. The Nutritional Risk Screening (NRS) and the Mini Nutritional Assessment (MNA Short and Long Form) were used. All patients were divided into three age groups: < 65 years, 65-80 years, and > 80 years. The prevalence of malnutrition in geriatric trauma patients and the correlation between the screening instruments were determined. For a better comparison, prescreening and main assessment were applied to all patients. For statistical evaluation, both quantitative and semi-quantitative parameters were used. Furthermore, the Kolmogorov-Smirnov test, Spearman's correlation analysis and the chi-square test were applied. These tests were two-sided and had a level of significance of 5 %. The present study was partially funded by the Oskar-Helene-Heim Foundation. Results: 521 patients (43.8 % women, 56.2 % men), with a mean age of 53.96 ± 18.13 years, were statistically evaluated within the present study. Depending on the method of the data survey, malnutrition (NRS≥3) in geriatric trauma patients varied from 31.3 % (65-80 years) to 60 % (> 80 years). With MNA, 28.8 and 54.3 % of patients were at risk of malnutrition (MNA 17-23.5), while the fractions of patients already suffering from malnutrition (MNA < 17) were 5.4 and 8.6 %, respectively. The correlation between the NRS and MNA total scores increases with the age of the patients. The correlation coefficient for patients under 65 years is r = - 0.380, while among patients aged between 65 and 80, it is r = - 0.481, and for patients over 80 years, there is a medium to strong correlation of r = - 0.638 (each with a Spearman correlation of p < 0.001). For the total population as well as the different age groups, statistically significant correlations were recorded between the categorised scores (chi-square test for linear trend, p < 0.001). Summary: The present study demonstrates high prevalence of malnutrition among the geriatric trauma patients. Because of its easy and rapid application, the NRS has an advantage in clinical use. It was shown that the two methods of data survey were highly correlated. Georg Thieme Verlag KG Stuttgart · New York.

[Endovascular interventions for multiple trauma].

PubMed

Kinstner, C; Funovics, M

2014-09-01

In recent years interventional radiology has significantly changed the management of injured patients with multiple trauma. Currently nearly all vessels can be reached within a reasonably short time with the help of specially preshaped catheters and guide wires to achieve bleeding control of arterial und venous bleeding. Whereas bleeding control formerly required extensive open surgery, current interventional methods allow temporary vessel occlusion (occlusion balloons), permanent embolization and stenting. In injured patients with multiple trauma preinterventional procedural planning is performed with the help of multidetector computed tomography whenever possible. Interventional radiology not only allows minimization of therapeutic trauma but also a considerably shorter treatment time. Interventional bleeding control has developed into a standard method in the management of vascular trauma of the chest and abdomen as well as in vascular injuries of the upper and lower extremities when open surgical access is associated with increased risk. Additionally, pelvic trauma, vascular trauma of the superior thoracic aperture and parenchymal arterial lacerations of organs that can be at least partially preserved are primarily managed by interventional methods. In an interdisciplinary setting interventional radiology provides a safe and efficient means of rapid bleeding control in nearly all vascular territories in addition to open surgical access.

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.

[The evaluation of the suitability of our cases for referral to a level I trauma center].

PubMed

Taviloğlu, K; Aydin, A; Cuhali, B D; Demiralp, T; Güloğlu, R; Ertekin, C

2001-07-01

This study was performed on 200 patients with a prospective method, between July and October 1998. The aim of the study was to analyze the patients who were admitted directly or referred from another hospital, if they were suitable with the transfer criteria to a level I trauma center. One hundred and seven patients (53.5%) were admitted without ambulance and 93 patients (46.5%) by ambulance to our center. 34% of those patients applied directly and 66% of them were sent from other hospitals. Private ambulances consisted 70%, and 30% the belonged to the national health service. Only 26% of the ambulances had doctor as staff. The most common trauma etiologies were: traffic accidents (42.5%), falling from a height (37.5%) and assaults (11.5%). The mean Glasgow coma score (GCS) of the patients was calculated as 13.9 and mean revised trauma score was 11.7. The Glasgow coma score, revised trauma score and appropriateness to the transfer criteria of the American College of Surgeons were statistically analyzed according to the Fischer Exact test. The results revealed that 96% of the patients with RTS, 86% of the patients with GCS and 60% of the patients with ACS were not appropriate to the transfer criteria to a level I trauma center. In conclusion; we believe that GCS will predict better results in the triage of trauma patients with head trauma in our country.

Trauma patterns in patients attending the Emergency Department of Jazan General Hospital, Saudi Arabia

PubMed Central

Hokkam, Emad; Gonna, Abdelaziz; Zakaria, Ossama; El-shemally, Amany

2015-01-01

BACKGROUND: Modern civilization and the sharp rise in living standards have led to dramatic changes in trauma pattern in Saudi Arabia. This study aimed to describe the different patterns of injuries of patients attending the Emergency Department of Jazan General Hospital (JGH) in the southwest corner of Saudi Arabia. METHODS: A total number of 1 050 patients were enrolled in the study. A pre-organized data sheet was prepared for each patient attended the Emergency Department of JGH from February 2012 to January 2013. It contains data about socio-demographics, trauma data, clinical evaluation results, investigations as well as treatment strategies. RESULTS: The mean age of the patients was 25.3±16.8 years. Most (45.1%) of the patients were at age of 18–30 years. Males (64.3%) were affected by trauma more common than females. More than half (60.6%) of the patients were from urban areas. The commonest kind of injury was minor injury (60%), followed by blunt trauma (30.9%) and then penetrating trauma (9.1%). The mean time from the incident to arrival at hospital was 41.3±79.8 minutes. The majority (48.2%) of the patients were discharged after management of trivial trauma, whereas 2.3% were admitted to ICU, 7.7% transferred to inpatient wards, and 17.7% observed and subsequently discharged. The mortality rate of the patients was 2.6%. CONCLUSION: Trauma is a major health problem, especially in the young population in Saudi Arabia. Blunt trauma is more frequent than penetrating trauma, with road traffic accidents accounting for the majority. PMID:25802567

Clinical Gestalt and the Prediction of Massive Transfusion after Trauma

PubMed Central

Pommerening, Matthew J.; Goodman, Michael D.; Holcomb, John B.; Wade, Charles E.; Fox, Erin E.; del Junco, Deborah J.; Brasel, Karen J.; Bulger, Eileen M.; Cohen, Mitch J.; Alarcon, Louis H.; Schreiber, Martin A.; Myers, John G.; Phelan, Herb A.; Muskat, Peter; Rahbar, Mohammad; Cotton, Bryan A.

2016-01-01

Introduction Early recognition and treatment of trauma patients requiring massive transfusion (MT) has been shown to reduce mortality. While many risk factors predicting MT have been demonstrated, there is no universally accepted method or algorithm to identify these patients. We hypothesized that even among experienced trauma surgeons, the clinical gestalt of identifying patients who will require MT is unreliable. Methods Transfusion and mortality outcomes after trauma were observed at 10 U.S. Level-1 trauma centers in patients who survived ≥30 minutes after admission and received ≥1 unit of RBC within 6 hours of arrival. Subjects who received ≥ 10 units within 24 hours of admission were classified as MT patients. Trauma surgeons were asked the clinical gestalt question “Is the patient likely to be massively transfused?” ten minutes after the patients arrival. The performance of clinical gestalt to predict MT was assessed using chi-square tests and ROC analysis to compare gestalt to previously described scoring systems. Results Of the 1,245 patients enrolled, 966 met inclusion criteria and 221 (23%) patients received MT. 415 (43%) were predicted to have a MT and 551(57%) were predicted to not have MT. Patients predicted to have MT were younger, more often sustained penetrating trauma, had higher ISS scores, higher heart rates, and lower systolic blood pressures (all p < 0.05). Gestalt sensitivity was 65.6% and specificity was 63.8%. PPV and NPV were 34.9% and 86.2% respectively. Conclusion Data from this large multicenter trial demonstrates that predicting the need for MT continues to be a challenge. Because of the increased mortality associated with delayed therapy, a more reliable algorithm is needed to identify and treat these severely injured patients earlier. Level of Evidence II; Diagnostic study - Development of diagnostic criteria on basis of consecutive patients (with universally applied reference standard) PMID:25682314

Trauma-induced myelopathy in patients with ossification of the posterior longitudinal ligament.

PubMed

Matsunaga, Shunji; Sakou, Takashi; Hayashi, Kyoji; Ishidou, Yasuhiro; Hirotsu, Masataka; Komiya, Setsuro

2002-09-01

In these prospective and retrospective studies the authors evaluated trauma-induced myelopathy in patients with ossification of the posterior longitudinal ligament (OPLL) to determine the effectiveness of preventive surgery for this disease. The authors studied 552 patients with cervical OPLL, including 184 with myelopathy at the time of initial consultation and 368 patients without myelopathy at that time. In the former group of 184 patients retrospective analysis was performed using an interview survey to ascertain the relationship between onset of myelopathy and trauma. In the latter group of 368 patients prospective examination was conducted by assessing radiographic findings and noting changes in clinical symptoms apparent during regular physical examination. The follow-up period ranged from 10 to 32 years (mean 19.6 years). In the retrospective investigation, 24 patients (13%) identified cervical trauma as the trigger of their myelopathy. In the prospective investigation, 70% of patients did not develop myelopathy over a follow-up period greater than 20 years (determined using the Kaplan-Meier method). Of the 368 patients without myelopathy at the time of initial consultation, only six patients (2%) subsequently developed trauma-induced myelopathy. Types of ossification in patients who developed trauma-induced myelopathy were primarily a mixed type. All patients in whom stenosis affected 60% or greater of the spinal canal developed myelopathy regardless of a history of trauma. Preventive surgery prior to onset of myelopathy is unnecessary in most patients with OPLL.

Abdominal injuries in a major Scandinavian trauma center – performance assessment over an 8 year period

PubMed Central

2014-01-01

Introduction Damage control surgery and damage control resuscitation have reduced mortality in patients with severe abdominal injuries. The shift towards non-operative management in haemodynamically stable patients suffering blunt abdominal trauma has further contributed to the improved results. However, in many countries, low volume of trauma cases and limited exposure to trauma laparotomies constitute a threat to trauma competence. The aim of this study was to evaluate the institutional patient volume and performance for patients with abdominal injuries over an eight-year period. Methods Data from 955 consecutive trauma patients admitted in Oslo University Hospital Ulleval with abdominal injuries during the eight-year period 2002-2009 were retrospectively explored. A separate analysis was performed on all trauma patients undergoing laparotomy during the same period, whether abdominal injuries were identified or not. Variable life-adjusted display (VLAD) was used in order to describe risk-adjusted survival trends throughout the period and the patients admitted before (Period 1) and after (Period 2) the institution of a formal Trauma Service (2005) were compared. Results There was a steady increase in admitted patients with abdominal injuries, while the number of patients undergoing laparotomy was constant exposing the surgical trauma team leaders to an average of 8 trauma laparotomies per year. No increase in missed injuries or failures of non-operative management was detected. Unadjusted mortality rates decreased from period 1 to period 2 for all patients with abdominal injuries as well as for the patients undergoing laparotomy. However, this apparent decrease was not confirmed as significant in TRISS-based analysis of risk-adjusted mortality. VLAD demonstrated a steady performance throughout the study period. Conclusion Even in a high volume trauma center the exposure to abdominal injuries and trauma laparotomies is limited. Due to increasing NOM, an increasing number of patients with abdominal injuries was not accompanied by an increase in number of laparotomies. However, we have demonstrated a stable performance throughout the study period as visualized by VLAD without an increase in missed injuries or failures of NOM. PMID:25097664

[Haemothorax after blunt thoracic trauma].

PubMed

Siller, J; Havlícek, K

2009-05-01

Haemothorax is frequent consequence of blunt and penetrating thoracic trauma and is usually associated with pneumothorax. The occurence of haemothorax in blunt thoracic trauma patients is estimated between 25-75%. The reason of bleeding is impairment of intercostal arteries or lung parenchyma after trauma of the ribs. Uncontrolled bleeding is the main cause of the death. The article is focused on the treatment of this injury. There were enrolled 238 patients with thoracic trauma, who were admitted into our department, into the study. The average age of the patients was 42.5 years. The ISS > or = 16 were in 101 patients. Forty two patients were artefitially ventilated. Conservative treatment prevails, almost in 65%. Special care was indicated in patients with haemothorax (fluidotoraxem). Clinically and based on other screening methods the presence of the fluid in thoracic cavity was in 131 patients. Surgical treatment (punction, drainage, videothoracoscopy and thoracotomy) was necessary in 47 (35.0%). Thoracotomy for the bleeding was indicated in seven cases (5.3 %). In diagnostics and in treatment of the bleeding in thoracic trauma patients the most important factor is clinical status of the patient. Indication for thoracotomy must be unambigous. Massive haemotorax leads to restrictive ventilation disorder with decreased preload and can be activator of the haemocolaguation disorders. This fact decreases chance for the survival of the patient.

Primary care management of non-English-speaking refugees who have experienced trauma: a clinical review.

PubMed

Crosby, Sondra S

2013-08-07

Refugees are a vulnerable class of immigrants who have fled their countries, typically following war, violence, or natural disaster, and who have frequently experienced trauma. In primary care, engaging refugees to develop a positive therapeutic relationship is challenging. Relative to care of other primary care patients, there are important differences in symptom evaluation and developing treatment plans. To discuss the importance of and methods for obtaining refugee trauma histories, to recognize the psychological and physical manifestations of trauma characteristic of refugees, and to explore how cultural differences and limited English proficiency affect the refugee patient-clinician relationship and how to best use interpreters. MEDLINE and the Cochrane Library were searched from 1984 to 2012. Additional citations were obtained from lists of references from select research and review articles on this topic. Engagement with a refugee patient who has experienced trauma requires an understanding of the trauma history and the trauma-related symptoms. Mental health symptoms and chronic pain are commonly experienced by refugee patients. Successful treatment requires a multidisciplinary approach that is culturally acceptable to the refugee. Refugee patients frequently have experienced trauma requiring a directed history and physical examination, facilitated by an interpreter if necessary. Intervention should be sensitive to the refugee's cultural mores.

Pattern of maxillofacial fractures in severe multiple trauma patients: a 7-year prospective study.

PubMed

Alves, La-Salete; Aragão, Irene; Sousa, Maria-José Carneiro; Gomes, Ernestina

2014-01-01

The incidence of facial trauma is high. This study has the primary objective of documenting and cataloging maxillofacial fractures in polytrauma patients. From a total of 1229 multiple trauma cases treated at the Emergency Room of the Santo Antonio Hospital - Oporto Hospital Center, Portugal, between August 2001 and December 2007, 251 patients had facial wounds and 209 had maxillofacial fractures. Aged ranged form 13 to 86 years. The applied selective method was based on the presence of facial wound with Abbreviated Injury Scale ≥1. Men had a higher incidence of maxillofacial fractures among multiple trauma patients (86.6%) and road traffic accidents were the primary cause of injuries (69.38%). Nasoorbitoethmoid complex was the most affected region (67.46%) followed by the maxilla (57.42%). The pattern and presentation of maxillofacial fractures had been studied in many parts of the world with varying results. Severe multiple trauma patients had different patterns of maxillofacial injuries. The number of maxillofacial trauma is on the rise worldwide as well as the incidence of associated sequelae. Maxillofacial fractures on multiple trauma patients were more frequent among males and in road traffic crashes. Knowing such data is elementary. The society should have a key role in the awareness of individuals and in prevention of road traffic accidents.

Damage control – trauma care in the first hour and beyond: a clinical review of relevant developments in the field of trauma care

PubMed Central

Midwinter, M

2013-01-01

Introduction Trauma provision in the UK is a topic of interest. Regional trauma networks and centres are evolving and research is blossoming, but what bearing does all this have on the care that is delivered to the individual patient? This article aims to provide an overview of key research concepts in the field of trauma care, to guide the clinician in decision making in the management of major trauma. Methods The Ovid MEDLINE®, EMBASE™ and PubMed databases were used to search for relevant articles on haemorrhage control, damage control resuscitation and its exceptions, massive transfusion protocols, prevention and correction of coagulopathy, acidosis and hypothermia, and damage-control surgery. Findings A wealth of research is available and a broad range has been reviewed to summarise significant developments in trauma care. Research has been categorised into disciplines and it is hoped that by considering each, a tailored management plan for the individual trauma patient will evolve, potentially improving patient outcome. PMID:23827287

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

Incremental cost-effectiveness of trauma service improvements for road trauma casualties: experience of an Australian major trauma centre.

PubMed

Dinh, Michael M; Bein, Kendall J; Hendrie, Delia; Gabbe, Belinda; Byrne, Christopher M; Ivers, Rebecca

2016-09-01

Objective The aim of the present study was to estimate the cost-effectiveness of trauma service funding enhancements at an inner city major trauma centre. Methods The present study was a cost-effectiveness analysis using retrospective trauma registry data of all major trauma patients (injury severity score >15) presenting after road trauma between 2001 and 2012. The primary outcome was cost per life year gained associated with the intervention period (2007-12) compared with the pre-intervention period (2001-06). Incremental costs were represented by all trauma-related funding enhancements undertaken between 2007 and 2010. Risk adjustment for years of life lost was conducted using zero-inflated negative binomial regression modelling. All costs were expressed in 2012 Australian dollar values. Results In all, 876 patients were identified during the study period. The incremental cost of trauma enhancements between 2007 and 2012 totalled $7.91million, of which $2.86million (36%) was attributable to road trauma patients. After adjustment for important covariates, the odds of in-hospital mortality reduced by around half (adjusted odds ratio (OR) 0.48; 95% confidence interval (CI) 0.27, 0.82; P=0.01). The incremental cost-effectiveness ratio was A$7600 per life year gained (95% CI A$5524, $19333). Conclusion Trauma service funding enhancements that enabled a quality improvement program at a single major trauma centre were found to be cost-effective based on current international and Australian standards. What is known about this topic? Trauma quality improvement programs have been implemented across most designated trauma hospitals in an effort to improve hospital care processes and outcomes for injured patients. These involve a combination of education and training, the use of audit and key performance indicators. What does this paper add? A trauma quality improvement program initiated at an Australian Major Trauma Centre was found to be cost-effective over 12 years with respect to years of life saved in road trauma patients. What are the implications for practitioners? The results suggest that adequate resourcing of trauma centres to enable quality improvement programs may be a cost-effective measure to reduce in-hospital mortality following road trauma.

Comparison of Helicopter Emergency Medical Services Transport Types and Delays on Patient Outcomes at Two Level I Trauma Centers.

PubMed

Nolan, Brodie; Tien, Homer; Sawadsky, Bruce; Rizoli, Sandro; McFarlan, Amanda; Phillips, Andrea; Ackery, Alun

2017-01-01

Helicopter emergency medical services (HEMS) have become an engrained component of trauma systems. In Ontario, transportation for trauma patients is through one of three ways: scene call, modified scene call, or interfacility transfer. We hypothesize that differences exist between these types of transports in both patient demographics and patient outcomes. This study compares the characteristics of patients transported by each of these methods to two level 1 trauma centers and assesses for any impact on morbidity or mortality. As a secondary outcome reasons for delay were identified. A local trauma registry was used to identify and abstract data for all patients transported to two trauma centers by HEMS over a 36-month period. Further chart abstraction using the HEMS patient care reports was done to identify causes of delay during HEMS transport. During the study period HEMS transferred a total of 911 patients of which 139 were scene calls, 333 were modified scene calls and 439 were interfacility transfers. Scene calls had more patients with an ISS of less than 15 and had more patients discharged home from the ED. Modified scene calls had more patients with an ISS greater than 25. The most common delays that were considered modifiable included the sending physician doing a procedure, waiting to meet a land EMS crew, delays for diagnostic imaging and confirming disposition or destination. Differences exist between the types of transports done by HEMS for trauma patients. Many identified reasons for delay to HEMS transport are modifiable and have practical solutions. Future research should focus on solutions to identified delays to HEMS transport. Key words: helicopter emergency medical services; trauma; prehospital care; delays.

Terror Attacks Increase the Risk of Vascular Injuries

PubMed Central

Heldenberg, Eitan; Givon, Adi; Simon, Daniel; Bass, Arie; Almogy, Gidon; Peleg, Kobi

2014-01-01

Objectives: Extensive literature exists about military trauma as opposed to the very limited literature regarding terror-related civilian trauma. However, terror-related vascular trauma (VT), as a unique type of injury, is yet to be addressed. Methods: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from 09/2000 to 12/2005 were included. The subgroup of patients with documented VT (N = 1,545) was analyzed and further subdivided into those suffering from terror-related vascular trauma (TVT) and non-terror-related vascular trauma (NTVT). Both groups were analyzed according to mechanism of trauma, type and severity of injury and treatment. Results: Out of 2,446 terror-related trauma admissions, 243 sustained TVT (9.9%) compared to 1302 VT patients from non-terror trauma (1.1%). TVT injuries tend to be more complex and most patients were operated on. Intensive care unit admissions and hospital length of stay was higher in the TVT group. Penetrating trauma was the prominent cause of injury among the TVT group. TVT group had a higher proportion of patients with severe injuries (ISS ≥ 16) and mortality. Thorax injuries were more frequent in the TVT group. Extremity injuries were the most prevalent vascular injuries in both groups; however NTVT group had more upper extremity injuries, while the TVT group had significantly much lower extremity injuries. Conclusion: Vascular injuries are remarkably more common among terror attack victims than among non-terror trauma victims and the injuries of terror casualties tend to be more complex. The presence of a vascular surgeon will ensure a comprehensive clinical care. PMID:24910849

Comparison of the 1999 and 2006 Trauma Triage Guidelines: Where do Patients Go?

PubMed Central

Lerner, E. Brooke; Shah, Manish N.; Swor, Robert; Cushman, Jeremy T.; Guse, Clare E.; Brasel, Karen; Blatt, Alan; Jurkovich, Gregory J.

2010-01-01

In 2006, the CDC released a revised Field Triage Decision Scheme. It is unknown how this modified scheme will affect the number of patients identified by EMS for transport to a trauma center. Objective To determine the change in the number of patients transported by EMS who meet the 2006 scheme, compared to the 1999 scheme, and to determine how the scheme change would affect under- and over-triage rates. Methods EMS providers in charge of care for injured adult patients transported to a regional trauma center in three mid-sized cities were interviewed immediately after completing transport. All injured patients were included, regardless of severity. The interview included patient demographics, vital signs, apparent anatomic injury, and the mechanism of injury. Included patients were then followed through hospital discharge. The 1999 and 2006 scheme criteria were each retrospectively applied to the collected data. The number of patients identified by the two schemes was determined. Patients were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. Data were analyzed using descriptive statistics including 95% confidence intervals. Results EMS interviews were conducted for 11,892 patients and outcome data was unavailable for one patient. Average patient age was 48 years; 51% were men. Providers reported bringing 54% of the enrolled patients to the trauma center based on their local trauma protocol. 12% of enrolled patients were identified as needing a trauma center based on medical record review. Use of the 2006 scheme would have resulted in 1,423 fewer patients (12%; 95% CI:11-13%) being identified as needing a trauma center by EMS providers (40%; 95%CI:39-41% versus 28%; 95%CI:27-29%). 1,344 of those patients did not actually need the resources of a trauma center (94%). 78 (6%) of those patients actually needed the resources of a trauma center and would have been under-triaged. Conclusion Use of the 2006 Field Triage Decision Scheme would have resulted in a significant decrease in the number of patients identified as needing the resources of a trauma center. These changes reduced over-triage while causing a small increase in the number of patients who would have been under-triaged. PMID:21054176

Management and treatment of splenic trauma in children.

PubMed

Arslan, Serkan; Guzel, Mahmut; Turan, Cuneyt; Doğanay, Selim; Kopru, Mehmet

2015-01-01

To assess types of splenic traumas, accompanying injuries, their management and results. We studied the reports of 90 patients (64 boys, 26 girls) who were treated for splenic injuries as a result of blunt abdominal trauma between 2005-2012. Age, sex, hospitalization time, mechanisms of traumas, accompanying injuries and management methods were recorded. Causes of trauma were falls from height (46 patients, 51%), pedestrian traffic accidents (17 patients, 19%), passenger traffic accidents (11 patients, 12%), bicycle accidents (10 patients, 11%) and falling objects from height (6 patients, 6.6%). Splenic injury alone was observed in 57 patients (63.3%) and other organ injuries together with splenic injury in 33 patients (36.7%). Splenectomy was performed in six patients (6.6%) due to hemodynamic instability and small intestine repair due to small intestine injury in one patient (1.1%). None of these patients died from their injuries. A large proportion of splenic injuries recover with conservative therapy. Some of the advantages of conservative therapy include short hospitalization time, less need for blood transfusion, and less morbidity and mortality. Falls from height and traffic accidents are important factors in etiology. The possibility of other organ injuries together with splenic injuries should be considered.

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

Defining and Measuring Decision-Making for the Management of Trauma Patients.

PubMed

Madani, Amin; Gips, Amanda; Razek, Tarek; Deckelbaum, Dan L; Mulder, David S; Grushka, Jeremy R

Effective management of trauma patients is heavily dependent on sound judgment and decision-making. Yet, current methods for training and assessing these advanced cognitive skills are subjective, lack standardization, and are prone to error. This qualitative study aims to define and characterize the cognitive and interpersonal competencies required to optimally manage injured patients. Cognitive and hierarchical task analyses for managing unstable trauma patients were performed using qualitative methods to map the thoughts, behaviors, and practices that characterize expert performance. Trauma team leaders and board-certified trauma surgeons participated in semistructured interviews that were transcribed verbatim. Data were supplemented with content from published literature and prospectively collected field notes from observations of the trauma team during trauma activations. The data were coded and analyzed using grounded theory by 2 independent reviewers. A framework was created based on 14 interviews with experts (lasting 1-2 hours each), 35 field observations (20 [57%] blunt; 15 [43%] penetrating; median Injury Severity Score 20 [13-25]), and 15 literary sources. Experts included 11 trauma surgeons and 3 emergency physicians from 7 Level 1 academic institutions in North America (median years in practice: 12 [8-17]). Twenty-nine competencies were identified, including 17 (59%) related to situation awareness, 6 (21%) involving decision-making, and 6 (21%) requiring interpersonal skills. Of 40 potential errors that were identified, root causes were mapped to errors in situation awareness (20 [50%]), decision-making (10 [25%]), or interpersonal skills (10 [25%]). This study defines cognitive and interpersonal competencies that are essential for the management of trauma patients. This framework may serve as the basis for novel curricula to train and assess decision-making skills, and to develop quality-control metrics to improve team and individual performance. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Aetiology, epidemiology and management strategies for blunt scrotal trauma.

PubMed

Dalton, D M; Davis, N F; O'Neill, D C; Brady, C M; Kiely, E A; O'Brien, M F

2016-02-01

To describe our experience of all patients presenting to a tertiary referral centre over a 3 year time period with blunt scrotal trauma and to describe a methodical approach for managing this group of patients. A retrospective analysis was performed on all patients presenting to the Emergency Department (ED) of a level 1 trauma centre with blunt scrotal trauma from 2010 to 2013 inclusive. Inclusion criteria included a recent history of blunt scrotal trauma with associated pain and/or swelling of the affected testis on clinical examination. Twenty-seven male patients with a median age of 19 (range 8-65) years were included and all but 1 patient underwent scrotal ultrasonography upon presentation. Sixteen patients (59%) presented with scrotal trauma secondary to a sports related injury. Fifteen patients were managed conservatively and of the 12 who underwent urgent exploration 9 had a testicular rupture, including 1 who had an emergency orchidectomy due to a completely shattered testis. Four patients had >30% of the testis replaced by necrotic tissue/haematoma; of which 2 ultimately underwent orchidectomy and insertion of testicular prosthesis. Our findings demonstrate that the necessity for scrotal protection in sports that predispose to scrotal trauma should be reviewed. We also demonstrate the importance of scrotal ultrasonography for determining an appropriate management strategy (i.e., conservative versus surgical treatment) in this young patient cohort. Copyright © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Auricular Chromotherapy in the Treatment of Psychologic Trauma, Phobias, and Panic Disorder

PubMed Central

Asis, Daniel Guillermo; Luz, Fabiola Andrade

2018-01-01

Abstract Auricular chromotherapy has shown promising results in the treatment of psychologic trauma and anxiety disorders, such as phobias and panic attacks. With its relatively easy and quick technical application, this procedure could be an indispensable tool for physicians. However, its mechanism of action is not yet understood completely. Objective: To treat patients suffering from trauma, phobia, and panic attack with auricular chromotherapy. Materials and Methods: The protocol was applied in 160 patients (135 who experienced traumas; 15 patients with specific phobias and 10 patients with panic disorder). They are 134 women, 26 men, ages 20–60. Results: The treatment showed 93% of positive response. Conclusion: This procedure shows the possibility of drawing a path from the external ear to traumatic memories, anxiety disorders and phobias.

Implementation of recommended trauma system criteria in south-eastern Norway: a cross-sectional hospital survey

PubMed Central

2012-01-01

Background Formalized trauma systems have shown beneficial effects on patient survival and have harvested great recognition among health care professionals. In spite of this, the implementation of trauma systems is challenging and often met with resistance. Recommendations for a national trauma system in Norway were published in 2007. We wanted to assess the level of implementation of these recommendations. Methods A survey of all acute care hospitals that receive severely injured patients in the south-eastern health region of Norway was conducted. A structured questionnaire based on the 2007 national recommendations was used in a telephone interview of hospital trauma personnel between January 17 and 21, 2011. Seventeen trauma system criteria were identified from the recommendations. Results Nineteen hospitals were included in the study and these received more than 2000 trauma patients annually via their trauma teams. Out of the 17 criteria that had been identified, the hospitals fulfilled a median of 12 criteria. Neither the size of the hospitals nor the distance between the hospitals and the regional trauma centre affected the level of trauma resources available. The hospitals scored lowest on the criteria for transfer of patients to higher level of care and on the training requirements for members of the trauma teams. Conclusion Our study identifies a major shortcoming in the efforts of regionalizing trauma in our region. The findings indicate that training of personnel and protocols for inter-hospital transfer are the major deficiencies from the national trauma system recommendations. Resources for training of personnel partaking in trauma teams and development of inter-hospital transfer agreements should receive immediate attention. PMID:22281020

Temporal distribution of trauma deaths: quality of trauma care in a developing country.

PubMed

Masella, Cesar Augusto; Pinho, Vitor Ferreira; Costa Passos, Afonso Dinis; Spencer Netto, Fernando A C; Rizoli, Sandro; Scarpelini, Sandro

2008-09-01

Examination of the epidemiology and timing of trauma deaths has been deemed a useful method to evaluate the quality of trauma care. The purpose of this study was to evaluate the quality of trauma care in a regional trauma system and in a university hospital in Brazil by comparing the timing of deaths in the studied prehospital and in-hospital settings to those published for trauma systems in other areas. We analyzed the National Health Minister's System of Deaths Information for the prehospital mortality and we retrospectively collected the demographics, timelines, and trauma severity scores of all in-hospital patients who died after admission through the Emergency Unit of Hospital das Clinicas de Ribeirao Preto between 2000 and 2001. During the study period, there were 787 trauma fatalities in the city: 448 (56.9%) died in the prehospital setting and 339 (43.1%) died after being admitted to a medical facility. In 2 years, 238 trauma deaths occurred in the studied hospital, and we found a complete clinical set of data for 224 of these patients. The majority of deaths in the prehospital setting were caused by penetrating injuries (66.7%), whereas in-hospital mortality was mainly because of blunt traumas (59.1%). The largest number of in-hospital deaths occurred beyond 72 hours of stay (107 patients-47%). The region studied showed some deficiencies in prehospital and in-hospitals settings, in particular in the critical care and short-term follow-up of trauma patients when compared with the literature. Particularly, the late mortality may be related to training and human resources deficiency. Based on the timeline of trauma deaths, we can suggest that the studied region needs improvements in the prehospital trauma system and in hospital critical care.

SU-F-SPS-03: Direct Measurement of Organ Doses Resulting From Head and Cervical Spine Trauma CT Protocols

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

Carranza, C; Lipnharski, I; Quails, N

Purpose: This retrospective study analyzes the exposure history of emergency department (ED) patients undergoing head and cervical spine trauma computed tomography (CT) studies. This study investigated dose levels received by trauma patients and addressed any potential concerns regarding radiation dose issues. Methods: Under proper IRB approval, a cohort of 300 trauma cases of head and cervical spine trauma CT scans received in the ED was studied. The radiological image viewing software of the hospital was used to view patient images and image data. The following parameters were extracted: the imaging history of patients, the reported dose metrics from the scannermore » including the volumetric CT Dose Index (CTDIvol) and Dose Length Product (DLP). A postmortem subject was scanned using the same scan techniques utilized in a standard clinical head and cervical spine trauma CT protocol with 120 kVp and 280 mAs. The CTDIvol was recorded for the subject and the organ doses were measured using optically stimulated luminescent (OSL) dosimeters. Typical organ doses to the brain, thyroid, lens, salivary glands, and skin, based on the cadaver studies, were then calculated and reported for the cohort. Results: The CTDIvol reported by the CT scanner was 25.5 mGy for the postmortem subject. The average CTDIvol from the patient cohort was 34.1 mGy. From these metrics, typical average organ doses in mGy were found to be: Brain (44.57), Thyroid (33.40), Lens (82.45), Salivary Glands (61.29), Skin (47.50). The imaging history of the cohort showed that on average trauma patients received 26.1 scans over a lifetime. Conclusion: The average number of scans received on average by trauma ED patients shows that radiation doses in trauma patients may be a concern. Available dose tracking software would be helpful to track doses in trauma ED patients, highlighting the importance of minimizing unnecessary scans and keeping doses ALARA.« less

Gun trauma and ophthalmic outcomes.

PubMed

Chopra, N; Gervasio, K A; Kalosza, B; Wu, A Y

2018-04-01

PurposeThis retrospective cohort study assesses the visual outcomes of patients who survive gunshot wounds to the head.MethodsThe Elmhurst City Hospital Trauma Registry and Mount Sinai Data Warehouse were queried for gun trauma resulting in ocular injury over a 16-year period. Thirty-one patients over 16 years of age were found who suffered a gunshot wound to the head and resultant ocular trauma: orbital fracture, ruptured globe, foreign body, or optic nerve injury. Gun types included all firearms and air guns. Nine patients were excluded due to incorrect coding or unavailable charts. Statistical analysis was performed using a simple bivariate analysis (χ 2 ).ResultsOf the 915 victims of gun trauma to the head, 27 (3.0%) sustained ocular injuries. Of the 22 patients whose records were accessible, 18 survived. Eight of the 18 surviving patients (44%) suffered long-term visual damage, defined as permanent loss of vision in at least one eye to the level of counting fingers or worse. Neither location of injury (P=0.243), nor type of gun used (P=0.296), nor cause of gun trauma (P=0.348) predicted visual loss outcome. The Glasgow Coma Scale eye response score on arrival to the hospital also did not predict visual loss outcome (P=0.793).ConclusionThere has been a dearth of research into gun trauma and even less research on the visual outcomes following gun trauma. Our study finds that survivors of gun trauma to the head suffer long-term visual damage 44% of the time after injury.

Effect of Advanced Trauma Life Support program on medical interns' performance in simulated trauma patient management.

PubMed

Ahmadi, Koorosh; Sedaghat, Mohammad; Safdarian, Mahdi; Hashemian, Amir-Masoud; Nezamdoust, Zahra; Vaseie, Mohammad; Rahimi-Movaghar, Vafa

2013-01-01

Since appropriate and time-table methods in trauma care have an important impact on patients'outcome, we evaluated the effect of Advanced Trauma Life Support (ATLS) program on medical interns' performance in simulated trauma patient management. A descriptive and analytical study before and after the training was conducted on 24 randomly selected undergraduate medical interns from Imam Reza Hospital in Mashhad, Iran. On the first day, we assessed interns' clinical knowledge and their practical skill performance in confronting simulated trauma patients. After 2 days of ATLS training, we performed the same study and evaluated their score again on the fourth day. The two findings, pre- and post- ATLS periods, were compared through SPSS version 15.0 software. P values less than 0.05 were considered statistically significant. Our findings showed that interns'ability in all the three tasks improved after the training course. On the fourth day after training, there was a statistically significant increase in interns' clinical knowledge of ATLS procedures, the sequence of procedures and skill performance in trauma situations (P less than 0.001, P equal to 0.016 and P equal to 0.01 respectively). ATLS course has an important role in increasing clinical knowledge and practical skill performance of trauma care in medical interns.

Use of intraosseous devices in trauma: a survey of trauma practitioners in Canada, Australia and New Zealand

PubMed Central

Engels, Paul T.; Erdogan, Mete; Widder, Sandy L.; Butler, Michael B.; Kureshi, Nelofar; Martin, Kate; Green, Robert S.

2016-01-01

Background Although used primarily in the pediatric population for decades, the use of intraosseous (IO) devices in the resuscitation of severely injured adult trauma patients has recently become more commonplace. The objective of this study was to determine the experience level, beliefs and attitudes of trauma practitioners in Canada, Australia and New Zealand regarding the use of IO devices in adult trauma patients. Methods We administered a web-based survey to all members of 4 national trauma and emergency medicine organizations in Canada, Australia and New Zealand. Survey responses were analyzed using descriptive statistics, univariate comparisons and a proportional odds model. Results Overall, 425 of 1771 members completed the survey, with 375 being trauma practitioners. IO devices were available to 97% (353 of 363), with EZ-IO being the most common. Nearly all physicians (98%, 357 of 366) had previous training with IO devices, and 85% (223 of 261) had previously used an IO device in adult trauma patients. Most respondents (79%, 285 of 361) were very comfortable placing an IO catheter in the proximal tibia. Most physicians would always or often use an IO catheter in a patient without intravenous access undergoing CPR for traumatic cardiac arrest (84%, 274 of 326) or in a hypotensive patient (without peripheral intravenous access) after 2 attempts or 90 s of trying to establish vascular access (81%, 264 of 326). Conclusion Intraosseous devices are readily available to trauma practitioners in Canada, Australia and New Zealand, and most physicians are trained in device placement. Most physicians surveyed felt comfortable using an IO device in resuscitation of adult trauma patients and would do so for indications broader than current guidelines. PMID:27669404

[Interdisciplinary treatment in geriatric traumatology from the trauma surgeons' perspective : Results of a survey in Germany].

PubMed

Bücking, B; Walz, M; Hartwig, E; Friess, T; Liener, U; Knobe, M; Ruchholtz, S; Bliemel, C

2017-01-01

Many patients treated on trauma surgery wards are geriatric trauma patients. To improve treatment of these often multimorbid patients, various interdisciplinary treatment concepts have been established in Germany between trauma surgeons and geriatricians. The aim of this study was to evaluate the dissemination and the impact of the different orthogeriatric treatment concepts for geriatric trauma in Germany. Material and methods In March and April 2014 an electronic questionnaire for assessing the interdisciplinary treatment of geriatric trauma patients was sent to 691 medical directors of trauma surgery departments in Germany. A total of 259 (37 %) fully answered questionnaires could be analyzed. The analysis revealed that 70 % of all responding trauma surgery departments had an orthogeriatric treatment cooperation. Most of them reported having patient discharge agreements to geriatric rehabilitation facilities (59 %). Geriatric counseling services were reported by 39 % while 24 % reported having regular interdisciplinary visits and orthogeriatric wards were available in 13 %. The need for orthogeriatric services was considered to be high by 79 % of the participants and benefits especially for the patients were expected. These expectations were largely fulfilled. More than 70 % of respondents planned to intensify the orthogeriatric cooperation. In this context difficulties were seen in the lack of personnel resources, especially in a lack of geriatricians. The results of this survey underline the impact and the positive experiences in orthogeriatric services. Solutions have to be found to address the emerging problem of capacity constraints.

Whole-body CT-based imaging algorithm for multiple trauma patients: radiation dose and time to diagnosis

PubMed Central

Gordic, S; Hodel, S; Simmen, H-P; Brueesch, M; Frauenfelder, T; Wanner, G; Sprengel, K

2015-01-01

Objective: To determine the number of imaging examinations, radiation dose and the time to complete trauma-related imaging in multiple trauma patients before and after introduction of whole-body CT (WBCT) into early trauma care. Methods: 120 consecutive patients before and 120 patients after introduction of WBCT into the trauma algorithm of the University Hospital Zurich were compared regarding the number and type of CT, radiography, focused assessment with sonography for trauma (FAST), additional CT examinations (defined as CT of the same body regions after radiography and/or FAST) and the time to complete trauma-related imaging. Results: In the WBCT cohort, significantly more patients underwent CT of the head, neck, chest and abdomen (p < 0.001) than in the non-WBCT cohort, whereas the number of radiographic examinations of the cervical spine, chest and pelvis and of FAST examinations were significantly lower (p < 0.001). There were no significant differences between cohorts regarding the number of radiographic examinations of the upper (p = 0.56) and lower extremities (p = 0.30). We found significantly higher effective doses in the WBCT (29.5 mSv) than in the non-WBCT cohort (15.9 mSv; p < 0.001), but fewer additional CT examinations for completing the work-up were needed in the WBCT cohort (p < 0.001). The time to complete trauma-related imaging was significantly shorter in the WBCT (12 min) than in the non-WBCT cohort (75 min; p < 0.001). Conclusion: Including WBCT in the initial work-up of trauma patients results in higher radiation doses, but fewer additional CT examinations are needed, and the time for completing trauma-related imaging is shorter. Advances in knowledge: WBCT in trauma patients is associated with a high radiation dose of 29.5 mSv. PMID:25594105

Outcomes after pancreatic trauma: experience at a single institution

PubMed Central

Al-Ahmadi, Khaled; Ahmed, Najma

2008-01-01

Objective Pancreatic injury following trauma is unusual, and there are few data regarding outcomes, particularly with respect to endocrine and exocrine function. The purpose of this study was to review our institutional experience in regard to this relatively infrequent injury and to determine the incidence of trauma-induced endocrine and exocrine pancreatic dysfunction as indicated by patient self-report. Methods After receiving institutional research ethics approval, we identified all patients with pancreatic injuries in our trauma registry database over a 5-year period. The diagnostic, operative information, hospital course and complication rates were abstracted from medical records. Patients who could be contacted completed a telephone-administered questionnaire to assess pancreatic function. Results We identified 25 patients who had suffered a pancreatic injury. Of these, 16 patients suffered blunt injury, and 9 suffered penetrating injury. Of the 25 patients, 13 underwent pancreatic surgery, and 6 required distal pancreatectomy. Early pancreas-specific complications occurred in 7 of 22 surviving patients (31.8%). Of the 25 patients identified, 6 could not be contacted for follow-up information. Of 19 patients contacted, 4 reported endocrine dysfunction. One of these was insulin-dependant before injury. No patient in this series reported exocrine dysfunction. The overall mortality rate in our series was 12%. Conclusion Pancreatic injuries comprised about 1% of injuries captured by our trauma registry. Outcomes were similar in patients who suffered blunt or penetrating trauma. Of these patients, 52% underwent pancreatic surgery; 16% of patients in this small series reported endocrine deficiency posttrauma. PMID:18377752

The management of colonic trauma in the damage control era

PubMed Central

Shazi, B; Bruce, JL; Laing, GL; Sartorius, B

2017-01-01

INTRODUCTION The purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) surgery. METHODS All patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair [PR], primary diversion [PD] or DC) and outcome (complications and mortality rate). Results A total of 128 patients sustained a colonic injury during the study period. Ninety-seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died. CONCLUSIONS PR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable. PMID:27659359

The management of colonic trauma in the damage control era.

PubMed

Shazi, B; Bruce, J L; Laing, G L; Sartorius, B; Clarke, D L

2017-01-01

INTRODUCTION The purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) surgery. METHODS All patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair [PR], primary diversion [PD] or DC) and outcome (complications and mortality rate). Results A total of 128 patients sustained a colonic injury during the study period. Ninety-seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died. CONCLUSIONS PR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable.

[Integration of psychodynamic imaginative trauma therapy in a modified psychoanalytic concept of a inpatient psychotherapy unit].

PubMed

Beckrath-Wilking, Ulrike

2004-11-01

Results of latest neurobiological trauma-research suggest that many psychic disorders like personality disorders with complex traumatisation in patient's history and co-morbidities should better be treated as posttraumatic disorders. This is important for any therapy planning: should a modified psychoanalytic approach (like TFP by Kernberg) with emphasis on interpreting the transference-relation be preferred for patients with Borderline personality disorder or - diagnosing the same patients as complex posttraumatic stress disorder - a phase oriented trauma-specific approach. As such PITT combines psychodynamic understanding with hypnotherapeutic and imaginative methods. Crucial points are an active and supporting therapeutic relation, safety and reduction of stress, focus on all individual resources and use of imaginative ways for stabilization and later trauma-confrontation work.

[Establishement for regional pelvic trauma database in Hunan Province].

PubMed

Cheng, Liang; Zhu, Yong; Long, Haitao; Yang, Junxiao; Sun, Buhua; Li, Kanghua

2017-04-28

To establish a database for pelvic trauma in Hunan Province, and to start the work of multicenter pelvic trauma registry.
 Methods: To establish the database, literatures relevant to pelvic trauma were screened, the experiences from the established trauma database in China and abroad were learned, and the actual situations for pelvic trauma rescue in Hunan Province were considered. The database for pelvic trauma was established based on the PostgreSQL and the advanced programming language Java 1.6.
 Results: The complex procedure for pelvic trauma rescue was described structurally. The contents for the database included general patient information, injurious condition, prehospital rescue, conditions in admission, treatment in hospital, status on discharge, diagnosis, classification, complication, trauma scoring and therapeutic effect. The database can be accessed through the internet by browser/servicer. The functions for the database include patient information management, data export, history query, progress report, video-image management and personal information management.
 Conclusion: The database with whole life cycle pelvic trauma is successfully established for the first time in China. It is scientific, functional, practical, and user-friendly.

Using existing case-mix methods to fund trauma cases.

PubMed

Monakova, Julia; Blais, Irene; Botz, Charles; Chechulin, Yuriy; Picciano, Gino; Basinski, Antoni

2010-01-01

Policymakers frequently face the need to increase funding in isolated and frequently heterogeneous (clinically and in terms of resource consumption) patient subpopulations. This article presents a methodologic solution for testing the appropriateness of using existing grouping and weighting methodologies for funding subsets of patients in the scenario where a case-mix approach is preferable to a flat-rate based payment system. Using as an example the subpopulation of trauma cases of Ontario lead trauma hospitals, the statistical techniques of linear and nonlinear regression models, regression trees, and spline models were applied to examine the fit of the existing case-mix groups and reference weights for the trauma cases. The analyses demonstrated that for funding Ontario trauma cases, the existing case-mix systems can form the basis for rational and equitable hospital funding, decreasing the need to develop a different grouper for this subset of patients. This study confirmed that Injury Severity Score is a poor predictor of costs for trauma patients. Although our analysis used the Canadian case-mix classification system and cost weights, the demonstrated concept of using existing case-mix systems to develop funding rates for specific subsets of patient populations may be applicable internationally.

Attempting to validate the overtriage/undertriage matrix at a Level I trauma center

PubMed Central

Davis, James W.; Dirks, Rachel C.; Sue, Lawrence P.; Kaups, Krista L.

2017-01-01

BACKGROUND The Optimal Resources Document mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the overtriage/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different, and Matrix does not discriminate the needs or outcomes of these different groups of patients. METHODS Trauma registry data, from January 2013 to December 2015, at a Level I trauma center, were reviewed. Overtriage and undertriage rates were calculated by Matrix. Patients with Injury Severity Score (ISS) of 16 or greater were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared with patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, intensive care unit admission, length of stay, and mortality. RESULTS Seven thousand thirty-one patients met activation criteria. Compliance with American College of Surgeons tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2,282 patients with an ISS of 16 or greater, 1,026 were appropriately triaged (full activation), and 1,256 were undertriaged. Undertriaged patients had better Glasgow Coma Scale score, blood pressure, and base deficit than patients with full activation. Intensive care unit admission, hospital stays, and mortality were lower in the undertriaged group. The undertriaged group required fewer operative interventions with fewer delays to procedure. CONCLUSION Despite having an ISS of 16 or greater, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The American College of Surgeons Committee on Trauma full and tiered activation criteria are a robust means to have the appropriate personnel present based on the available prehospital information. Evaluation of the process of care, regardless of level of activation, should be used to evaluate trauma center performance. LEVEL OF EVIDENCE Therapeutic and care management, level III. PMID:29189678

Ventilator-associated pneumonia rates at major trauma centers compared with a national benchmark: a multi-institutional study of the AAST.

PubMed

Michetti, Christopher P; Fakhry, Samir M; Ferguson, Pamela L; Cook, Alan; Moore, Forrest O; Gross, Ronald

2012-05-01

Ventilator-associated pneumonia (VAP) rates reported by the National Healthcare Safety Network (NHSN) are used as a benchmark and quality measure, yet different rates are reported from many trauma centers. This multi-institutional study was undertaken to elucidate VAP rates at major trauma centers. VAP rate/1,000 ventilator days, diagnostic methods, institutional, and aggregate patient data were collected retrospectively from a convenience sample of trauma centers for 2008 and 2009 and analyzed with descriptive statistics. At 47 participating Level I and II centers, the pooled mean VAP rate was 17.2 versus 8.1 for NHSN (2006-2008). Hospitals' rates were highly variable (range, 1.8-57.6), with 72.3% being above NHSN's mean. Rates differed based on who determined the rate (trauma service, 27.5; infection control or quality or epidemiology, 11.9; or collaborative effort, 19.9) and the frequency with which VAP was excluded based on aspiration or diagnosis before hospital day 5. In 2008 and 2009, blunt trauma patients had higher VAP rates (17.3 and 17.6, respectively) than penetrating patients (11.0 and 10.9, respectively). More centers used a clinical diagnostic strategy (57%) than a bacteriologic strategy (43%). Patients with VAP had a mean Injury Severity Score of 28.7, mean Intensive Care Unit length of stay of 20.8 days, and a 12.2% mortality rate. 50.5% of VAP patients had a traumatic brain injury. VAP rates at major trauma centers are markedly higher than those reported by NHSN and vary significantly among centers. Available data are insufficient to set benchmarks, because it is questionable whether any one data set is truly representative of most trauma centers. Application of a single benchmark to all centers may be inappropriate, and reliable diagnostic and reporting standards are needed. Prospective analysis of a larger data set is warranted, with attention to injury severity, risk factors specific to trauma patients, diagnostic method used, VAP definitions and exclusions, and reporting guidelines. III, prognostic study.

The significance of routine thoracic computed tomography in patients with blunt chest trauma.

PubMed

Çorbacıoğlu, Seref Kerem; Er, Erhan; Aslan, Sahin; Seviner, Meltem; Aksel, Gökhan; Doğan, Nurettin Özgür; Güler, Sertaç; Bitir, Aysen

2015-05-01

The purpose of this study is to investigate whether the use of thoracic computed tomography (TCT) as part of nonselective computed tomography (CT) guidelines is superior to selective CT during the diagnosis of blunt chest trauma. This study was planned as a prospective cohort study, and it was conducted at the emergency department between 2013 and 2014. A total of 260 adult patients who did not meet the exclusion criteria were enrolled in the study. All patients were evaluated by an emergency physician, and their primary surveys were completed based on the Advanced Trauma Life Support (ATLS) principles. Based on the initial findings and ATLS recommendations, patients in whom thoracic CT was indicated were determined (selective CT group). Routine CTs were then performed on all patients. Thoracic injuries were found in 97 (37.3%) patients following routine TCT. In 53 (20%) patients, thoracic injuries were found by selective CT. Routine TCT was able to detect chest injury in 44 (16%) patients for whom selective TCT would not otherwise be ordered based on the EP evaluation (nonselective TCT group). Five (2%) patients in this nonselective TCT group required tube thoracostomy, while there was no additional treatment provided for thoracic injuries in the remaining 39 (15%). In conclusion, we found that the nonselective TCT method was superior to the selective TCT method in detecting thoracic injuries in patients with blunt trauma. Furthermore, we were able to demonstrate that the nonselective TCT method can change the course of patient management albeit at low rates. Copyright © 2014 Elsevier Ltd. All rights reserved.

The Epidemiology of and Outcome from Pancreatoduodenal Trauma in the UK, 1989–2013

PubMed Central

Bouamra, O; Kausar, A; Dickson, EJ; Lecky, F

2015-01-01

Introduction Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989–2013. Methods The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both. Results Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14–35) for blunt trauma and 14 (IQR: 9–18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation. Conclusions Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets. PMID:25723689

Neuro-, Trauma -, or Med/Surg-ICU: Does it matter where polytrauma patients with TBI are admitted? Secondary analysis of AAST-MITC decompressive craniectomy study

PubMed Central

Scalea, Tom; Sperry, Jason; Coimbra, Raul; Vercruysse, Gary; Jurkovich, Gregory J; Nirula, Ram

2016-01-01

Introduction Patients with non-traumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without TBI fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU) and trauma intensive care units (TICU) in the management of TBI patients, and it remains unclear which TBI patients are best served in NICU, TICU, or general (Med/Surg) ICU. Methods This study is a secondary analysis of The American Association for the Surgery of Trauma Multi-Institutional Trials Committee (AAST-MITC) decompressive craniectomy study. Twelve Level 1 trauma centers provided clinical data and head CT scans of patients with Glasgow Coma Scale (GCS) ≤13 and CT evidence of TBI. Non-ICU admissions were excluded. Multivariate logistic regression was performed to measure the association between ICU-type and survival and calculate the probability of death for increasing ISS. Polytrauma patients (ISS > 15) with TBI and isolated TBI patients (other AIS < 3) were analyzed separately. Results There were 3641 patients with CT evidence of TBI with 2951 admitted to an ICU. Prior to adjustment, patient demographics, injury severity, and survival differed significantly by unit type. After adjustment, unit-type, age and ISS remained independent predictors of death. Unit-type modified the effect of ISS on mortality. TBI-polytrauma patients admitted to a TICU had improved survival across increasing ISS (Fig1). Survival for isolated TBI patients was similar between TICU and NICU. Med/Surg ICU carried the greatest probability of death. Conclusion Polytrauma patients with TBI have lower mortality risk when admitted to a Trauma ICU. This survival benefit increases with increasing injury severity. Isolated TBI patients have similar mortality risk when admitted to a Neuro ICU compared to a Trauma ICU. Med/Surg ICU admission carries the highest mortality risk. PMID:28225527

Extracting Sexual Trauma Mentions from Electronic Medical Notes Using Natural Language Processing.

PubMed

Divita, Guy; Brignone, Emily; Carter, Marjorie E; Suo, Ying; Blais, Rebecca K; Samore, Matthew H; Fargo, Jamison D; Gundlapalli, Adi V

2017-01-01

Patient history of sexual trauma is of clinical relevance to healthcare providers as survivors face adverse health-related outcomes. This paper describes a method for identifying mentions of sexual trauma within the free text of electronic medical notes. A natural language processing pipeline for information extraction was developed and scaled to handle a large corpus of electronic medical notes used for this study from US Veterans Health Administration medical facilities. The tool was used to identify sexual trauma mentions and create snippets around every asserted mention based on a domain-specific lexicon developed for this purpose. All snippets were evaluated by trained human reviewers. An overall positive predictive value (PPV) of 0.90 for identifying sexual trauma mentions from the free text and a PPV of 0.71 at the patient level are reported. The metrics are superior for records from female patients.

Distribution of different yeasts isolates among trauma patients and comparison of accuracy in identification of yeasts by automated method versus conventional methods for better use in low resource countries.

PubMed

Rajkumari, N; Mathur, P; Xess, I; Misra, M C

2014-01-01

As most trauma patients require long-term hospital stay and long-term antibiotic therapy, the risk of fungal infections in such patients is steadily increasing. Early diagnosis and rapid treatment is life saving in such critically ill trauma patients. To see the distribution of various species of Candida among trauma patients and compare the accuracy, rapid identification and cost effectiveness between VITEK 2, CHROMagar and conventional methods. Retrospective laboratory-based surveillance study performed over a period of 52 months (January 2009 to April 2013) at a level I trauma centre in New Delhi, India. All microbiological samples positive for Candida were processed for microbial identification using standard methods. Identification of Candida was done using chromogenic medium and by automated VITEK 2 Compact system and later confirmed using the conventional method. Time to identification in both was noted and accuracy compared with conventional method. Performed using the SPSS software for Windows (SPSS Inc. Chicago, IL, version 15.0). P values calculated using χ2 test for categorical variables. A P<0.05 was considered significant. Out of 445 yeasts isolates, Candida tropicalis (217, 49%) was the species that was maximally isolated. VITEK 2 was able to correctly identify 354 (79.5%) isolates but could not identify 48 (10.7%) isolates and wrongly identified or showed low discrimination in 43 (9.6%) isolates but CHROM agar correctly identified 381 (85.6%) isolates with 64 (14.4%) misidentification. Highest rate of misidentification was seen in C. tropicalis and C. glabrata (13, 27.1% each) by VITEK 2 and among C. albicans (9, 14%) by CHROMagar. Though CHROMagar gives identification at a lower cost compared with VITEK 2 and are more accurate, which is useful in low resource countries, its main drawback is the long duration taken for complete identification.

Retrospective Analysis of Duodenal Injuries: A Comprehensive Overview

PubMed Central

Pandey, Sanjay; Niranjan, Ashutosh; Mishra, Shashank; Agrawal, Tarun; Singhal, Basant M.; Prakash, Akhil; Attri, Prakash C.

2011-01-01

Background/Aim: Duodenal injury is an uncommon finding, accounting for about about 3 – 5% of abdominal trauma, mainly resulting from both penetrating and blunt trauma, and is associated with significant mortality (6 - 25%) and morbidity (30 - 60%). Patients and Methods: Retrospective analysis was performed in terms of presentation, management, morbidity and mortality on 14 patients of duodenal injuries out of a total of 172 patients of abdominal trauma attending Subharti Medical College. Results: Epigastric pain (100%) along with vomiting (100%) is the usual presentation of duodenal injuries in blunt abdominal trauma, especially to the upper abdomen. Computed tomography (CT) was diagnostic in all cases. Isolated duodenal injury is a rare finding and the second part is mostly affected. Conclusion: Duodenal injury should always be suspected in blunt upper abdominal trauma, especially in those presenting with epigastric pain and vomiting. Investigation by CT and early surgical intervention in these patients are valuable tools to reduce the morbidity and mortality. PMID:21372354

[Minilaparoscopy in penetrating abdominal trauma emergency room procedure with local anesthesia].

PubMed

Ariel, Peralta; Sebastián, Vélez; Sergio, Locicero; Nicolini, Francisco Florez

2007-01-01

There are a number of unnecessary laparotomies in penetrating trauma, with a non worthless percentage of complications. When the peritoneal injury is identified, surgical exploration of the abdomen should be evaluated. Evaluate the penetration of the peritoneum, using a diagnose method with direct vision. Hospital de Urgencias de Córdoba. Trauma Hospital. To evidence peritoneum trespassing, laparoscopy was performed with local anaesthesia in patients with penetrating abdominal trauma without signs of abdominal injury in the imaging methods and doubts in the physical examination, in a prospective setting. Patient with penetrating abdominal trauma, treated between May 2004 to January 2005, with doubtful diagnose of peritoneal violation. Under sedation and local anaesthesia, a 5 millimetres laparoscope with 90 degrees vision was placed at umbilicus. The anterior abdominal wall, flanks and diaphragm were exanimate, looking for the peritoneal wound or free fluid. Laparotomy could be avoided in four patients. In the four remaining, laparoscopy or conventional surgery was performed. Two presented hollow viscera injury, one hemoperitoneo and the other, minimum liver damage. There were not complications in both groups. The average hospital stay of the first group was 13 hours. In selected patients, the minilaparoscopy is useful in decreased the percentage of unnecessary laparotomies and general anaesthesia, and its complications.

Acute management and outcome of multiple trauma patients with pelvic disruptions

PubMed Central

2012-01-01

Introduction Data on prehospital and trauma-room fluid management of multiple trauma patients with pelvic disruptions are rarely reported. Present trauma algorithms recommend early hemorrhage control and massive fluid resuscitation. By matching the German Pelvic Injury Register (PIR) with the TraumaRegister DGU (TR) for the first time, we attempt to assess the initial fluid management for different Tile/OTA types of pelvic-ring fractures. Special attention was given to the patient's posttraumatic course, particularly intensive care unit (ICU) data and patient outcome. Methods A specific match code was applied to identify certain patients with pelvic disruptions from both PIR and TR anonymous trauma databases, admitted between 2004 and 2009. From the resulting intersection set, a retrospective analysis was done of prehospital and trauma-room data, length of ICU stay, days of ventilation, incidence of multiple organ dysfunction syndrome (MODS), sepsis, and mortality. Results In total, 402 patients were identified. Mean ISS was 25.9 points, and the mean of patients with ISS ≥16 was 85.6%. The fracture distribution was as follows: 19.7% type A, 29.4% type B, 36.6% type C, and 14.3% isolated acetabular and/or sacrum fractures. The type B/C, compared with type A fractures, were related to constantly worse vital signs that necessitated a higher volume of fluid and blood administration in the prehospital and/or the trauma-room setting. This group of B/C fractures were also related to a significantly higher presence of concomitant injuries and related to increased ISS. This was related to increased ventilation and ICU stay, increased rate of MODS, sepsis, and increased rate of mortality, at least for the type C fractures. Approximately 80% of the dead had sustained type B/C fractures. Conclusions The present study confirms the actuality of traditional trauma algorithms with initial massive fluid resuscitation in the recent therapy of multiple trauma patients with pelvic disruptions. Low-volume resuscitation seems not yet to be accepted in practice in managing this special patient entity. Mechanically unstable pelvic-ring fractures type B/C (according to the Tile/OTA classification) form a distinct entity that must be considered notably in future trauma algorithms. PMID:22913820

Ten years of major equestrian injury: are we addressing functional outcomes?

PubMed Central

Ball, Jill E; Ball, Chad G; Mulloy, Robert H; Datta, Indraneel; Kirkpatrick, Andrew W

2009-01-01

Background Horseback riding is considered more dangerous than motorcycle riding, skiing, automobile racing, football and rugby. The integral role of rehabilitation therapy in the recovery of patients who have sustained a major horse-related injury is previously not described. The goals of this paper were to (1) define the incidence and pattern of severe equestrian trauma, (2) identify the current level of in-patient rehabilitation services, (3) describe functional outcomes for patients, and (4) discuss methods for increasing rehabilitation therapy in this unique population. Methods and results A retrospective review of the trauma registry at a level 1 center (1995–2005) was completed in conjunction with a patient survey outlining formal in-hospital therapy. Forty-nine percent of patients underwent in-patient rehabilitation therapy. Injuries predictive of receiving therapy included musculoskeletal and spinal cord trauma. Previous injury while horseback riding was predictive of not receiving therapy. The majority (55%) of respondents had chronic physical difficulties following their accident. Conclusion Rehabilitation therapy is significantly underutilized following severe equestrian trauma. Increased therapy services should target patients with brain, neck and skull injuries. Improvements in the initial provision, and follow-up of rehabilitation therapy could enhance functional outcomes in the treatment resistant Western equestrian population. PMID:19228424

Trauma Registry of the Pan-American Trauma Society: One year of experience in two hospitals in southwest Colombia

PubMed Central

Ordoñez, Carlos A; Rojas-Mirquez, Johanna Carolina; Bonilla-Escobar, Francisco Javier; Badiel, Marisol; Miñán Arana, Fernando; González, Adolfo; Pino, Luis Fernando; Uribe-Gómez, Amadeus; Herrera, Mario Alain; Gutiérrez-Martínez, Maria Isabel; Puyana, Juan Carlos; Abutanos, Michael; Ivatury, Rao R

2016-01-01

Background: Trauma information systems are needed to improve decision making and to identify potential areas of intervention. Objective: To describe the first year of experience with a trauma registry in two referral centers in southwest Colombia. Methods: The study was performed in two referral centers in Cali. Patients with traumatic injuries seen between January 1 and December 31, 2012, were included. The collected information included demographics, mechanism of trauma, injury severity score (ISS), and mortality. A descriptive analysis was carried out. Results: A total of 17,431 patients were registered, of which 67.8% were male with an average age of 30 (±20) years. Workplace injuries were the cause of emergency consultations in 28.2% of cases, and falls were the most common mechanism of trauma (37.3%). Patients with an ISS ≥15 were mostly found in the 18-35-year age range (6.4%). Most patients who suffered a gunshot wound presented an ISS ≥15. A total of 2.5% of all patients died, whereas the mortality rate was 54% among patients with an ISS ≥15 and a gunshot wound. Conclusion: Once the trauma registry was successfully implemented in two institutions in Cali, the primary causes of admission were identified as falls and workplace injuries. The most severely compromised patients were in the population range between 18 and 35 years of age. The highest mortality was caused by gunshot wounds. PMID:27821894

Helicopter Emergency Medical Services (HEMS) over-triage and the financial implications for major trauma centres in NSW, Australia

PubMed Central

2013-01-01

Background In NSW Australia, a formal trauma system including the use of helicopter emergency medical services (HEMS) has existed for over 20 years. Despite providing many advantages in NSW, HEMS patients are frequently over-triaged; leading to financial implications for major trauma centres that receive HEMS patients. The aim of this study was to investigate the financial implications of HEMS over-triage from the perspective of major trauma centres in NSW. Methods The study sample included all trauma patients transported via HEMS to 12 major trauma centres in NSW during the period: 1 July 2008 to 30 June 2009. Clinical data were gathered from individual hospital trauma registries and merged with financial information obtained from casemix units at respective hospitals. HEMS over-triage was estimated based on the local definition of minor to moderate trauma (ISS≤12) and hospital length of stay of less than 24 hrs. The actual treatment costs were determined and compared to state-wide peer group averages to obtain estimates of potential funding discrepancies. Results A total of 707 patients transported by HEMS were identified, including 72% pre-hospital (PH; n=507) and 28% inter-hospital (IH; n=200) transports. Over-triage was estimated at 51% for PH patients and 29% for IH patients. Compared to PH patients, IH patients were more costly to treat on average (IH: $42,604; PH: $25,162), however PH patients were more costly overall ($12,329,618 [PH]; $8,265,152 [IH]). When comparing actual treatment costs to peer group averages we found potential funding discrepancies ranging between 4% and 32% across patient groups. Using a sensitivity analysis, the potential funding discrepancy increased with increasing levels of over-triage. Conclusions HEMS patients are frequently over-triaged in NSW, leading to funding implications for major trauma centres. In general, HEMS patient treatment costs are higher than the peer group average and the potential funding discrepancy varies by injury severity and the type of transport performed. Although severely injured HEMS patients are more costly to treat, HEMS patients with minor injuries make up the majority of HEMS transports and have larger relative potential funding discrepancies. Future episode funding models need to account for the variability of trauma patients and the proportion of patients transported via HEMS. PMID:23815080

Scapular Fractures in Blunt Chest Trauma – Self-Experience Study

PubMed Central

Al-Sadek, Tabet A.; Niklev, Desislav; Al-Sadek, Ahmed; Al-Sadek, Lina

2016-01-01

AIM: The aim of this retrospective study was to report the scapular fractures in patients with blunt chest trauma and to present the type and the frequency of associated thoracic injuries. MATERIAL AND METHODS: Nine patients with fractures of the scapula were included in the study. The mechanisms of the injury, the type of scapular fractures and associated thoracic injuries were analysed. RESULTS: Scapular fractures were caused by high-energy blunt chest trauma. The body of the scapula was fractured in all scapular fractures. In all cases, scapular fractures were associated with other thoracic injuries (average 3.25/per case). Rib fractures were present in eight patients, fractured clavicula - in four cases, the affection of pleural cavity - in eight of the patients and pulmonary contusion in all nine cases. Eight patients were discharged from the hospital up to the 15th day. One patient had died on the 3rd day because of postconcussional lung oedema. CONCLUSIONS: The study confirms the role of scapular fractures as a marker for the severity of the chest trauma (based on the number of associated thoracic injuries), but doesn’t present scapular fractures as an indicator for high mortality in blunt chest trauma patients. PMID:28028415

Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center

PubMed Central

Wang, Hao; Coppola, Marco; Robinson, Richard D.; Scribner, James T.; Vithalani, Veer; de Moor, Carrie E.; Gandhi, Raj R.; Burton, Mandy; Delaney, Kathleen A.

2013-01-01

Background It has been found that significantly different clinical outcomes occur in trauma patients with different mechanisms of injury. Ground level falls (GLF) are usually considered “minor trauma” with less injury occurred in general. However, it is not uncommon that geriatric trauma patients sustain cervical spine (C-spine) fractures with other associated injuries due to GLF or less. The aim of this study is to determine the injury patterns and the roles of clinical risk factors in these geriatric trauma patients. Methods Data were reviewed from the institutional trauma registry of our local level 1 trauma center. All patients had sustained C-spine fracture(s). Basic clinical characteristics, the distribution of C-spine fracture(s), and mechanism of injury in geriatric patients (65 years or older) were compared with those less than 65 years old. Furthermore, different clinical variables including age, gender, Glasgow coma scale (GCS), blood alcohol level, and co-existing injuries were analyzed by multivariate logistic regression in geriatric trauma patients due to GLF and internally validated by random bootstrapping technique. Results From 2006 - 2010, a total of 12,805 trauma patients were included in trauma registry, of which 726 (5.67%) had sustained C-spine fracture(s). Among all C-spine fracture patients, 19.15% (139/726) were geriatric patients. Of these geriatric patients 27.34% (38/139) and 53.96% (75/139) had C1 and C2 fractures compared with 13.63% (80/587) and 21.98% (129/587) in young trauma patients (P < 0.001). Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139) had C6 and C7 fractures compared with 32.03% (188/587) and 41.40% (243/587) in younger ones separately (P < 0.001). Furthermore, 53.96% (75/139) geriatric patients had sustained C-spine fractures due to GLF with more upper C-spine fractures (C1 and C2). Only 3.2% of those had positive blood alcohol levels compared with 52.9% of younger patients (P < 0.001). In addition, 6.34% of geriatric patients due to GLF had intracranial pathology (ICP) which was one of the most common co-injuries with C-spine fractures. Logistic regression analysis showed the adjusted odds ratios of 1.17 (age) and 91.57 (male) in geriatric GLF patients to predict this co-injury pattern of C-spine fracture and ICP. Conclusion Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. GLF or less not only can cause isolated C-spines fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients. PMID:23519239

Severity-Adjusted Mortality in Trauma Patients Transported by Police

PubMed Central

Band, Roger A.; Salhi, Rama A.; Holena, Daniel N.; Powell, Elizabeth; Branas, Charles C.; Carr, Brendan G.

2018-01-01

Study objective Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia. Methods This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Results Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. Conclusion We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care. PMID:24387925

A 2D threshold of the condylar-C1 interval to maximize identification of patients at high risk for atlantooccipital dislocation using computed tomography.

PubMed

Ravindra, Vijay M; Riva-Cambrin, Jay; Horn, Kevin P; Ginos, Jason; Brockmeyer, Russell; Guan, Jian; Rampton, John; Brockmeyer, Douglas L

2017-04-01

OBJECTIVE Measurement of the occipital condyle-C1 interval (CCI) is important in the evaluation of atlantooccipital dislocation (AOD) in pediatric trauma patients. The authors studied a large cohort of children with and without AOD to identify a 2D measurement threshold that maximizes the diagnostic yield of the CCI on cervical spine CT scans obtained in trauma patients. METHODS This retrospective, single-center study included all children who underwent CT of the cervical spine at Primary Children's Hospital from January 1, 2011, through December 31, 2014, for trauma evaluation. Bilateral CCI measurements in the coronal (3 measurements per side) and sagittal (4 measurements per side) planes were recorded. Using an iterative method, the authors determined optimal cutoffs for the maximal CCI in each plane in relation to AOD. The primary outcome was AOD requiring occipitocervical fusion. RESULTS A total of 597 pediatric patients underwent cervical spine CT for trauma evaluation: 578 patients without AOD and 19 patients with AOD requiring occipitocervical fusion. The authors found a statistically significant correlation between CCI and age (p < 0.001), with younger patients having higher CCIs. Using a 2D threshold requiring a sagittal CCI ≥ 2.5 mm and a coronal CCI ≥ 3.5 mm predicted AOD with a sensitivity of 95%, a specificity of 73%, positive predictive value of 10.3%, and negative predictive value of 99%. The accuracy of this 2D threshold was 84%. CONCLUSIONS In the present study population, age-dependent differences in the CCI were found on CT scans of the cervical spine in a large cohort of patients with and without AOD. A 2D CCI threshold as a screening method maximizes identification of patients at high risk for AOD while minimizing unnecessary imaging studies in children being evaluated for trauma.

Childhood Trauma and Minimization/Denial in People with and without a Severe Mental Disorder.

PubMed

Church, Chelsea; Andreassen, Ole A; Lorentzen, Steinar; Melle, Ingrid; Aas, Monica

2017-01-01

Background: Childhood trauma has garnered extensive research concerning its role in the psychopathology of mental disorders, including psychosis. The Childhood Trauma Questionnaire (CTQ) utilizes a minimization/denial (MD) scale to denote potential under-reporters of trauma, yet MD scores are infrequently reported and validations of the scale are lacking in the literature. Elucidate differences in MD between patients with severe mental disorders to healthy individuals, and secondly, investigate if MD influences reports of childhood trauma between the groups. Methods: We included 621 patients with a DSM-schizophrenia spectrum, bipolar spectrum diagnosis, or major depression disorder with psychotic features and 299 healthy controls as part of the NORMENT study in Oslo, Norway. History of childhood trauma was obtained using the CTQ. Clinical diagnoses were assessed using the Structured Clinical Interview for DSM Disorders. Results: A significantly greater proportion of healthy controls (42.8%) had a positive MD score compared to patients (26.7%). When controlling for MD, the patient group still exhibited elevated reports of childhood trauma compared to controls (Cohen's d = 1.27), concordant with reports of childhood trauma being more frequently reported in a population of severe mental disorders. Conclusion: Elevated MD in the healthy control group could suggest an enhanced self-serving bias, potentially attenuated in the psychiatric group. Clinicians and researchers would benefit from including the MD component of CTQ when assessing retrospective information on childhood trauma to rule out potential effect of MD.

The Perception of Trauma Patients from Social Support in Adjustment to Lower-Limb Amputation: A Qualitative Study

PubMed Central

Valizadeh, Sousan; Dadkhah, Behrouz; Mohammadi, Eissa; Hassankhani, Hadi

2014-01-01

Introduction: The effect of amputation on an individual's psychological condition as well as family and social relationships is undeniable because physical disability not just affects the psycho-social adjustment, but also the mental health. When compared to normal people, such people are mostly experiencing social isolation. On the other hand, social support is known as the most powerful force to cope with stressful situations and it allows patients to withstand problems. The present study aims to explain understanding the trauma of patients and the experience of support sources during the process of adaptation to a lower limb amputation. Materials and Methods: The present study was conducted using qualitative content analysis. Participants included 20 patients with lower limb amputation due to trauma. Sampling was purposive initially and continued until data saturation. Unstructured interviews were used as the main method of data collection. Collected data were analyzed using qualitative content analysis and constant comparison methods. Results: The main theme extracted from the data was support sources. The classes include “supportive family”, “gaining friends’ support”, “gaining morale from peers”, and “assurance and satisfaction with the workplace.” Conclusion: Given the high number of physical, mental and social problems in trauma patients, identifying and strengthening support sources can be effective in their adaptation with the disease and improvement of the quality of their life. PMID:25191013

Trauma Transitional Care Coordination: protecting the most vulnerable trauma patients from hospital readmission

PubMed Central

Hall, Erin C; Tyrrell, Rebecca; Scalea, Thomas M; Stein, Deborah M

2018-01-01

Background Unplanned hospital readmissions increase healthcare costs and patient morbidity. We hypothesized that a program designed to reduce trauma readmissions would be effective. Methods A Trauma Transitional Care Coordination (TTCC) program was created to support patients at high risk for readmission. TTCC interventions included call to patient (or caregiver) within 72 hours of discharge to identify barriers to care, complete medication reconciliation, coordination of appointments, and individualized problem solving. Information on all 30-day readmissions was collected. 30-day readmission rates were compared with center-specific readmission rates and population-based, risk-adjusted rates of readmission using published benchmarks. Results 260 patients were enrolled in the TTCC program from January 2014 to September 2015. 30.8% (n=80) of enrollees were uninsured, 41.9% (n=109) reported current substance abuse, and 26.9% (n=70) had a current psychiatric diagnosis. 74.2% (n=193) attended outpatient trauma appointments within 14 days of discharge. 96.3% were successfully followed. Only 6.6% (n=16) of patients were readmitted in the first 30 days after discharge. This was significantly lower than both center-specific readmission rates before start of the program (6.6% vs. 11.3%, P=0.02) and recently published population-based trauma readmission rates (6.6% vs. 27%, P<0.001). Discussion A nursing-led TTCC program successfully followed patients and was associated with a significant decrease in 30-day readmission rates for patients with high-risk trauma. Targeted outpatient support for these most vulnerable patients can lead to better utilization of outpatient resources, increased patient satisfaction, and more consistent attainment of preinjury level of functioning or better. Level of evidence Level IV. PMID:29766133

Sphenoid Sinus and Sphenoid Bone Fractures in Patients with Craniomaxillofacial Trauma

PubMed Central

Cantini Ardila, Jorge Ernesto; Mendoza, Miguel Ángel Rivera; Ortega, Viviana Gómez

2013-01-01

Background and Purpose Sphenoid bone fractures and sphenoid sinus fractures have a high morbidity due to its association with high-energy trauma. The purpose of this study is to describe individuals with traumatic injuries from different mechanisms and attempt to determine if there is any relationship between various isolated or combined fractures of facial skeleton and sphenoid bone and sphenoid sinus fractures. Methods We retrospectively studied hospital charts of all patients who reported to the trauma center at Hospital de San José with facial fractures from December 2009 to August 2011. All patients were evaluated by computed tomography scan and classified into low-, medium-, and high-energy trauma fractures, according to the classification described by Manson. Design This is a retrospective descriptive study. Results The study data were collected as part of retrospective analysis. A total of 250 patients reported to the trauma center of the study hospital with facial trauma. Thirty-eight patients were excluded. A total of 212 patients had facial fractures; 33 had a combination of sphenoid sinus and sphenoid bone fractures, and facial fractures were identified within this group (15.5%). Gender predilection was seen to favor males (77.3%) more than females (22.7%). The mean age of the patients was 37 years. Orbital fractures (78.8%) and maxillary fractures (57.5%) were found more commonly associated with sphenoid sinus and sphenoid bone fractures. Conclusions High-energy trauma is more frequently associated with sphenoid fractures when compared with medium- and low-energy trauma. There is a correlation between facial fractures and sphenoid sinus and sphenoid bone fractures. A more exhaustive multicentric case-control study with a larger sample and additional parameters will be essential to reach definite conclusions regarding the spectrum of fractures of the sphenoid bone associated with facial fractures. PMID:24436756

The Necessity of Follow-Up Brain Computed-Tomography Scans: Is It the Pathology Itself Or Our Fear that We Should Overcome?

PubMed Central

Öğrenci, Ahmet; Koban, Orkun; Ekşi, Murat; Yaman, Onur; Dalbayrak, Sedat

2017-01-01

AIM: This study aimed to make a retrospective analysis of pediatric patients with head traumas that were admitted to one hospital setting and to make an analysis of the patients for whom follow-up CT scans were obtained. METHODS: Pediatric head trauma cases were retrospectively retrieved from the hospital’s electronic database. Patients’ charts, CT scans and surgical notes were evaluated by one of the authors. Repeat CT scans for operated patients were excluded from the total number of repeat CT scans. RESULTS: One thousand one hundred and thirty-eight pediatric patients were admitted to the clinic due to head traumas. Brain CT scan was requested in 863 patients (76%) in the cohort. Follow-up brain CT scans were obtained in 102 patients. Additional abnormal finding requiring surgical intervention was observed in only one patient (isolated 4th ventricle hematoma) on the control CTs (1% of repeat CT scans), who developed obstructive hydrocephalus. None of the patients with no more than 1 cm epidural hematoma in its widest dimension and repeat CT scans obtained 1.5 hours after the trauma necessitated surgery. CONCLUSION: Follow-up CT scans changed clinical approach in only one patient in the present series. When ordering CT scan in the follow-up of pediatric traumas, benefits and harms should be weighted based upon time interval from trauma onset to initial CT scan and underlying pathology. PMID:29104682

Complications in the management of bladder trauma in a third level hospital.

PubMed

Echeverría-García, Fernando Enrique; García-Perdomo, Herney Andrés; Barney, Erika

2014-05-01

To determine the frecuency of complications during the management of bladder trauma and its associated factors in a third level reference Hospital. A cross-sectional study of adult patients admitted in a reference Hospital from January 2006 to June 2011 with the diagnosis of bladder trauma. We identified demographic variables, type of trauma (blunt, penetrating), diagnostic method, associated traumatisms, management of bladder traumatism, frequency of complications and mortality. Univariate analysis was performed with frequency tables, measures of central tendency and dispersion. Similarly, bivariate analysis was performed to explore the association between variables. We used chi-square test for categorical variables and Student's t test to compare quantitative variables. We reviewed 40 medical records, which met the eligibility criteria. The median age was 27 years (range 16-;67) and 85% (34 patients) were male. Twenty-nine patients (72.5%) had penetrating injuries, being mainly firearm projectile (96.55%) and 11 patients (27.5%) blunt injuries. Most patients had intraoperative diagnosis (67.5%), while 25%, 5% and 2% were diagnosed by CT-cystography, cystoscopy and voiding cystography respectively. 70% (28 patients) had intraperitoneal bladder injuries. Of the forty patients enrolled, thirty six (90%) underwent surgery, while only four (10%) received conservative management. A total of ten patients (25%) had some type of complication. The most frequent was persistent hematuria (40%) followed by surgical site infection (30%), orchitis (20%), urinary tract infection (10%), urine leakage through the operative site, or to the peritoneal cavity (10%). No mortality was detected. On the bivariate logistic regression model type of trauma, number of injuries, performance of cystostomy, use of perivesical drainage tube, chest trauma and small bowel trauma, no association was found with the presence of complications. The frequency of complications was 25%. The presence of gross hematuria after 72 hours of trauma was found to be the most common complication. The type of trauma, performance or not performance of cystostomy, perivesical drain, presence of associated lesions in chest or small bowel were not associated with complications.

Prediction of Chronic Subdural Hematoma in Minor Head Trauma Patients

PubMed Central

Han, Sang-Beom; Song, Shi-Hun; Youm, Jin-Young; Koh, Hyeon-Song; Kim, Seon-Hwan; Kwon, Hyon-Jo

2014-01-01

Objective Chronic subdural hematoma (CSDH) is relatively common in neurosurgical field. However not all patients develop CSDH after minor head trauma. In this study, we evaluate the risk factors of post-traumatic CSDH. Methods Two-hundred and seventy-seven patients were enrolled and analyzed in this study from January 2012 to December 2013. Of those, 20 participants had minor head trauma developed CSDH afterward. We also included 257 patients with minor head trauma who did not develop CSDH during the same follow-up period as the control group. We investigated the risk factors related to the development of CSDH after minor head trauma. Results Old age (p=0.014), preexisting diabetes mellitus (p=0.010), hypertension (p=0.026), history of cerebral infarction (p=0.035), antiplatelet agents (p=0.000), acute subdural hematoma in the convexity (p=0.000), encephalomalacia (p=0.029), and long distance between skull and brain parenchyma (p=0.000) were significantly correlated with the development of CSDH after trauma. Multivariate analysis revealed that only the maximum distance between the skull and the cerebral parenchyma was the independent risk factor for the occurrence of CSDH (hazard ratio 2.55, p=0.000). Conclusion We should consider the possibility of developing CSDH in the post-traumatic patients with the identified risk factors. PMID:27169043

The effect of paramedic training on pre-hospital trauma care (EPPTC-study): a study protocol for a prospective semi-qualitative observational trial

PubMed Central

2014-01-01

Background Accidents are the leading cause of death in adults prior to middle age. The care of severely injured patients is an interdisciplinary challenge. Limited evidence is available concerning pre-hospital trauma care training programs and the advantage of such programs for trauma patients. The effect on trauma care procedures or on the safety of emergency crews on the scene is limited; however, there is a high level of experience and expert opinion. Methods I – Video-recorded case studies are the basis of an assessment tool and checklist being developed to verify the results of programs to train participants in the care of seriously injured patients, also known as “objective structured clinical examination” (OSCE). The timing, completeness and quality of the individual measures are assessed using appropriate scales. The evaluation of team communication and interaction will be analyzed with qualitative methods and quantified and verified by existing instruments (e.g. the Clinical Team Scale). The developed assessment tool is validated by several experts in the fields of trauma care, trauma research and medical education. II a) In a German emergency medical service, the subjective assessment of paramedics of their pre-hospital care of trauma patients is evaluated at three time points, namely before, immediately after and one year after training. b) The effect of a standardized course concept on the quality of documentation in actual field operations is determined based on three items relevant to patient safety before and after the course. c) The assessment tool will be used to assess the effect of a standardized course concept on procedures and team communication in pre-hospital trauma care using scenario-based case studies. Discussion This study explores the effect of training on paramedics. After successful study completion, further multicenter studies are conceivable, which would evaluate emergency-physician staffed teams. The influence on the patients and prehospital measures should be assessed based on a retrospective analysis of the emergency room data. Trials registration German Clinical Trials Register, ID DRKS00004713. PMID:24528532

Traumatic diaphragmatic injury: a review of CT signs and the difference between blunt and penetrating injury

PubMed Central

Panda, Ananya; Kumar, Atin; Gamanagatti, Shivanand; Patil, Aruna; Kumar, Subodh; Gupta, Amit

2014-01-01

PURPOSE We aimed to present the frequency of computed tomography (CT) signs of diaphragmatic rupture and the differences between blunt and penetrating trauma. MATERIALS AND METHODS The CT scans of 23 patients with surgically proven diaphragmatic tears (both blunt and penetrating) were retrospectively reviewed for previously described CT signs of diaphragmatic injuries. The overall frequency of CT signs was reported; frequency of signs in right- and left-sided injuries and blunt and penetrating trauma were separately tabulated and statistically compared. RESULTS The discontinuous diaphragm sign was the most common sign, observed in 95.7% of patients, followed by diaphragmatic thickening (69.6%). While the dependent viscera sign and collar sign were exclusively observed in blunt-trauma patients, organ herniation (P = 0.05) and dangling diaphragm (P = 0.0086) signs were observed significantly more often in blunt trauma than in penetrating trauma. Contiguous injury on either side of the diaphragm was observed more often in penetrating trauma (83.3%) than in blunt trauma (17.7%). CONCLUSION Knowledge of the mechanism of injury and familiarity with all CT signs of diaphragmatic injury are necessary to avoid a missed diagnosis because there is variability in the overall occurrence of these signs, with significant differences between blunt and penetrating trauma. PMID:24412818

Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois

PubMed Central

Dresden, Scott M.; Powell, Emilie S.; Feinglass, Joe

2018-01-01

Introduction Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois. Methods We performed a retrospective cohort study of 87,001 trauma inpatients from third quarter 2010 through second quarter 2015, which spans the implementation of the ACA in Illinois. We examined the effects of insurance expansion on trauma mortality using multivariable Poisson regression. Results There was no significant difference in mortality comparing the post-ACA period to the pre-ACA period incident rate ratio (IRR)=1.05 (95% confidence interval [CI] [0.93–1.17]). However, mortality was significantly higher among the uninsured in the post-ACA period when compared with the pre-ACA uninsured population IRR=1.46 (95% CI [1.14–1.88]). Conclusion While the ACA has reduced the number of uninsured trauma patients in Illinois, we found no significant decrease in inpatient trauma mortality. However, the group that remains uninsured after ACA implementation appears to be particularly vulnerable. This group should be studied in order to reduce disparate outcomes after trauma. PMID:29560058

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience

PubMed Central

Xu, Min Li; Lopez, Joseph

2016-01-01

Background: Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center. Methods: We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes. Results: There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients. Conclusions: The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients. PMID:26877626

Prognostic significance of blood lactate and lactate clearance in trauma patients.

PubMed

Régnier, Marie-Alix; Raux, Mathieu; Le Manach, Yannick; Asencio, Yves; Gaillard, Johann; Devilliers, Catherine; Langeron, Olivier; Riou, Bruno

2012-12-01

Lactate has been shown to be a prognostic biomarker in trauma. Although lactate clearance has already been proposed as an intermediate endpoint in randomized trials, its precise role in trauma patients remains to be determined. Blood lactate levels and lactate clearance (LC) were calculated at admission and 2 and 4 h later in trauma patients. The association of initial blood lactate level and lactate clearance with mortality was tested using receiver-operating characteristics curve, logistic regression using triage scores, Trauma Related Injury Severity Score as a reference standard, and reclassification method. The authors evaluated 586 trauma patients (mean age 38±16 yr, 84% blunt and 16% penetrating, mortality 13%). Blood lactate levels at admission were elevated in 327 (56%) patients. The lactate clearance should be calculated within the first 2 h after admission as LC0-2 h was correlated with LC0-4 h (R=0.55, P<0.001) but not with LC2-4 h (R=0.04, not significant). The lactate clearance provides additional predictive information to initial blood lactate levels and triage scores and the reference score. This additional information may be summarized using a categorical approach (i.e., less than or equal to -20 %/h) in contrast to initial blood lactate. The results were comparable in patients with high (5 mM/l or more) initial blood lactate. Early (0-2 h) lactate clearance is an important and independent prognostic variable that should probably be incorporated in future decision schemes for the resuscitation of trauma patients.

[Modern concepts of trauma care and multiple trauma management in oral and maxillofacial region].

PubMed

Tan, Yinghui

2015-06-01

Multiple trauma management requires the application of modem trauma care theories. Optimal treatment results can be achieved by reinforcing cooperation and stipulating a treatment plan together with other disciplines. Based on modem theories in trauma care and our understanding of the theoretical points, this paper analyzes the injury assessment strategies and methods in oral and maxillofacial multiple trauma management. Moreover, this paper discusses operating time and other influencing factors as well as proposed definitive surgical timing and indications in comprehensive management of oral and maxillofacial multiple trauma patients associated with injuries in other body parts. We hope that this paper can help stomatological physicians deepen their understanding of modem trauma care theories and improve their capacity and results in the treatment of oral and maxillofacial multiple trauma.

Impact of a TeamSTEPPS Trauma Nurse Academy at a Level 1 Trauma Center.

PubMed

Peters, V Kristen; Harvey, Ellen M; Wright, Andi; Bath, Jennifer; Freeman, Dan; Collier, Bryan

2018-01-01

Nurses are crucial members of the team caring for the acutely injured trauma patient. Until recently, nurses and physicians gained an understanding of leadership and supportive roles separately. With the advent of a multidisciplinary team approach to trauma care, formal team training and simulation has transpired. Since 2007, our Level I trauma system has integrated TeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety; Agency for Healthcare Research and Quality, Rockville, MD) into our clinical care, joint training of nurses and physicians, using simulations with participation of all health care providers. With the increased expectations of a well-orchestrated team and larger number of emergency nurses, our program created the Trauma Nurse Academy. This academy provides a core of experienced nurses with an advanced level of training while decreasing the variability of personnel in the trauma bay. Components of the academy include multidisciplinary didactic education, the Essentials of TeamSTEPPS, and interactive trauma bay learning, to include both equipment and drug use. Once completed, academy graduates participate in the orientation and training of General Surgery and Emergency Medicine residents' trauma bay experience and injury prevention activities. Internal and published data have demonstrated growing evidence linking trauma teamwork training to knowledge and self-confidence in clinical judgment to team performance, patient outcomes, and quality of care. Although trauma resuscitations are stressful, high risk, dynamic, and a prime environment for error, new methods of teamwork training and collaboration among trauma team members have become essential. Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

[The efficiency of emergency therapy in patients with head-brain, multiple injury. Quality assurance in emergency medicine].

PubMed

Schüttler, J; Schmitz, B; Bartsch, A C; Fischer, M

1995-12-01

For cardio-pulmonary resuscitation there are standardized treatment concepts, but there have been few prospective investigations examining the efficacy of prehospital advanced trauma life support and its effect on the outcome in patients with severe head injury and multiple trauma treated within the German emergency system. The results of this study underline the importance of intensive prehospital treatment and highlight some problems that should be taken into account in future in the training of emergency physicians. METHODS. A total of 179 patients with cerebral trauma were investigated. Data obtained included demographic and logistic data of the patients and the emergency physicians, diagnoses and treatment at the scene of the accident and state of the patient on admission in each case. Having divided the patients into three groups by severity of the trauma, we distinguished between sufficient and insufficient treatment and assessed infusion therapy, ventilatory support, positioning and immobilization, and analgesic and sedative therapy. For statistical analysis of the data we used chi 2-test and Fisher's exact test. P < 0.05 was considered significant. RESULTS. There were 102 patients who had sustained a cerebral trauma without other life-threatening lesions (score 1), 40 with multiple trauma (score 2) and 37 with multiple trauma (score 3). On average 2.4 IV lines were established and the patients received 1186 +/- 765 cc of crystalloid in addition to 801 +/- 411 cc of colloid fluids. In all groups, patients who received adequate infusion therapy had a better outcome; even in the group with score 1 significantly fewer had a fatal outcome. In all, 167 (93%) patients had endotracheal tubes placed, and in 150 cases (84%) ventilatory therapy was considered sufficient. The proportion of score 1 patients with sufficient ventilatory support who had a fatal outcome was significantly lower than that in the group with insufficient treatment. In patients with multiple trauma we could not separate the benefits of sufficient respiratory therapy and infusion therapy. In only 54% of the cases a vacuum mattress was used and in only 41% the patients were positioned with the upper part of the body elevated by 30 degrees. These were 28 patients (16%) who received neither analgesics nor sedatives. Regardless of the quality of prehospital treatment of isolated head injury, a Glasgow Coma Scale (GCS) score lower than 5 involved a very high mortality and all patients with a GCS score of 9 or more survived. In the group with GCS scores between 5 and 8, however, significantly more of the patients who received adequate treatment survived (82.5% vs 40%). CONCLUSIONS. The present study confirms that sufficient advanced trauma life support can improve the outcome of trauma victims with cerebral trauma. Adequate infusion and respiratory therapy reduce the mortality among such patients significantly. In patients with multiple trauma a clear positive effect of generous infusion therapy also is evident. The clearest effect of sufficient prehospital treatment is seen in patients with isolated cerebral trauma and a GCS score between 5 and 8. These results demonstrate the importance of advanced trauma life support and show emphatically that the so-called scoop-and-run strategy should be abandoned when resources are available for extended preclinical emergency treatment. On the other hand, we detected some problem areas in the prehospital treatment of trauma victims, such as positioning, immobilization and drug therapy with analgesics and sedatives. These findings allow us to pinpoint specific points that should be stressed in the training of emergency physicians and paramedics.

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.

The Effect of Availability of Manpower on Trauma Resuscitation Times in a Tertiary Academic Hospital

PubMed Central

Quek, Nathaniel Xin Ern; Koh, Zhi Xiong; Nadkarni, Nivedita; Singaram, Kanageswari; Ho, Andrew Fu Wah; Ong, Marcus Eng Hock

2016-01-01

Background For trauma patients, delays to assessment, resuscitation, and definitive care affect outcomes. We studied the effects of resuscitation area occupancy and trauma team size on trauma team resuscitation speed in an observational study at a tertiary academic institution in Singapore. Methods From January 2014 to January 2015, resuscitation videos of trauma team activated patients with an Injury Severity Score of 9 or more were extracted for review within 14 days by independent reviewers. Exclusion criteria were patients dead on arrival, inter-hospital transfers, and up-triaged patients. Data captured included manpower availability (trauma team size and resuscitation area occupancy), assessment (airway, breathing, circulation, logroll), interventions (vascular access, imaging), and process-of-care time intervals (time to assessment/intervention/adjuncts, time to imaging, and total time in the emergency department). Clinical data were obtained by chart review and from the trauma registry. Results Videos of 70 patients were reviewed over a 13-month period. The median time spent in the emergency department was 154.9 minutes (IQR 130.7–207.5) and the median resuscitation team size was 7, with larger team sizes correlating with faster process-of-care time intervals: time to airway assessment (p = 0.08) and time to disposition (p = 0.04). The mean resuscitation area occupancy rate (RAOR) was 1.89±2.49, and the RAOR was positively correlated with time spent in the emergency department (p = 0.009). Conclusion Our results suggest that adequate staffing for trauma teams and resuscitation room occupancy are correlated with faster trauma resuscitation and reduced time spent in the emergency department. PMID:27136299

Clinical practice guidelines for the management of acute limb compartment syndrome following trauma.

PubMed

Wall, Christopher J; Lynch, Joan; Harris, Ian A; Richardson, Martin D; Brand, Caroline; Lowe, Adrian J; Sugrue, Michael

2010-03-01

Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency, and is associated with significant morbidity if not managed appropriately. There is variation in management of acute limb compartment syndrome in Australia. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma were developed in accordance with Australian National Health and Medical Research Council recommendations. The guidelines were based on critically appraised literature evidence and the consensus opinion of a multidisciplinary team involved in trauma management who met in a nominal panel process. Recommendations were developed for key decision nodes in the patient care pathway, including methods of diagnosis in alert and unconscious patients, appropriate assessment of compartment pressure, timing and technique of fasciotomy, fasciotomy wound management, and prevention of compartment syndrome in patients with limb injuries. The recommendations were largely consensus based in the absence of well-designed clinical trial evidence. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma have been developed that will support consistency in management and optimize patient health outcomes.

Are retrievable vena cava filters placed in trauma patients really retrievable?

PubMed

Leeper, W R; Murphy, P B; Vogt, K N; Leeper, T J; Kribs, S W; Gray, D K; Parry, N G

2016-08-01

Concerns have arisen regarding the use of retrievable inferior vena cava filters (rIVCFs) in trauma patients due to increasing reports of low retrieval rates. We hypothesized that complete follow-up with a dedicated trauma nurse practitioner would be associated with a higher rate of retrievability. This study was undertaken to determine the rate of retrievability of rIVCFs placed in a Canadian Lead Trauma Centre, and to compare the rate of retrievability in our trauma population to our non-trauma patients. We performed a retrospective cohort study of all patients with rIVCF placed between Jan 1 2000 and June 30 2014. Data were collected on demographics, indication for filter placement, retrieval status, and reasons for non-retrieval. Comparison was made between trauma patients and non-trauma patients. A total of 374 rIVCFs were placed (61 in trauma patients and 313 in non-trauma patients) and follow-up was complete for the entire cohort. Filter retrieval was achieved in 86.9 % of trauma patients. Reasons for non-retrieval were technical in two patients, and death before retrieval in six patients. Retrieval was successful in 48.9 % of non-trauma patients. This study demonstrates that rIVCFs can be successfully retrieved amongst trauma patients. We demonstrated a higher rate of successful retrieval amongst trauma patients than non-trauma patients in our institution. Careful patient follow-up may play a role in successful retrieval of rIVCFs.

Presence of the dissociative subtype of PTSD does not moderate the outcome of intensive trauma-focused treatment for PTSD

PubMed Central

2018-01-01

ABSTRACT Background: There is a widely-held belief in the trauma field that the presence of dissociative symptoms is associated with poor treatment response. However, previous research on the effect of dissociation in treatment outcomes pertained to specific patients and trauma populations. Objective: To test the hypothesis that the presence of the dissociative subtype of PTSD (DS) would have a detrimental effect on the outcome of an intensive trauma-focused treatment programme. Methods: PTSD symptom scores (Clinician Administered PTSD Scale [CAPS] and PTSD Symptom Scale Self-Report [PSS-SR]) were analysed using the data of 168 consecutive patients (70.6% female) who had been exposed to a wide variety of multiple traumas, including childhood sexual abuse, and of whom 98.2% were diagnosed with severe PTSD (CAPS > 65). Most of them suffered from multiple comorbidities and 38 (22.6%) met the criteria for DS. They took part in an intensive trauma-focused treatment programme for PTSD. Pre- and post-treatment differences were compared between patients with and without DS. Results: Large effect sizes were achieved for PTSD symptom reduction on CAPS and the PSS-SR, both for patients with DS and those without. Although patients with DS showed a significantly greater PTSD symptom severity at the beginning, and throughout, treatment, both groups showed equal reductions in PTSD symptoms. Of those who met the criteria for DS, 26 (68.4%) no longer fulfilled the criteria for this classification after treatment. Conclusion: The results provide no support for the notion that the presence of DS negatively impacts trauma-focused treatment outcomes. Accordingly, PTSD patients with DS should not be denied effective trauma-focused treatments. PMID:29805779

Presence of the dissociative subtype of PTSD does not moderate the outcome of intensive trauma-focused treatment for PTSD.

PubMed

Zoet, Harmen A; Wagenmans, Anouk; van Minnen, Agnes; de Jongh, Ad

2018-01-01

Background : There is a widely-held belief in the trauma field that the presence of dissociative symptoms is associated with poor treatment response. However, previous research on the effect of dissociation in treatment outcomes pertained to specific patients and trauma populations. Objective : To test the hypothesis that the presence of the dissociative subtype of PTSD (DS) would have a detrimental effect on the outcome of an intensive trauma-focused treatment programme. Methods : PTSD symptom scores (Clinician Administered PTSD Scale [CAPS] and PTSD Symptom Scale Self-Report [PSS-SR]) were analysed using the data of 168 consecutive patients (70.6% female) who had been exposed to a wide variety of multiple traumas, including childhood sexual abuse, and of whom 98.2% were diagnosed with severe PTSD (CAPS > 65). Most of them suffered from multiple comorbidities and 38 (22.6%) met the criteria for DS. They took part in an intensive trauma-focused treatment programme for PTSD. Pre- and post-treatment differences were compared between patients with and without DS. Results : Large effect sizes were achieved for PTSD symptom reduction on CAPS and the PSS-SR, both for patients with DS and those without. Although patients with DS showed a significantly greater PTSD symptom severity at the beginning, and throughout, treatment, both groups showed equal reductions in PTSD symptoms. Of those who met the criteria for DS, 26 (68.4%) no longer fulfilled the criteria for this classification after treatment. Conclusion : The results provide no support for the notion that the presence of DS negatively impacts trauma-focused treatment outcomes. Accordingly, PTSD patients with DS should not be denied effective trauma-focused treatments.

Somnambulism: Emergency Department Admissions Due to Sleepwalking-Related Trauma

PubMed Central

Sauter, Thomas C.; Veerakatty, Sajitha; Haider, Dominik G.; Geiser, Thomas; Ricklin, Meret E.; Exadaktylos, Aristomenis K.

2016-01-01

Introduction Somnambulism is a state of dissociated consciousness, in which the affected person is partially asleep and partially awake. There is pervasive public opinion that sleepwalkers are protected from hurting themselves. There have been few scientific reports of trauma associated with somnambulism and no published investigations on the epidemiology or trauma patterns associated with somnambulism. Methods We included all emergency department (ED) admissions to University Hospital Inselspital, Berne, Switzerland, from January 1, 2000, until August 11, 2015, when the patient had suffered a trauma associated with somnambulism. Demographic data (age, gender, nationality) and medical data (mechanism of injury, final diagnosis, hospital admission, mortality and medication on admission) were included. Results Of 620,000 screened ED admissions, 11 were associated with trauma and sleepwalking. Two patients (18.2%) had a history of known non-rapid eye movement parasomnias. The leading cause of admission was falls. Four patients required hospital admission for orthopedic injuries needing further diagnostic testing and treatment (36.4%). These included two patients with multiple injuries (18.2%). None of the admitted patients died. Conclusion Although sleepwalking seems benign in the majority of cases and most of the few injured patients did not require hospitalization, major injuries are possible. When patients present with falls of unknown origin, the possibility should be evaluated that they were caused by somnambulism. PMID:27833677

Evaluation of massive transfusion protocol practices by type of trauma at a level I trauma center.

PubMed

Givergis, Roshan; Munnangi, Swapna; Fayaz M Fomani, Katayoun; Boutin, Anthony; Zapata, Luis Carlos; Angus, Ld George

2018-04-18

To evaluate massive transfusion protocol practices by trauma type at a level I trauma center. A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained. Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01). Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients. Copyright © 2018 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

Coordination and management of multicenter clinical studies in trauma: Experience from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study

PubMed Central

Rahbar, Mohammad H.; Fox, Erin E.; del Junco, Deborah J.; Cotton, Bryan A.; Podbielski, Jeanette M.; Matijevic, Nena; Cohen, Mitchell J.; Schreiber, Martin A.; Zhang, Jiajie; Mirhaji, Parsa; Duran, Sarah; Reynolds, Robert J.; Benjamin-Garner, Ruby; Holcomb, John B.

2011-01-01

Aim Early death due to hemorrhage is a major consequence of traumatic injury. Transfusion practices differ among hospitals and it is unknown which transfusion practices improve survival. This report describes the experience of the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study Data Coordination Center in designing and coordinating a study to examine transfusion practices at ten Level 1 trauma centers in the U.S. Methods PROMMTT was a multisite prospective observational study of severely injured transfused trauma patients. The clinical sites collected real-time information on the timing and amounts of blood product infusions as well as colloids and crystalloids, vital signs, initial diagnostic and clinical laboratory tests, life saving interventions and other clinical care data. Results Between July 2009 and October 2010, PROMMTT screened 12,561 trauma admissions and enrolled 1,245 patients who received one or more blood transfusions within 6 hours of ED admission. A total of 297 massive transfusions were observed over the course of the study at a combined rate of 5.0 massive transfusion patients/week. Conclusion PROMMTT is the first multisite study to collect real-time prospective data on trauma patients requiring transfusion. Support from the Department of Defense and collaborative expertise from the ten participating centers helped to demonstrate the feasibility of prospective trauma transfusion studies. The observational data collected from this study will be an invaluable resource for research in trauma surgery and it will guide the design and conduct of future randomized trials. PMID:22001613

Trauma center staffing, infrastructure, and patient characteristics that influence trauma center need.

PubMed

Faul, Mark; Sasser, Scott M; Lairet, Julio; Mould-Millman, Nee-Kofi; Sugerman, David

2015-01-01

The most effective use of trauma center resources helps reduce morbidity and mortality, while saving costs. Identifying critical infrastructure characteristics, patient characteristics and staffing components of a trauma center associated with the proportion of patients needing major trauma care will help planners create better systems for patient care. We used the 2009 National Trauma Data Bank-Research Dataset to determine the proportion of critically injured patients requiring the resources of a trauma center within each Level I-IV trauma center (n=443). The outcome variable was defined as the portion of treated patients who were critically injured. We defined the need for critical trauma resources and interventions ("trauma center need") as death prior to hospital discharge, admission to the intensive care unit, or admission to the operating room from the emergency department as a result of acute traumatic injury. Generalized Linear Modeling (GLM) was used to determine how hospital infrastructure, staffing Levels, and patient characteristics contributed to trauma center need. Nonprofit Level I and II trauma centers were significantly associated with higher levels of trauma center need. Trauma centers that had a higher percentage of transferred patients or a lower percentage of insured patients were associated with a higher proportion of trauma center need. Hospital infrastructure characteristics, such as bed capacity and intensive care unit capacity, were not associated with trauma center need. A GLM for Level III and IV trauma centers showed that the number of trauma surgeons on staff was associated with trauma center need. Because the proportion of trauma center need is predominantly influenced by hospital type, transfer frequency, and insurance status, it is important for administrators to consider patient population characteristics of the catchment area when planning the construction of new trauma centers or when coordinating care within state or regional trauma systems.

Translation of alcohol screening and brief intervention guidelines to pediatric trauma centers.

PubMed

Mello, Michael J; Bromberg, Julie; Baird, Janette; Nirenberg, Ted; Chun, Thomas; Lee, Christina; Linakis, James G

2013-10-01

As part of the American College of Surgeons verification to be a Level 1 trauma center, centers are required to have the capacity to identify trauma patients with risky alcohol use and provide an intervention. Despite supporting scientific evidence and national policy statements encouraging alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT), barriers still exist, which prevent the integration of SBIRT into clinical care. Study objectives of this multisite translational research study were to identify best practices for integrating SBIRT services into routine care for pediatric trauma patients, to measure changes in practice with adoption and implementation of a SBIRT policy, and to define barriers and opportunities for adoption and implementation of SBIRT services at pediatric trauma centers. This translational research study was conducted at seven US pediatric trauma centers during a 3-year period. Changes in SBIRT practice were measured through self-report and medical record review at three different study phases, namely, adoption, implementation, and maintenance phases. According to medical record review, at baseline, 11% of eligible patients were screened and received a brief intervention (if necessary) across all sites. After completion of the SBIRT technical assistance activities, all seven participating trauma centers had effectively developed, adopted, and implemented SBIRT policies for injured adolescent inpatients. Furthermore, across all sites, 73% of eligible patients received SBIRT services after both the implementation and maintenance phases. Opportunities and barriers for successful integration were identified. This model may serve as method for translating SBIRT services into practice within pediatric trauma centers.

Psychological and social consequences after reconstruction of upper extremity trauma: methods of detection and management.

PubMed

Galanakos, Spyridon P; Bot, Arjan G J; Zoubos, Aristides B; Soucacos, Panayotis N

2014-03-01

Upper extremity trauma and resulting disability is a stressful event and can affect a patient's personality. Several studies have shown that this injury type has serious psychological and/or social consequences. We systematically reviewed the evidence on the consequences of disability after a complex trauma (combination of soft tissue, osseous, vascular, and nerve involvement) of the upper extremity. We tried to find out the potential crucial factors that could determine the final hand function. In addition, we considered the challenges that need to be addressed to eliminate the adverse or negative effects that arise from upper limb trauma. In the literature, there is a growing interest to study changes in patients' quality of life and return to work. Psychological morbidity is an important part of patients' perceived general health. These issues could play an important role in the final functional outcome of the therapy. An early identification and treatment of trauma-related distress in patients may prevent progression of psychological pathology and mitigate negative effects on general health status. It may be important to evaluate the amount of psychological distress when caring for patients with hand injuries. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Epidemiology of trauma deaths in an urban level-1 trauma center predominantly among African Americans--implications for prevention.

PubMed Central

Lyn-Sue, Jerome; Siram, Suryanarayana; Williams, Daniel; Mezghebe, Haile

2006-01-01

This is a retrospective review to determine demographics, presentation and injury characteristics of trauma deaths at Howard University Hospital over an 1-year period (1994-2005) and to make recommendations for education and prevention in the community based on our findings. Data was obtained from the Howard University Hospital trauma registry. From the study period 1994-2005, there was a total of 365 trauma deaths. The injuries sustained were mainly intentional, which accounted for almost 75% of cases--the majority of deaths being due to penetrating injuries. There was an almost two-fold increase in trauma deaths on Saturdays compared to the rest of the week. The demographics of our study population were similar to those reported in the trauma literature. These were younger patients and predominantly male. Unique to our population was the overwhelming predominance of African-American patients (90%). With these unique features, injury prevention would be better served focusing on social and community prevention and education rather than the usual methods of blunt-trauma prevention--e.g., pedestrian- and motor-vehicle-oriented policies, which may be more beneficial in other trauma systems. PMID:17225838

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

Development and pilot testing of an informed consent video for patients with limb trauma prior to debridement surgery using a modified Delphi technique.

PubMed

Lin, Yen-Ko; Chen, Chao-Wen; Lee, Wei-Che; Lin, Tsung-Ying; Kuo, Liang-Chi; Lin, Chia-Ju; Shi, Leiyu; Tien, Yin-Chun; Cheng, Yuan-Chia

2017-11-29

Ensuring adequate informed consent for surgery in a trauma setting is challenging. We developed and pilot tested an educational video containing information regarding the informed consent process for surgery in trauma patients and a knowledge measure instrument and evaluated whether the audiovisual presentation improved the patients' knowledge regarding their procedure and aftercare and their satisfaction with the informed consent process. A modified Delphi technique in which a panel of experts participated in successive rounds of shared scoring of items to forecast outcomes was applied to reach a consensus among the experts. The resulting consensus was used to develop the video content and questions for measuring the understanding of the informed consent for debridement surgery in limb trauma patients. The expert panel included experienced patients. The participants in this pilot study were enrolled as a convenience sample of adult trauma patients scheduled to receive surgery. The modified Delphi technique comprised three rounds over a 4-month period. The items given higher scores by the experts in several categories were chosen for the subsequent rounds until consensus was reached. The experts reached a consensus on each item after the three-round process. The final knowledge measure comprising 10 questions was developed and validated. Thirty eligible trauma patients presenting to the Emergency Department (ED) were approached and completed the questionnaires in this pilot study. The participants exhibited significantly higher mean knowledge and satisfaction scores after watching the educational video than before watching the video. Our process is promising for developing procedure-specific informed consent and audiovisual aids in medical and surgical specialties. The educational video was developed using a scientific method that integrated the opinions of different stakeholders, particularly patients. This video is a useful tool for improving the knowledge and satisfaction of trauma patients in the ED. The modified Delphi technique is an effective method for collecting experts' opinions and reaching a consensus on the content of educational materials for informed consent. Institutions should prioritize patient-centered health care and develop a structured informed consent process to improve the quality of care. The ClinicalTrials.gov Identifier is NCT01338480 . The date of registration was April 18, 2011 (retrospectively registered).

[Modified McPeek score in multiple trauma patients. Prospective evaluation of a points system for recording follow-up factors].

PubMed

Mathis, S; Kellermann, S; Schmid, S; Mutschlechner, H; Raab, H; Wenzel, V; El Attal, R; Kreutziger, J

2014-05-01

Many commonly available trauma scores predict mortality, but to evaluate the success of a certain therapy or for difficult scientific and epidemiological purposes this may be insufficient in the face of improved survival rates. For outcome analysis of multiple trauma patients, the extent of medical resources needed could be an additional outcome measurement. McPeek et al. developed a potential scoring system for elective surgery patients, which was recently modified for multiple trauma patients. The current study investigated if the McPeek score could be prospectively used in multiple trauma patients and whether it could become an additional helpful tool in outcome assessment. Applicability was assessed by practical examples. In this prospective single-centre study at the University Hospital of Innsbruck, Austria, between December 2008 and November 2010 multiple trauma patients (≥ 18 years) with an injury severity score (ISS) ≥ 17 were enrolled. Besides demographic data, prehospital vital parameters and diagnoses, all diagnoses from the trauma, mortality, length of stay in the intensive care unit and the hospital were recorded. The commonly used trauma scores ISS, revised trauma score (RTS), a severity characterization of trauma (ASCOT) and trauma and injury severity score (TRISS) were applied and an observed McPeek score was allocated following end of hospitalization. The McPeek scoring system was used according to the latest modifications. A correlation between trauma scores and the McPeek score was performed. The McPeek score was then predicted by a common trauma score using ordinal regression with the polytomous universal model (PLUM method). By subtracting the predicted from the observed McPeek scores the residual McPeek value was calculated and used for practical examples of outcome analysis with the McPeek scoring system. Out of 406 identified multiple trauma patients during the study phase, 183 had to be excluded due to missing data (mainly prehospital or following transfer). A total of 223 patients (mean ISS 31.2, mean age 47.2 years) were enrolled and assigned to the population-based observed McPeek score (median 4.0). Correlation coefficients were Glasgow coma scale (GCS) 0.59, ISS 0.62, RTS 0.65, TRISS 0.74 and ASCOT 0.77 (p < 0.0001). The TRISS predicted the McPeek score best in ordinal regression (pseudo-R(2) = 0.944, p < 0.0001). The residual McPeek score (observed minus predicted) was used to illustrate the influence of the blood glucose level on admission and the influence of head injury on outcome of multiple injury patients in detail. The modified McPeek score is applicable to multiple trauma patients to assess outcome for scientific or epidemiological purposes. Its main advantage is that it quantifies outcome independently of regional or national circumstances.

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

Prevalence rate, predictors and long-term course of probable posttraumatic stress disorder after major trauma: a prospective cohort study

PubMed Central

2012-01-01

Background Among trauma patients relatively high prevalence rates of posttraumatic stress disorder (PTSD) have been found. To identify opportunities for prevention and early treatment, predictors and course of PTSD need to be investigated. Long-term follow-up studies of injury patients may help gain more insight into the course of PTSD and subgroups at risk for PTSD. The aim of our long-term prospective cohort study was to assess the prevalence rate and predictors, including pre-hospital trauma care (assistance of physician staffed Emergency Medical Services (EMS) at the scene of the accident), of probable PTSD in a sample of major trauma patients at one and two years after injury. The second aim was to assess the long-term course of probable PTSD following injury. Methods A prospective cohort study was conducted of 332 major trauma patients with an Injury Severity Score (ISS) of 16 or higher. We used data from the hospital trauma registry and self-assessment surveys that included the Impact of Event Scale (IES) to measure probable PTSD symptoms. An IES-score of 35 or higher was used as indication for the presence of probable PTSD. Results One year after injury measurements of 226 major trauma patients were obtained (response rate 68%). Of these patients 23% had an IES-score of 35 or higher, indicating probable PTSD. At two years after trauma the prevalence rate of probable PTSD was 20%. Female gender and co-morbid disease were strong predictors of probable PTSD one year following injury, whereas minor to moderate head injury and injury of the extremities (AIS less than 3) were strong predictors of this disorder at two year follow-up. Of the patients with probable PTSD at one year follow-up 79% had persistent PTSD symptoms a year later. Conclusions Up to two years after injury probable PTSD is highly prevalent in a population of patients with major trauma. The majority of patients suffered from prolonged effects of PTSD, underlining the importance of prevention, early detection, and treatment of injury-related PTSD. PMID:23270522

Incidence and Imaging Findings of Costal Cartilage Fractures in Patients with Blunt Chest Trauma: A Retrospective Review of 1461 Consecutive Whole-Body CT Examinations for Trauma.

PubMed

Nummela, Mari T; Bensch, Frank V; Pyhältö, Tuomo T; Koskinen, Seppo K

2018-02-01

Purpose To assess the incidence of costal cartilage (CC) fractures in whole-body computed tomographic (CT) examinations for blunt trauma and to evaluate distribution of CC fractures, concomitant injuries, mechanism of injury, accuracy of reporting, and the effect on 30-day mortality. Materials and Methods Institutional review board approval was obtained for this retrospective study. All whole-body CT examinations for blunt trauma over 36 months were reviewed retrospectively and chest trauma CT studies were evaluated by a second reader. Of 1461 patients who underwent a whole-body CT examination, 39% (574 of 1461) had signs of thoracic injuries (men, 74.0% [425 of 574]; mean age, 46.6 years; women, 26.0% [149 of 574]; mean age, 48.9 years). χ 2 and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was calculated by using Cohen kappa values. Results A total of 114 patients (men, 86.8% [99 of 114]; mean age, 48.6 years; women, 13.2% [15 of 114]; mean age, 45.1 years) had 221 CC fractures. The incidence was 7.8% (114 of 1461) in all whole-body CT examinations and 19.9% (114 of 574) in patients with thoracic trauma. Cartilage of rib 7 (21.3%, 47 of 221) was most commonly injured. Bilateral multiple consecutive rib fractures occurred in 36% (41 of 114) versus 14% (64 of 460) in other patients with chest trauma (OR, 3.48; 95% CI: 2.18, 5.53; P < .0001). Hepatic injuries were more common in patients with chest trauma with CC fractures (13%, 15 of 114) versus patients with chest trauma without CC fractures (4%, 18 of 460) (OR, 3.72; 95% CI: 1.81, 7.64; P = .0001), as well as aortic injuries (n = 4 vs n = 0; P = .0015; OR, unavailable). Kappa value for interobserver agreement in detecting CC fractures was 0.65 (substantial agreement). CC fractures were documented in 39.5% (45 of 114) of primary reports. The 30-day mortality of patients with CC fractures was 7.02% (eight of 114) versus 4.78% (22 of 460) of other patients with chest trauma (OR, 1.50; 95% CI: 0.65, 3.47; P = .3371). Conclusion CC fractures are common in high-energy blunt chest trauma and often occur with multiple consecutive rib fractures. Aortic and hepatic injuries were more common in patients with CC fractures than in patients without CC fractures. © RSNA, 2017.

Factors Associated with the Use of Helicopter Inter-facility Transport of Trauma Patients to Tertiary Trauma Centers within an Organized Rural Trauma System

PubMed Central

Stewart, Kenneth; Garwe, Tabitha; Bhandari, Naresh; Danford, Brandon; Albrecht, Roxie

2016-01-01

Objective A review of the literature yielded little information regarding factors associated with the decision to use ground (GEMS) or helicopter (HEMS) emergency medical services for trauma patients transferred inter-facility. Furthermore, studies evaluating the impact of inter-facility transport mode on mortality have reported mixed findings. Since HEMS transport is generally reserved for more severely injured patients, this introduces indication bias, which may explain the mixed findings. Our objective was to identify factors at referring non-tertiary trauma centers (NTC) influencing transport mode decision. Methods This was a case-control study of trauma patients transferred from a Level III or IV NTC to a tertiary trauma center (TTC) within 24-hours reported to the Oklahoma State Trauma Registry between 2005 and 2012. Multivariable logistic regression was used to determine clinical and non-clinical factors associated with the decision to use HEMS. Results A total of 7380 patients met the study eligibility. Of these, 2803(38%) were transported inter-facility by HEMS. Penetrating injury, prehospital EMS transport, severe torso injury, hypovolemic shock, and TBI were significant predictors (p<0.05) of HEMS use regardless of distance to a TTC. Association between HEMS use and male gender, Level IV NTC, and local ground EMS resources varied by distance from the TTC. Many HEMS transported patients had minor injuries and normal vital signs. Conclusions Our results suggest that while distance remains the most influential factor associated with HEMS use, significant differences exist in clinical and non-clinical factors between patients transported by HEMS versus GEMS. To ensure comparability of study groups, studies evaluating outcome differences between HEMS and GEMS should take factors determining transport mode into account. The findings will be used to develop propensity scores to balance baseline risk between GEMS and HEMS patients for use in subsequent studies of outcomes. PMID:26986053

Potential impact of ACA-related insurance expansion on trauma care reimbursement

PubMed Central

Scott, John W; Upadhyaya, Pooja; Najjar, Peter; Tsai, Thomas C; Scott, Kirstin W; Shrime, Mark G; Cutler, David M; Salim, Ali; Haider, Adil H

2017-01-01

Introduction Nearly one-quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect. Methods We abstracted nonelderly adults (ages 18–64y) admitted for trauma from the Nationwide Inpatient Sample (NIS) during 2010—the last year prior to most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using NIS-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population. Results 145,849 patients (representing 737,852 patients nationwide) were included. National inpatient trauma costs for 18–64y patients totaled $14.8 billion (95%CI:12.5,17.1). Pre-expansion reimbursements totaled $13.7 billion (10.8,14.7), yielding a national margin of −7.9% (−10.6, −5.1). Post-expansion projected reimbursements totaled $15.0 billion (12.7,17.3), increasing the margin by 9.3 absolute percentage-points to +1.4% (−0.3,+3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using post-expansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains. Conclusion Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers’ financial viability and their ability to provide care for their communities. Level of Evidence Level II: Sensible costs and alternatives; values obtained from limited sources; multi-way sensitivity analyses Study Type Policy Analysis / Economic Analysis PMID:28431415

Non-traumatic hemorrhage is controlled with REBOA in acute phase then mortality increases gradually by non-hemorrhagic causes: DIRECT-IABO registry in Japan.

PubMed

Matsumura, Y; Matsumoto, J; Idoguchi, K; Kondo, H; Ishida, T; Kon, Y; Tomita, K; Ishida, K; Hirose, T; Umakoshi, K; Funabiki, T

2017-08-22

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is now a feasible and less invasive resuscitation procedure. This study aimed to compare the clinical course of trauma and non-trauma patients undergoing REBOA. Patient demographics, etiology, bleeding sites, hemodynamic response, length of critical care, and cause of death were recorded. Characteristics and outcomes were compared between non-trauma and trauma patients. Kaplan-Meier survival analysis was then conducted. Between August 2011 and December 2015, 142 (36 non-trauma; 106 trauma) cases were analyzed. Non-traumatic etiologies included gastrointestinal bleeding, obstetrics and gynecology-derived events, visceral aneurysm, abdominal aortic aneurysm, and post-abdominal surgery. The abdomen was a common bleeding site (69%), followed by the pelvis or extra-pelvic retroperitoneum. None of the non-trauma patients had multiple bleeding sites, whereas 45% of trauma patients did (P < 0.001). No non-trauma patients required resuscitative thoracotomy compared with 28% of the trauma patients (P < 0.001). Non-trauma patients presented a lower 24-h mortality than trauma patients (19 vs. 51%, P = 0.001). The non-trauma cases demonstrated a gradual but prolonged increased mortality, whereas survival in trauma cases rapidly declined (P = 0.009) with similar hospital mortality (68 vs. 64%). Non-trauma patients who survived for 24 h had 0 ventilator-free days and 0 ICU-free days vs. a median of 19 and 12, respectively, for trauma patients (P = 0.33 and 0.39, respectively). Non-hemorrhagic death was more common in non-trauma vs. trauma patients (83 vs. 33%, P < 0.001). Non-traumatic hemorrhagic shock often resulted from a single bleeding site, and resulted in better 24-h survival than traumatic hemorrhage among Japanese patients who underwent REBOA. However, hospital mortality increased steadily in non-trauma patients affected by non-hemorrhagic causes after a longer period of critical care.

Childhood Trauma in Substance Use Disorder and Depression: An Analysis by Gender among a Brazilian Clinical Sample

ERIC Educational Resources Information Center

Tucci, Adriana M.; Kerr-Correa, Florence; Souza-Formigoni, Maria Lucia O.

2010-01-01

Objective: In this study, we compared the frequency and intensity of childhood traumas in alcohol- or other drug-dependent patients, in patients with depression, and in a control group without psychiatric diagnoses. Methods: The study had a retrospective design of a clinical sample of men and women from the groups listed above. They were evaluated…

Benchmarking statewide trauma mortality using Agency for Healthcare Research and Quality's patient safety indicators.

PubMed

Ang, Darwin; McKenney, Mark; Norwood, Scott; Kurek, Stanley; Kimbrell, Brian; Liu, Huazhi; Ziglar, Michele; Hurst, James

2015-09-01

Improving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the state's registry are not publicly available. Promotion of optimal care throughout the state is not possible unless clinical benchmarks are available for comparison. Using publicly available administrative data from the State Department of Health and the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), we sought to create a statewide method for benchmarking trauma mortality and at the same time also identifying a pattern of unique complications that have an independent influence on mortality. Data for this study were obtained from State of Florida Agency for Health Care Administration. Adult trauma patients were identified as having International Classification of Disease ninth edition codes defined by the state. Multivariate logistic regression was used to create a predictive inpatient expected mortality model. The expected value of PSIs was created using the multivariate model and their beta coefficients provided by the AHRQ. Case-mix adjusted mortality results were reported as observed to expected (O/E) ratios to examine mortality, PSIs, failure to prevent complications, and failure to rescue from death. There were 50,596 trauma patients evaluated during the study period. The overall fit of the expected mortality model was very strong at a c-statistic of 0.93. Twelve of 25 trauma centers had O/E ratios <1 or better than expected. Nine statewide PSIs had failure to prevent O/E ratios higher than expected. Five statewide PSIs had failure to rescue O/E ratios higher than expected. The PSI that had the strongest influence on trauma mortality for the state was PSI no. 9 or perioperative hemorrhage or hematoma. Mortality could be further substratified by PSI complications at the hospital level. AHRQ PSIs can have an integral role in an adjusted benchmarking method that screens at risk trauma centers in the state for higher than expected mortality. Stratifying mortality based on failure to prevent PSIs may identify areas of needed improvement at a statewide level. Copyright © 2015 Elsevier Inc. All rights reserved.

Training in Trauma Surgery

PubMed Central

Reilly, Patrick M.; Schwab, C William; Haut, Elliott R.; Gracias, Vicente H.; Dabrowski, G Paul; Gupta, Rajan; Pryor, John P.; Kauder, Donald R.

2003-01-01

Objective: To describe outcomes from a clinical trauma surgical education program that places the board-eligible/board-certified fellow in the role of the attending surgeon (fellow-in-exception [FIE]) during the latter half of a 2-year trauma/surgical critical care fellowship. Summary Background Data: National discussions have begun to explore the question of optimal methods for postresidency training in surgery. Few objective studies are available to evaluate current training models. Methods: We analyzed provider-specific data from both our trauma registry and performance improvement (PI) databases. In addition, we performed TRISS analysis when all data were available. Registry and PI data were analyzed as 2 groups (faculty trauma surgeons and FIEs) to determine experience, safety, and trends in errors. We also surveyed graduate fellows using a questionnaire that evaluated perceptions of training and experience on a 6-point Likert scale. Results: During a 4-year period 7,769 trauma patients were evaluated, of which 46.3% met criteria to be submitted to the PA Trauma Outcome Study (PTOS, ie, more severe injury). The faculty group saw 5,885 patients (2,720 PTOS); the FIE group saw 1,884 patients (879 PTOS). The groups were similar in respect to mechanism of injury (74% blunt; 26% penetrating both groups) and injury severity (mean ISS faculty 10.0; FIEs 9.5). When indexed to patient contacts, FIEs did more operations than the faculty group (28.4% versus 25.6%; P < 0.05). Death rates were similar between groups (faculty 10.5%; FIEs 10.0%). Analysis of deaths using PI and TRISS data failed to demonstrate differences between the groups. Analysis of provider-specific errors demonstrated a slightly higher rate for FIEs when compared with faculty when indexed to PTOS cases (4.1% versus 2.1%; P < 0.01). For both groups, errors in management were more common than errors in technique. Twenty-one (91%) of twenty-three surveys were returned. Fellows’ feelings of preparedness to manage complex trauma patients improved during the fellowship (mean 3.2 prior to fellowship versus 4.5 after first year versus 5.8 after FIE year; P < 0.05 by ANOVA). Eighty percent rated the FIE educational experience “great -5” or “exceptional– 6.” Eighty-five percent consider the current structure of the fellowship (with FIE year) as ideal. Ninety percent would repeat the fellowship. Conclusion: The educational experience and training improvement offered by the inclusion of a FIE period during a trauma fellowship is exceptional. Patient outcomes are unchanged. The potential for an increased error rate is present during this period of clinical autonomy and must be addressed when designing the methods of supervision of care to assure concurrent senior staff review. PMID:14530731

Chest computed tomography for penetrating thoracic trauma after normal screening chest roentgenogram.

PubMed

Mollberg, Nathan M; Wise, Stephen R; De Hoyos, Alberto L; Lin, Fang-Ju; Merlotti, Gary; Massad, Malek G

2012-06-01

Chest computed tomography (CCT) is a method of screening for intrathoracic injuries in hemodynamically stable patients with penetrating thoracic trauma. The objective of this study was to examine the changes in utilization of CCT over time and evaluate its contribution to guiding therapeutic intervention. A level 1 trauma center registry was queried between 2006 and 2011. Patients undergoing CCT in the emergency department after penetrating thoracic trauma as well as patients undergoing thoracic operations for penetrating thoracic trauma were identified. Patient demographics, operative indications, use of CCT, injuries, and hospital admissions were analyzed. In all, 617 patients had CCTs performed, of whom 61.1% (371 of 617) had a normal screening plain chest radiograph (CXR). In 14.0% (51 of 371) of these cases, the CCT revealed findings not detected on screening CXR. The majority of these injuries were occult pneumothoraces or hemothoraces (84.3%; 43 of 51), of which 27 (62.8%) underwent tube thoracostomy. In only 0.5% (2 of 371), did the results of CCT alone lead to an operative indication: exploration for hemopericardium. The use of CCT in our patients significantly increased overall (28.8% to 71.4%) as well as after a normal screening CXR (23.3% to 74.6%) over the study period. The use of CCT for penetrating thoracic trauma increased 3.5-fold during the study period with a concurrent increase in findings of uncertain clinical significance. Patients with a normal screening CXR should be triaged with 3-hour delayed CXR, serial physical examinations, and focused assessment with sonography for trauma; and CCT should only be used selectively as a diagnostic modality. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Analysis of Pediatric Maxillofacial Fractures Requiring Operative Treatment: Characteristics, Management, and Outcomes.

PubMed

Allred, Lindsay J; Crantford, John C; Reynolds, Michael F; David, Lisa R

2015-11-01

Maxillofacial fractures in pediatric trauma patients require significant force and frequently are associated with concomitant injuries. The anatomic and developmental differences between the adult and child that impact patterns of injury also affect management and outcomes. The aim of this study was to analyze fracture location, mechanism, concomitant injuries as well as methods of surgical treatment and outcomes, to improve management of this patient population. A retrospective review was conducted of pediatric patients with maxillofacial fractures presenting to a level-1 trauma center during an 8-year span. Only patients requiring surgical intervention, 204, were included in this study. Data pertaining to the location of injury, mechanism, associated injuries, surgical treatment, outcomes, and complications were analyzed. The most common fracture location was the mandible (36.3%), then the nasal bone (35.3%), followed by the tripod fracture (10.8%). A total of 30.7% of patients were involved in motor vehicle accidents, with the next most common mechanisms being sports (24.4%), and assault (13.7%). A total of 46% of the patients sustained concomitant injuries, with the majority involving cerebral trauma (14.7%) or the extremities (9.3%). Total 75.4% of all fractures, excluding the nose, were treated with open reduction and internal fixation (ORIF). Our complication rate was 11.2%. Pediatric craniofacial trauma remains a frequent presentation to the emergency department of trauma centers. Facial fracture patterns and mechanism of trauma observed in the pediatric population presenting to this facility are consistent with incidences reported in the literature. Knowledge of treatment options and potential complications is an important tool in the management of the pediatric trauma patient.

Characteristics and visual outcomes of patients hospitalized for ocular trauma in central China: 2006–2011

PubMed Central

Qi, Ying; Zhang, Feng-Yan; Peng, Guang-Hua; Zhu, Yu; Wan, Guang-Ming; Wang, Wen-Zhan; Ma, Jing; Ren, Shi-Jie

2015-01-01

AIM To complete the data of ocular trauma in central China, as a well-known tertiary referral center for ocular trauma, we documented the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in this region. METHODS A retrospective study of patients hospitalized for ocular trauma in central China from 2006 to 2011 was performed. RESULTS This study included 5964 eyes of 5799 patients. The average age was 35.5±21.8y with a male-to-female ratio of 2.8:1. The most common age was 45-59y age group. Most patients were farmers and workers (51.9%). The most common injuries were firework related (24.5%), road traffic related (24.2%), and work related (15.0%). Among the most common causative agents were firecrackers (24.5%), followed by metal/knife/scissors (21.4%). Most injuries occurred in January (14.2%), February (27.0%), and August (10.0%). There were 8.5% patients with ocular injuries combined with other injuries. The incidence of open ocular injuries (4585 eyes, 76.9%) was higher than closed ocular injuries (939 eyes, 15.7%). The incidences of chemical and thermal ocular injuries were 1.2% and 0.6%. Ocular trauma score (OTS) predicted final visual acuity at non light perception (NLP), 20/200-20/50 and 20/40 with a sensitivity of 100%, and light perception (LP)/hand motion (HM) and 1/200-19/200 with a specificity of 100%. CONCLUSIONS This study provides recent epidemiological data of patients hospitalized for ocular trauma in central China. Some factors influencing the visual outcome include time interval between injury and visit to the clinic, wound location, open or closed globe injury, initial visual acuity, and OTS. PMID:25709927

Differences in trauma history and psychopathology between PTSD patients with and without co-occurring dissociative disorders

PubMed Central

Wabnitz, Pascal; Gast, Ursula; Catani, Claudia

2013-01-01

Background The interplay between different types of potentially traumatizing events, posttraumatic symptoms, and the pathogenesis of PTSD or major dissociative disorders (DD) has been extensively studied during the last decade. However, the phenomenology and nosological classification of posttraumatic disorders is currently under debate. The current study was conducted to investigate differences between PTSD patients with and without co-occurring major DD with regard to general psychopathology, trauma history, and trauma-specific symptoms. Methods Twenty-four inpatients were administered the Clinician-Administered PTSD Scale for DSM-IV (CAPS) and the Mini-Structured Clinical Interview for DSM-IV Dissociative Disorders (MINI-SKID-D) to assess DD and PTSD. Additionally, participants completed questionnaires to assess general psychopathology and health status. Results Symptom profiles and axis I comorbidity were similar in all patients. Traumatic experiences did not differ between the two groups, with both reporting high levels of childhood trauma. Only trauma-specific avoidance behavior and dissociative symptoms differed between groups. Conclusion Results support the view that PTSD and DD are affiliated disorders that could be classified within the same diagnostic category. Our results accord with a typological model of dissociation in which profound forms of dissociation are specific to DD and are accompanied with higher levels of trauma-specific avoidance in DD patients. PMID:24298325

Factors Associated with Complications in Older Adults with Isolated Blunt Chest Trauma

PubMed Central

Lotfipour, Shahram; Kaku, Shawn K.; Vaca, Federico E.; Patel, Chirag; Anderson, Craig L.; Ahmed, Suleman S.; Menchine, Michael D.

2009-01-01

Objective: To determine the prevalence of adverse events in elderly trauma patients with isolated blunt thoracic trauma, and to identify variables associated with these adverse events. Methods: We performed a chart review of 160 trauma patients age 65 and older with significant blunt thoracic trauma, drawn from an American College of Surgeons Level I Trauma Center registry. Patients with serious injury to other body areas were excluded to prevent confounding the cause of adverse events. Adverse events were defined as acute respiratory distress syndrome or pneumonia, unanticipated intubation, transfer to the intensive care unit for hypoxemia, or death. Data collected included history, physical examination, radiographic findings, length of hospital stay, and clinical outcomes. Results: Ninety-nine patients had isolated chest injury, while 61 others had other organ systems injured and were excluded. Sixteen patients developed adverse events [16.2% 95% confidence interval (CI) 9.5–24.9%], including two deaths. Adverse events were experienced by 19.2%, 6.1%, and 28.6% of those patients 65–74, 75–84, and ≥85 years old, respectively. The mean length of stay was 14.6 days in patients with an adverse event and 5.8 days in patients without. Post hoc analysis revealed that all 16 patients with an adverse event had one or more of the following: age ≥85, initial systolic blood pressure <90 mmHg, hemothorax, pneumothorax, three or more unilateral rib fractures, or pulmonary contusion (sensitivity 100%, CI 79.4–100%; specificity 38.6%, CI 28.1–49.9%). Conclusion: Adverse events from isolated thoracic trauma in elderly patients complicate 16% of our sample. These criteria were 100% sensitive and 38.5% specific for these adverse events. This study is a first step to identifying variables that might aid in identifying patients at high risk for serious adverse events. PMID:19561823

Using video recording to identify management errors in pediatric trauma resuscitation.

PubMed

Oakley, Ed; Stocker, Sergio; Staubli, Georg; Young, Simon

2006-03-01

To determine the ability of video recording to identify management errors in trauma resuscitation and to compare this method with medical record review. The resuscitation of children who presented to the emergency department of the Royal Children's Hospital between February 19, 2001, and August 18, 2002, for whom the trauma team was activated was video recorded. The tapes were analyzed, and management was compared with Advanced Trauma Life Support guidelines. Deviations from these guidelines were recorded as errors. Fifty video recordings were analyzed independently by 2 reviewers. Medical record review was undertaken for a cohort of the most seriously injured patients, and errors were identified. The errors detected with the 2 methods were compared. Ninety resuscitations were video recorded and analyzed. An average of 5.9 errors per resuscitation was identified with this method (range: 1-12 errors). Twenty-five children (28%) had an injury severity score of >11; there was an average of 2.16 errors per patient in this group. Only 10 (20%) of these errors were detected in the medical record review. Medical record review detected an additional 8 errors that were not evident on the video recordings. Concordance between independent reviewers was high, with 93% agreement. Video recording is more effective than medical record review in detecting management errors in pediatric trauma resuscitation. Management errors in pediatric trauma resuscitation are common and often involve basic resuscitation principles. Resuscitation of the most seriously injured children was associated with fewer errors. Video recording is a useful adjunct to trauma resuscitation auditing.

Optimizing the assessment of pediatric injury severity in low-resource settings: Consensus generation through a modified Delphi analysis.

PubMed

St-Louis, Etienne; Deckelbaum, Dan Leon; Baird, Robert; Razek, Tarek

2017-06-01

Although a plethora of pediatric injury severity scoring systems is available, many of them present important challenges and limitations in the low resource setting. Our aim is to generate consensus among a group of experts regarding the optimal parameters, outcomes, and methods of estimating injury severity for pediatric trauma patients in low resource settings. A systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. Qualitative data was extracted from the systematic review, including scoring parameters, settings and outcomes. In order to establish consensus regarding which of these elements are most adapted to pediatric patients in low-resource settings, they were subjected to a modified Delphi survey for external validation. The Delphi process is a structured communication technique that relies on a panel of experts to develop a systematic, interactive consensus method. We invited a group of 38 experts, including adult and pediatric surgeons, emergency physicians and anesthesiologists trauma team leaders from a level 1 trauma center in Montreal, Canada, and a pediatric referral trauma hospital in Santiago, Chile to participate in two successive rounds of our survey. Consensus was reached regarding various features of an ideal pediatric trauma score. Specifically, our experts agreed pediatric trauma scoring tool should differ from its adult counterpart, that it can be derived from point of care data available at first assessment, that blood pressure is an important variable to include in a predictive model for pediatric trauma outcomes, that blood pressure is a late but specific marker of shock in pediatric patients, that pulse rate is a more sensitive marker of hemodynamic instability than blood pressure, that an assessment of airway status should be included as a predictive variable for pediatric trauma outcomes, that the AVPU classification of neurologic status is simple and reliable in the acute setting, and more so than GCS at all ages. Therefore, we conclude that an opportunity exists to develop a new pediatric trauma score, combining the above consensus-generating ideas, that would be best adapted for use in low-resource settings. Copyright © 2017 Elsevier Ltd. All rights reserved.

Impact of the age of stored blood on trauma patient mortality: a systematic review

PubMed Central

Sowers, Nicholas; Froese, Patrick C.; Erdogan, Mete; Green, Robert S.

2015-01-01

Background The impact of the age of stored red blood cells on mortality in patients sustaining traumatic injuries requiring transfusion of blood products is unknown. The objective of this systematic review was to identify and describe the available literature on the use of older versus newer blood in trauma patient populations. Methods We searched PubMed, Embase, Lilac and the Cochrane Database for published studies comparing the transfusion of newer versus older red blood cells in adult patients sustaining traumatic injuries. Studies included for review reported on trauma patients receiving transfusions of packed red blood cells, identified the age of stored blood that was transfused and reported patient mortality as an end point. We extracted data using a standardized form and assessed study quality using the Newcastle–Ottawa Scale. Results Seven studies were identified (6780 patients) from 3936 initial search results. Four studies reported that transfusion of older blood was independently associated with increased mortality in trauma patients, while 3 studies did not observe any increase in patient mortality with the use of older versus newer blood. Three studies associated the transfusion of older blood with adverse patient outcomes, including longer stay in the intensive care unit, complicated sepsis, pneumonia and renal dysfunction. Studies varied considerably in design, volumes of blood transfused and definitions applied for old and new blood. Conclusion The impact of the age of stored packed red blood cells on mortality in trauma patients is inconclusive. Future investigations are warranted. PMID:26384149

Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital

PubMed Central

Hefny, Ashraf F; Kunhivalappil, Fathima T; Matev, Nikolay; Avila, Norman A; Bashir, Masoud O; Abu-Zidan, Fikri M

2018-01-01

INTRODUCTION Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. METHODS Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. RESULTS CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. CONCLUSION Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL. PMID:28741012

Vasopressor use following traumatic injury – A single center retrospective study

PubMed Central

Hylands, Mathieu; Godbout, Marie-Pier; Mayer, Sandeep K.; Fraser, William D.; Vanasse, Alain; Leclair, Marc-André; Turgeon, Alexis F.; Lauzier, François; Charbonney, Emmanuel; Trottier, Vincent; Razek, Tarek S.; Roy, André; D’Aragon, Frédérick; Belley-Côté, Emilie; Day, Andrew G.; Le Guillan, Soazig; Sabbagh, Robert

2017-01-01

Objectives Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers. Methods We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management. Results Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7–38.5). Conclusions In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards. PMID:28448605

Epidemiology and outcomes of pregnancy and obstetric complications in trauma in the United Kingdom.

PubMed

Battaloglu, Emir; McDonnell, Declan; Chu, Justin; Lecky, Fiona; Porter, Keith

2016-01-01

To understand the epidemiology of pregnancy and obstetric complications encountered in the management of pregnant trauma patients. Retrospective analysis of national trauma registry for recording of pregnancy status or obstetric complication in cases of trauma. Sub-division of patient cohort by severity of trauma and stage of pregnancy. Comparison of data sets between pregnant trauma patients and age-matched non-pregnant female trauma patients to determine patterns of injury and impact upon clinical outcomes. National registry data for the United Kingdom. For the five year period between 2009 and 2014, a total of 15,140 female patients, aged between 15 years old and 50 years old were identified within the trauma registry. A record of pregnancy was identified in 173 patients (1.14%) from within this cohort. Mechanisms of injury within the cohort of pregnant trauma patients saw increased rate of vehicular collision and interpersonal violence, especially penetrating trauma. Higher abbreviated injury scores were recorded for the abdominal region in pregnancy than in the non-pregnant cohort. Maternal mortality rates were seen to be higher, when compared with the non-pregnant trauma patient. Foetal survival rate from this series was 56% following trauma. Foetal death in pregnant trauma patients most frequently occurred in the 2nd trimester. No cases of isolated foetal survival were recorded following maternal trauma. Trauma to pregnant patients is rare in the United Kingdom, encountered in 1% of female trauma patients of child bearing age. Observations in altered mechanisms of injury and clinical outcomes were recorded. This provides useful information regarding the clinical management of pregnant trauma patients and offers potential areas to investigate to optimise their care, as well as to focus injury prevention measures. IV--Case series. Copyright © 2015 Elsevier Ltd. All rights reserved.

Evaluation of Chest and Abdominal Injuries in Trauma Patients Hospitalized in the Surgery Ward of Poursina Teaching Hospital, Guilan, Iran

PubMed Central

Hemmati, Hossein; Kazemnezhad-Leili, Ehsan; Mohtasham-Amiri, Zahra; Darzi, Ali Asghar; Davoudi-Kiakalayeh, Ali; Dehnadi-Moghaddam, Anoush; Kouchakinejad-Eramsadati, Leila

2013-01-01

Background Trauma, especially chest and abdominal trauma are increasing due to the growing number of vehicles on the roads, which leads to an increased incidence of road accidents. Urbanization, industrialization and additional problems are the other associated factors which accelerate this phenomenon. A better understanding of the etiology and pattern of such injuries can help to improve the management and ultimate the outcomes of these patients. Objectives This study aimed to evaluate the patients with chest and abdominal trauma hospitalized in the surgery ward of Poursina teaching hospital, Guilan, Iran. Patients and Methods In this cross-sectional study, the data of all chest and abdominal trauma patients hospitalized in the surgery ward of Poursina teaching hospital were collected from March 2011 to March 2012. Information about age, gender, injured areas, type of injury (penetrating or blunt), etiology of the injury, accident location (urban or rural) and patients' discharge outcomes were collected by a questionnaire. Results In total, 211 patients with a mean age of 34.1 ± 1.68 years was entered into the study. The most common cause of trauma was traffic accidents (51.7%). Among patients with chest trauma, 45 cases (35.4%) had penetrating injuries and 82 cases (64.6%) blunt lesions. The prevalence of chest injuries was 35.5% and rib fractures 26.5%. In chest injuries, the prevalence of hemothorax was 65.3%, pneumothorax 2.7%, lung contusion 4% and emphysema 1.3%, respectively. There were 24 cases (27.9%) with abdominal trauma which had penetrating lesions and 62 cases (72.1%) with blunt lesions. The most common lesions in patients with penetrating abdominal injuries were spleen (24.2%) and liver (12.1%) lesions. The outcomes of the patients were as follow: 95.7% recovery and 4.3% death. The majority of deaths were observed among road traffic victims (77.7%). Conclusions Considering the fact that road-related accidents are quite predictable and controllable; therefore, the quality promotion of traumatic patients' care, and the road safety should be noted as problems associated with public health. PMID:24396771

Impact of Sexual Trauma on HIV Care Engagement: Perspectives of Female Patients with Trauma Histories in Cape Town, South Africa.

PubMed

Watt, Melissa H; Dennis, Alexis C; Choi, Karmel W; Ciya, Nonceba; Joska, John A; Robertson, Corne; Sikkema, Kathleen J

2017-11-01

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no women had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Perioperative and acute care outcomes in morbidly obese patients with acetabular fractures at a Level 1 trauma center

PubMed Central

Vincent, Heather K.; Haupt, Edward; Tang, Sonya; Egwuatu, Adaeze; Vlasak, Richard; Horodyski, MaryBeth; Carden, Donna; Sadisivan, Kalia K.

2014-01-01

Background Controversy exists regarding obesity-related injury severity and clinical outcomes after orthopedic trauma. Purpose The purposes of this study were to expand our understanding of the effect of morbid obesity on perioperative and acute care outcomes after acetabular fracture. Methods This was a retrospective review of patients with acetabular fracture after trauma. Non-morbidly obese (BMI < 35 kg/m2) and morbidly obese (BMI ≥ 35 kg/m2; N = 81). Injury severity scores and Glasgow Coma Scale scores (GCS) were collected. Perioperative and acute care outcomes were positioning and operative time, extra fractures, estimated blood loss, complications, hospital charges, ventilator days, transfusions, length of stay (LOS) and discharge destination. Positioning and operative times were longer in morbidly obese patients (p < 0.05). No other differences existed between groups. Conclusions Orthopedic trauma surgeons and care teams can expect similar acute care outcomes in morbidly obese and non-morbidly obese patients with acetabular fracture. PMID:25104886

Non-trauma surgical emergencies in adults: Spectrum, challenges and outcome of care

PubMed Central

Ibrahim, N.A.; Oludara, M.A.; Ajani, A.; Mustafa, I.; Balogun, R.; Idowu, O.; Osuoji, R.; Omodele, F.O.; Aderounmu, A.O.A.; Solagberu, B.A.

2015-01-01

Introduction Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes. Methods A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0. Results Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases. Conclusion Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital. PMID:26566434

Emergency ultrasound in the acute assessment of haemothorax

PubMed Central

Brooks, A; Davies, B; Smethhurst, M; Connolly, J

2004-01-01

Aims: To evaluate thoracic ultrasound for the detection of haemothorax in patients with thoracic trauma against established investigations. Methods: Thoracic ultrasound was performed as an extension of the standard focused assessment with sonography for trauma (FAST) protocol used at the Queen's Medical Centre for the assessment of adult patients with torso trauma. Fluid was sought in both pleural cavities using a hand portable ultrasound system by one of two non-radiologists trained in FAST. Findings were compared against subsequent investigations/procedures performed at the discretion of the attending emergency physician—supine chest radiography, intercostal drain, computed tomography, or thoracotomy. The sensitivity of the technique and the time taken to diagnosis for each investigation were recorded. Results: Sixty one patients, 54 (89%) after blunt trauma, underwent thoracic ultrasound evaluation during the study. Twelve patients had a haemothorax detected by ultrasound and confirmed by computed tomography or by tube thoracostomy. Four haemothoraces detected on ultrasound were not apparent on trauma chest radiography. There were 12 true positives, 48 true negatives, no false positives, and one false negative scan. The sensitivity of ultrasound was 92% and specificity 100% with a positive predictive value of 100% and negative predictive value 98% for the detection of haemothorax after trauma. Conclusions: Emergency ultrasound of the chest performed as part of the primary survey of the traumatised patient can rapidly and accurately diagnose haemothorax and is a valuable tool to augment the immediate clinical assessment of these patients. PMID:14734374

A small case series of aortic balloon occlusion in trauma: lessons learned from its use in ruptured abdominal aortic aneurysms and a brief review.

PubMed

Hörer, T M; Skoog, P; Pirouzram, A; Nilsson, K F; Larzon, T

2016-10-01

EndoVascular and Hybrid Trauma Management (EVTM) is an emerging concept for the early treatment of trauma patients using aortic balloon occlusion (ABO), embolization agents and stent grafts to stop ongoing traumatic bleeding. These techniques have previously been implemented successfully in the treatment of ruptured aortic aneurysm. We describe our very recent experience of EVTM using ABO in bleeding patients and lessons learned over the last 20 years from the endovascular treatment of ruptured abdominal aortic aneurysms (rAAA). We also briefly describe current knowledge of ABO usage in trauma. A small series of educational cases in our hospital is described, where endovascular techniques were used to gain temporary hemorrhage control. The methods used for rAAA and their applicability to EVTM with a multidisciplinary approach are presented. Establishing femoral arterial access immediately on arrival at the emergency room and use of an angiography table in the surgical suite may facilitate EVTM at an early stage. ABO may be an effective method for the temporary stabilization of severely hemodynamically unstable patients with hemorrhagic shock, and may be useful as a bridge to definitive treatment of the bleeding patients. EVTM, including the usage of ABO, can be initiated on patient arrival and is feasible. Further data need to be collected to investigate proper indications for ABO, best clinical usage, results and potential complications. Accordingly, the ABOTrauma Registry has recently been set up. Existing experiences of EVTM and lessons from the endovascular treatment of rAAA may be useful in trauma management.

F227. PSYCHOLOGICAL TRAUMA OCCURRING DURING ADOLESCENCE IS ASSOCIATED WITH AN INCREASED RISK OF GREATER WAIST CIRCUMFERENCE IN EARLY PSYCHOSIS PATIENTS INDEPENDENTLY OF MEDICATION

PubMed Central

Alameda, Luis; Levier, Axel; Golay, Philippe; Gholam-Rezaee, Mehdi; Vandenberghe, Frederik; Delacretaz, Aurélie; Glatard, Anaïs; Dubath, Céline; Do, Kim Q; Eap, Chin B; Conus, Philippe

2018-01-01

Abstract Background The high prevalence of obesity in patients suffering from psychosis is a major concern as it dramatically increases the mortality rates of such patients in the long term. The mechanisms by which these patients develop overweight are poorly understood. It has been suggested that exposure to Childhood Trauma (CT) may play a role in the risk for obesity; however, whether this is the case for Early Psychosis (EP) patients and independently of the impact of medication has yet to be investigated. In addition, it is unknown whether the age at the time of exposure to CT can modulate the link between CT and obesity in EP patients. Methods 136 EP patients aged 18–35 were recruited from the Treatment and Early Intervention in Psychosis Program (TIPP-Lausanne). Body Mass Index (BMI), Weight Gain (WG) and Waist Circumference (WC) were measured and monitored prospectively after psychotropic prescription during a follow-up period of 1 year (patients were assessed at baseline, after 1, 2, 3, 6 months and 1 year of antipsychotic treatment). Patients were classified into Early-Trauma if they had faced at least one experience of abuse (physical, sexual, or emotional) or neglect (physical or emotional) before age 12, and Late-Trauma if the exposure had occurred between ages 12 and 16. Linear Mixed effect models with a random intercept were used to investigate the impact of Trauma (early or late) on the metabolic parameters longitudinally, Marko Chain Monte Carlo (MCMC) method was used to adjust these models with sufficiently large number of MCMC iterations. Models were adjusted for age, socioeconomic status, baseline BMI, medication intake prior to the first assessment and during the treatment phase, and by the diagnosis of depression. Results Patients were more likely to have a diagnosis of Schizophrenia (61%; N=83), they had a mean age of 26 at the time of first assessment, and exposure to 1 or more forms of traumatic experiences before 16 years of age was present in 32% of the sample. No differences between groups were found at baseline in terms of BMI or WC. Late-Trauma patients, when compared to Non-Trauma patients showed greater WCs during the follow-up (p=0.012). No differences between Early or Late-Trauma patients and Non-Trauma patients were found in any of the other outcome measures during the follow up. Baseline BMI and treatment duration were significantly associated with the level of BMI and WC during the follow up. None of the other potential confounding factors were significantly associated with the outcome measures during the follow up. Discussion Exposition to trauma during adolescence in EP patients is associated with a higher risk of greater WC during the early phase of the disease, independently of the medication intake, depression and other confounding factors. Specific preventive measures should be addressed in these patients in order to reduce the risk of obesity. Depending on the timing of traumatic exposure, different developmental mechanisms may underlie this differential possible impact on WC. Further studies on interactions between central consequences of traumatism and metabolic syndrome are warranted.

Stimulating neuroregeneration as a therapeutic drug approach for traumatic brain injury

PubMed Central

Mueller, Bernhard K; Mueller, Reinhold; Schoemaker, Hans

2009-01-01

Traumatic brain injury, a silent epidemic of modern societies, is a largely neglected area in drug development and no drug is currently available for the treatment of patients suffering from brain trauma. Despite this grim situation, much progress has been made over the last two decades in closely related medical indications, such as spinal cord injury, giving rise to a more optimistic approach to drug development in brain trauma. Fundamental insights have been gained with animal models of central nervous system (CNS) trauma and spinal cord injury. Neuroregenerative drug candidates have been identified and two of these have progressed to clinical development for spinal cord injury patients. If successful, these drug candidates may be used to treat brain trauma patients. Significant progress has also been made in understanding the fundamental molecular mechanism underlying irreversible axonal growth arrest in the injured CNS of higher mammals. From these studies, we have learned that the axonal retraction bulb, previously regarded as a marker for failure of regenerative growth, is not static but dynamic and, therefore, amenable to pharmacotherapeutic approaches. With the development of modified magnetic resonance imaging methods, fibre tracts can be visualised in the living human brain and such imaging methods will soon be used to evaluate the neuroregenerative potential of drug candidates. These significant advances are expected to fundamentally change the often hopeless situation of brain trauma patients and will be the first step towards overcoming the silent epidemic of brain injury. PMID:19422372

Citywide trauma experience in Mwanza, Tanzania: a need for urgent intervention

PubMed Central

2013-01-01

Background Trauma remains a leading cause of morbidity and mortality in resource limited countries. There is paucity of published reports on trauma care in Tanzania, particularly the study area. This study was carried out to describe our experiences in trauma management outlining the etiological spectrum, injury characteristics and treatment outcome of trauma patients at our local setting and compare our results with those from other centers in the world. Methods A descriptive prospective study of trauma patients was conducted at Bugando Medical Centre from April 2010 to March 2012. Statistical data analysis was done using SPSS software version 17.0. Results A total of 5672 trauma patients were enrolled in the study. The male to female ratio was 2.3: 1. The majority of patients were in the 2nd decade of life. Road traffic accident was the most common cause of trauma accounting for 60.7% of cases. The majority of patients (76.6%) sustained blunt injuries. Musculoskeletal (68.5%) and head/neck (52.6%) were the most frequent body region injured. Soft tissue injuries (open wounds) and fractures were the most common injuries accounting for 82.8% and 76.8% respectively. Majority of patients (74.4%) were treated surgically with wound debridement (94.0%) being the most frequently performed procedure. Postoperative complications were recorded in 31.5% of cases. The overall median duration of hospitalization was 26 days (range 1 day to 144 days). Mortality rate was 16.7%. Patients who had polytrauma, burn injuries and those who had tetanus and long bone fractures stayed longer in the hospital and this was statistically significant (P < 0.001), whereas the age > 65 years, severe trauma, admission Systolic Blood Pressure < 90 mmHg, presence of tetanus, severe head injury, the duration of loss of consciousness, the need for intensive care unit admission and finding of space occupying lesion on CT scan of the brain significantly influenced mortality (P < 0.001). Conclusion Trauma resulting from road traffic accidents remains a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of road traffic accidents is necessary to reduce the incidence of trauma in this region. PMID:24499566

The trauma registry compared to All Patient Refined Diagnosis Groups (APR-DRG).

PubMed

Hackworth, Jodi; Askegard-Giesmann, Johanna; Rouse, Thomas; Benneyworth, Brian

2017-05-01

Literature has shown there are significant differences between administrative databases and clinical registry data. Our objective was to compare the identification of trauma patients using All Patient Refined Diagnosis Related Groups (APR-DRG) as compared to the Trauma Registry and estimate the effects of those discrepancies on utilization. Admitted pediatric patients from 1/2012-12/2013 were abstracted from the trauma registry. The patients were linked to corresponding administrative data using the Pediatric Health Information System database at a single children's hospital. APR-DRGs referencing trauma were used to identify trauma patients. We compared variables related to utilization and diagnosis to determine the level of agreement between the two datasets. There were 1942 trauma registry patients and 980 administrative records identified with trauma-specific APR-DRG during the study period. Forty-two percent (816/1942) of registry records had an associated trauma-specific APR-DRG; 69% of registry patients requiring ICU care had trauma APR-DRGs; 73% of registry patients with head injuries had trauma APR-DRGs. Only 21% of registry patients requiring surgical management had associated trauma APR-DRGs, and 12.5% of simple fractures had associated trauma APR-DRGs. APR-DRGs appeared to only capture a fraction of the entire trauma population and it tends to be the more severely ill patients. As a result, the administrative data was not able to accurately answer hospital or operating room utilization as well as specific information on diagnosis categories regarding trauma patients. APR-DRG administrative data should not be used as the only data source for evaluating the needs of a trauma program. Copyright © 2016 Elsevier Ltd. All rights reserved.

Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth.

PubMed

Rose, Melanie K; Rosal, Lindy M; Gonzalez, Richard P; Rostas, Jack W; Baker, Jeremy A; Simmons, Jon D; Frotan, Mohammed A; Brevard, Sydney B

2012-08-01

The purpose of this study was to prospectively assess the sensitivity and efficacy of clinical examination for screening of cervical spine (c-spine) injury in awake and alert blunt trauma patients with concomitant "distracting injuries." During the 24-month period from December 2009 to December 2011, all blunt trauma patients older than 13 years were prospectively evaluated with a standard cervical spine examination protocol by the trauma surgery team at a Level 1 trauma center. Awake and alert patients with a Glasgow Coma Score (GCS) ≥14 underwent clinical examination of the cervical spine. Clinical examination was performed regardless of "distracting injuries." Patients without complaints of pain or tenderness on physical exam had their cervical collar removed, and the c-spine was considered clinically cleared of injury. All awake and alert patients with "distracting injuries," including those clinically cleared and those with complaints of c-spine pain or tenderness underwent computerized tomographic (CT) scanning of the entire c-spine. "Distracting injuries" were categorized into three anatomic regions: head injuries, torso injuries and long bone fractures. Patients with minor distracting injuries were not considered to have a "distracting injury." During the 24-month study period, 761 blunt trauma patients with GCS ≥14 and at least one "distracting injury" had been entered into the study protocol. Two-hundred ninety-six (39%) of the patients with "distracting injuries" had a positive c-spine clinical examination, 85 (29%) of whom were diagnosed with c-spine injury. Four hundred sixty-four (61%) of the patients with "distracting injuries"’ were initially clinically cleared, with one patient (0.2%) diagnosed with a c-spine injury. This yielded an overall sensitivity of 99% (85/86) and negative predictive value greater than 99% (463/464) for cervical spine clinical examination in awake and alert blunt trauma patients with "distracting injuries." In the awake and alert blunt trauma patient with "distracting injuries," clinical examination is a sensitive screening method for cervical spine injury. Radiological assessment is unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert blunt trauma patients with "distracting injuries." These findings suggest the concept of "distracting injury" in the context of cervical spine clinical examination is invalid. Expanding the utility of cervical spine clinical examination to patients with "distracting injuries" allows for significant reduction of both healthcare cost and radiation exposure.

Selective conservatism in the management of thoracic trauma remains appropriate in the 21st century

PubMed Central

Oosthuizen, GV; Clarke, DL

2015-01-01

Introduction Selective conservatism for thoracic trauma is well established but the emergence of new technologies may cause management strategies to continue to evolve. Methods A retrospective study was conducted on thoracic trauma patients managed in a single institution in South Africa over a 4-year period to determine the appropriateness of our current policy of selective conservatism. Results A total of 1,239 patients were included in the study; 112 required an emergency thoracotomy, 125 were admitted for observation and 1,002 required a tube thoracostomy (TT). Ninety-one per cent of the patients were male and the median age was 24 years. Seventy-five per cent of the cases were penetrating trauma and the remaining were blunt trauma. The indications for TT were pneumothorax (PTX) (n=382, 38%), haemothorax (HTX) (n=300, 30%) and haemopneumothorax (HPTX) (n=320, 32%). A total of 13% (127/1,002) of all chest x-rays (CXR) following tube removal demonstrated residual pathologies that precluded immediate discharge: 32 (8%) in Group A (PTX), 44 (15%) in Group B (HTX) and 51 (16%) in Group C (HPTX). All 32 patients in Group A were simply observed and did not require further intervention. In Group B, 17 patients required repeat TTs and 27 required video assisted thoracoscopic surgery (VATS) for clearance of residual HTX. Twenty-nine patients in Group C required repeat TTs and twenty-two required VATS. Conclusions The vast majority of patients with thoracic trauma can be managed conservatively with TT alone. Residual pathology appeared to be lowest in patients with a PTX, which seldom requires treatment, while only a minority of patients required repeat TTs or VATS for a retained HTX. Selective conservatism is still appropriate in the current era in a developing world setting. PMID:26263809

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.

Characterizing the relationship between age and venous thromboembolism in adult trauma patients: findings from the National Trauma Data Bank and the National Inpatient Sample.

PubMed

Nastasi, Anthony J; Canner, Joseph K; Lau, Brandyn D; Streiff, Michael B; Aboagye, Jonathan K; Kraus, Peggy S; Hobson, Deborah B; Van Arendonk, Kyle J; Haut, Elliott R

2017-08-01

Venous thromboembolism (VTE) is a tremendous burden in health care. However, current guidelines lack recommendations regarding the prevention of VTE in older adult trauma patients. Furthermore, the appropriate method of modeling of age in VTE models is currently unclear. Patients included in the National Trauma Data Bank (NTDB) between the years 2008 and 2014 and patients included in the National Inpatient Sample (NIS) between 2009 and 2013 were analyzed. Multiple logistic regression of VTE on age was performed. Of 3,598,881 patients in the NTDB, 34,202 (1.0%) were diagnosed with VTE compared to 5405 (1.1%) of the 505,231 patients in NIS. In both the fully adjusted NTDB and NIS model, age was positively associated with odds of VTE diagnosis under 65 years (NTDB, adjusted odds ratio [aOR]: 1.018, 95% confidence interval [CI]: 1.017-1.019, P < 0.001; NIS, aOR: 1.025, 95% CI 1.022-1.027, P < 0.001). In patients aged ≥65 years, age was negatively associated with odds of VTE diagnosis in the NTDB (aOR: 0.995, 95% CI: 0.992-0.999, P = 0.006) but not in the NIS (aOR: 0.998, 95% CI 0.994-1.002, P = 0.26). Incidence of VTE among adult trauma patients steadily increases with age until 65 years, after which the odds of VTE appear to level off or even slightly decrease. These findings should be applied for improved modeling of VTE in trauma patients. The mechanism behind these findings should be explored before using them to update guidelines for standardized VTE prevention in older adults. Copyright © 2017 Elsevier Inc. All rights reserved.

Profiles of Childhood Trauma in Patients with Alcohol Dependence and Their Associations with Addiction-Related Problems.

PubMed

Lotzin, Annett; Haupt, Lena; von Schönfels, Julia; Wingenfeld, Katja; Schäfer, Ingo

2016-03-01

The high occurrence of childhood trauma in individuals with alcohol dependence is well-recognized. Nevertheless, researchers have rarely studied which types of childhood trauma often co-occur and how these combinations of different types and severities of childhood trauma are related to the patients' current addiction-related problems. We aimed to identify childhood trauma profiles in patients with alcohol dependence and examined relations of these trauma profiles with the patients' current addiction-related problems. In 347 alcohol-dependent patients, 5 types of childhood trauma (sexual abuse, physical abuse, emotional abuse, emotional neglect, and physical neglect) were measured using the Childhood Trauma Questionnaire. Childhood trauma profiles were identified using cluster analysis. The patients' current severity of addiction-related problems was assessed using the European Addiction Severity Index. We identified 6 profiles that comprised different types and severities of childhood trauma. The patients' trauma profiles predicted the severity of addiction-related problems in the domains of psychiatric symptoms, family relationships, social relationships, and drug use. Childhood trauma profiles may provide more useful information about the patient's risk of current addiction-related problems than the common distinction between traumatized versus nontraumatized patients. Copyright © 2016 by the Research Society on Alcoholism.

Grey’s Anatomy effect: television portrayal of patients with trauma may cultivate unrealistic patient and family expectations after injury

PubMed Central

Serrone, Rosemarie O; Weinberg, Jordan A; Goslar, Pamela W; Wilkinson, Erin P; Thompson, Terrell M; Dameworth, Jonathan L; Dempsey, Shawna R; Petersen, Scott R

2018-01-01

Background Expectations of the healthcare experience may be influenced by television dramas set in the hospital workplace. It is our perception that the fictional television portrayal of hospitalization after injury in such dramas is misrepresentative. The purpose of this study was to compare trauma outcomes on television dramas versus reality. Methods We screened 269 episodes of Grey’s Anatomy, a popular medical drama. A television (TV) registry was constructed by collecting data for each fictional trauma portrayed in the television series. Comparison data for a genuine patient cohort were obtained from the 2012 National Trauma Databank (NTDB) National Program Sample. Results 290 patients composed of the TV registry versus 4812 patients from NTDB. Mortality was higher on TV (22% vs 7%, P<0.0001). Most TV patients went straight from emergency department (ED) to operating room (OR) (71% vs 25%, P<0.0001). Among TV survivors, a relative minority were transferred to long-term care (6% vs 22%, P<0.0001). For severely injured (Injury Severity Score ≥25) survivors, hospital length of stay was less than 1 week for 50% of TV patients versus 20% in NTDB (P<0.0001). Conclusions Trauma patients as depicted on television dramas typically go from ED to OR, and survivors usually return home. Television portrayal of rapid functional recovery after major injury may cultivate false expectations among patients and their families. Level of evidence Level III. PMID:29766127

Multiscale systems biology of trauma-induced coagulopathy.

PubMed

Tsiklidis, Evan; Sims, Carrie; Sinno, Talid; Diamond, Scott L

2018-07-01

Trauma with hypovolemic shock is an extreme pathological state that challenges the body to maintain blood pressure and oxygenation in the face of hemorrhagic blood loss. In conjunction with surgical actions and transfusion therapy, survival requires the patient's blood to maintain hemostasis to stop bleeding. The physics of the problem are multiscale: (a) the systemic circulation sets the global blood pressure in response to blood loss and resuscitation therapy, (b) local tissue perfusion is altered by localized vasoregulatory mechanisms and bleeding, and (c) altered blood and vessel biology resulting from the trauma as well as local hemodynamics control the assembly of clotting components at the site of injury. Building upon ongoing modeling efforts to simulate arterial or venous thrombosis in a diseased vasculature, computer simulation of trauma-induced coagulopathy is an emerging approach to understand patient risk and predict response. Despite uncertainties in quantifying the patient's dynamic injury burden, multiscale systems biology may help link blood biochemistry at the molecular level to multiorgan responses in the bleeding patient. As an important goal of systems modeling, establishing early metrics of a patient's high-dimensional trajectory may help guide transfusion therapy or warn of subsequent later stage bleeding or thrombotic risks. This article is categorized under: Analytical and Computational Methods > Computational Methods Biological Mechanisms > Regulatory Biology Models of Systems Properties and Processes > Mechanistic Models. © 2018 Wiley Periodicals, Inc.

Trauma patients: I can't get no (patient) satisfaction?

PubMed

Bentley-Kumar, Karalyn; Jackson, Theresa; Holland, Danny; LeBlanc, Brian; Agrawal, Vaidehi; Truitt, Michael S

2016-12-01

The Centers for Medicare and Medicaid Services (CMS) provides financial incentives to hospitals based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey. This data is made publicly available on their website to be utilized by patients and insurers. Hospitals are profoundly interested in identifying patient populations that negatively contribute to overall patient satisfaction scores. Hospitals consider trauma patients "high risk" from a HCAHPS perspective, but there is no data to inform this opinion. The purpose of this study is to evaluate trauma patient satisfaction scores and their impact on overall patient satisfaction. Three different analyses were performed. Group 1 was composed of ALL patients admitted to our hospital over a 7-month period who were administered a validated patient satisfaction survey by a 3rd party and compared patient satisfaction of trauma vs. non-trauma patients (ALL). Group 2 compared admitted patients with a specific ICD-9 procedure code to non-trauma patients who underwent a procedure with the same ICD-9 code (ICD). Group 3 examines patient satisfaction between three Level I Trauma Centers within our geographic area (TC). Patient satisfaction data of trauma vs non-trauma patients (ALL), those with a specific ICD-9 procedure code (ICD), and the 3 Level I Trauma Centers in our area (TC) were analyzed with the appropriate statistical test. In the ALL group, no difference in satisfaction was noted in 18/21 questions for trauma patients when compared to non-trauma patients at our hospital. In the ICD group, 57 ICD-9 procedure codes were analyzed. Of these, only patients who required spinal fusion secondary to trauma reported lower overall patient satisfaction. No meaningful difference was found in HCAHPS associated satisfaction between the Level I Trauma Centers in our area (TC). In contrast to commonly held opinion, trauma patients do not negatively contribute to overall patient satisfaction in our facility. Certain injuries may offer opportunities for improvement and efforts around improved physician-patient communication may be warranted. In the era of public reporting and financial penalties, surgeons should embrace patient satisfaction as it may be vital to the survival of the trauma center. Copyright © 2016. Published by Elsevier Inc.

Rhabdomyolysis in Critically Ill Surgical Patients

PubMed Central

Kuzmanovska, Biljana; Cvetkovska, Emilija; Kuzmanovski, Igor; Jankulovski, Nikola; Shosholcheva, Mirjana; Kartalov, Andrijan; Spirovska, Tatjana

2016-01-01

Introduction: Rhabdomyolysis is a syndrome of injury of skeletal muscles associated with myoglobinuria, muscle weakness, electrolyte imbalance and often, acute kidney injury as severe complication. The aim: of this study is to detect the incidence of rhabdomyolysis in critically ill patients in the surgical intensive care unit (ICU), and to raise awareness of this medical condition and its treatment among the clinicians. Material and methods: A retrospective review of all surgical and trauma patients admitted to surgical ICU of the University Surgical Clinic “Mother Teresa” in Skopje, Macedonia, from January 1st till December 31st 2015 was performed. Patients medical records were screened for available serum creatine kinase (CK) with levels > 200 U/l, presence of myoglobin in the serum in levels > 80 ng/ml, or if they had a clinical diagnosis of rhabdomyolysis by an attending doctor. Descriptive statistical methods were used to analyze the collected data. Results: Out of totally 1084 patients hospitalized in the ICU, 93 were diagnosed with rhabdomyolysis during the course of one year. 82(88%) patients were trauma patients, while 11(12%) were surgical non trauma patients. 7(7.5%) patients diagnosed with rhabdomyolysis developed acute kidney injury (AKI) that required dialysis. Average values of serum myoglobin levels were 230 ng/ml, with highest values of > 5000 ng/ml. Patients who developed AKI had serum myoglobin levels above 2000 ng/ml. Average values of serum CK levels were 400 U/l, with highest value of 21600 U/l. Patients who developed AKI had serum CK levels above 3000 U/l. Conclusion: Regular monitoring and early detection of elevated serum CK and myoglobin levels in critically ill surgical and trauma patients is recommended in order to recognize and treat rhabdomyolysis in timely manner and thus prevent development of AKI. PMID:27703296

Gastrointestinal Injuries in Blunt Abdominal Traumas.

PubMed

Gönüllü, D; Ilgun, S; Gedik, M L; Demiray, O; Öner, Z; Er, M; Köksoy, F N

2015-01-01

To discuss the efficiency of RTS (Revised TraumaScore), ISS (Injury Severity Score), and factors that affect mortality and morbidity in gastrointestinal injuries due to blunt trauma.Method and methods: Patients with gastrointestinal injuries due to blunt trauma operated within the last six years have been studied retrospectively in terms of demographics,injury mechanism and localization, additional injuries, RTS and ISS, operative technique, morbidity, mortality and duration of hospitalization. Of the eighteen cases, cause of injury was a traffic accident for 11 (61.1%), fall from height for 5 (27%) and physical attack for 2 (11%). Among the eighteen patients,there were 21 gastrointestinal injuries (11 intestinal, 6 colon,3 duodenum, 1 stomach). 10 (55.6%) had additional intraabdominal injuries while the number for extra-abdominal injuries were 12 (66.7%). Primary suture (10), segmentary resection (9) and pyloric exclusion (2) were the operations performed for the twenty-one gastrointestinal injuries.Although statistically not significant, 13(72.2%) patients with additional injuries compared with 5 (27.8%) patients with isolated gastrointestinal injuries, were found to have lower RTS (7.087/7.841), higher ISS (19.4/12.2), longer duration of hospitalization (11.5/8.4 day) as well as higher morbidity (7/1) and mortality (2/0) rates. Comparing the RTS (7.059/7.490) of patients who have and have not developed morbidity revealed no significant difference.However, ISS (23.9/12.2) was significantly higher in patients who have developed morbidity (p=0.003). RTS (6.085 7.445) and ISS (39.5/14.6) of patients who have survived were significantly different than patients who have not(p=0.037 and p=0.023, respectively) Additional injuries in patients with gastrointestinal injury due blunt abdominal traumas increases, although not significantly, morbidity, mortality and duration of hospitalization even when operated early. High ISS is significantly related to the risk of both morbidity and mortality while low RTS is significantly related only to the mortality risk. Celsius.

Thromboprophylaxis for trauma patients.

PubMed

Barrera, Luis M; Perel, Pablo; Ker, Katharine; Cirocchi, Roberto; Farinella, Eriberto; Morales Uribe, Carlos Hernando

2013-03-28

Trauma is a leading causes of death and disability in young people. Venous thromboembolism (VTE) is a principal cause of death. Trauma patients are at high risk of deep vein thrombosis (DVT). The incidence varies according to the method used to measure the DVT and the location of the thrombosis. Due to prolonged rest and coagulation abnormalities, trauma patients are at increased risk of thrombus formation. Thromboprohylaxis, either mechanical or pharmacological, may decrease mortality and morbidity in trauma patients who survive beyond the first day in hospital, by decreasing the risk of VTE in this population.A previous systematic review did not find evidence of effectiveness for either pharmacological or mechanical interventions. However, this systematic review was conducted 10 years ago and most of the included studies were of poor quality. Since then new trials have been conducted. Although current guidelines recommend the use of thromboprophylaxis in trauma patients, there has not been a comprehensive and updated systematic review since the one published. To assess the effects of thromboprophylaxis in trauma patients on mortality and incidence of deep vein thrombosis and pulmonary embolism. To compare the effects of different thromboprophylaxis interventions and their effects according to the type of trauma. We searched The Cochrane Injuries Group Specialised Register (searched April 30 2009), Cochrane Central Register of Controlled Trials 2009, issue 2 (The Cochrane Library), MEDLINE (Ovid) 1950 to April (week 3) 2009, EMBASE (Ovid) 1980 to (week 17) April 2009, PubMed (searched 29 April 2009), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to April 2009), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to April 2009). Randomized controlled clinical trials involving people of any age with major trauma defined by one or more of the following criteria: physiological: penetrating or blunt trauma with more than two organs and unstable vital signs, anatomical: people with an Injury Severity Score (ISS) higher than 9, mechanism: people who are involved in a 'high energy' event with a risk for severe injury despite stable or normal vital signs. We excluded trials that only recruited outpatients, trials that recruited people with hip fractures only, or people with acute spinal injuries. Four authors, in pairs (LB and CM, EF and RC), independently examined the titles and the abstracts, extracted data, assessed the risk of bias of the trials and analysed the data. PP resolved any disagreement between the authors. Sixteen studies were included (n=3005). Four trials compared the effect of any type (mechanical and/or pharmacological) of prophylaxis versus no prophylaxis. Prophylaxis reduced the risk of DVT in people with trauma (RR 0.52; 95% CI 0.32 to 0.84). Mechanical prophylaxis reduced the risk of DVT (RR = 0.43; 95% CI 0.25 to 0.73). Pharmacological prophylaxis was more effective than mechanical methods at reducing the risk of DVT (RR 0.48; 95% CI 0.25 to 0.95). LMWH appeared to reduce the risk of DVT compared to UH (RR 0.68; 95% CI 0.50 to 0.94). People who received both mechanical and pharmacological prophylaxis had a lower risk of DVT (RR 0.34; 95% CI 0.19 to 0.60) We did not find evidence that thromboprophylaxis reduces mortality or PE in any of the comparisons assessed. However, we found some evidence that thromboprophylaxis prevents DVT. Although the strength of the evidence was not high, taking into account existing information from other related conditions such as surgery, we recommend the use of any DVT prophylactic method for people with severe trauma.

Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients

PubMed Central

Soja, Stacie L.; Pandharipande, Pratik P.; Fleming, Sloan B.; Cotton, Bryan A.; Miller, Leanna R.; Weaver, Stefanija G.; Lee, Byron T.; Ely, E. Wesley

2013-01-01

Objective To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients. Design and setting Prospective, observational study in a Level 1 trauma unit of a tertiary care, university-based medical center. Patients Acutely injured patients admitted to the trauma unit from February 1, 2006–April 16, 2006. Measurements and Results Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU, in order to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period, the nurses completed a post-implementation survey. One thousand and eleven random CAM-ICU assessments were performed by the expert evaluator, within 1 hour of the bedside nurses’ assessments. Nurses completed the CAM-ICU assessments in 84% (849 of 1011) of evaluations. Overall agreement (κ) between nurses and the expert evaluator was 0.77 (0.721, 0.822; p<0.0001). In TBI patients κ was 0.75 (0.667, 0.829; p<0.0001), while in mechanically-ventilated patients κ was 0.62 (0.534, 0.704; p<0.0001). The survey revealed nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training they received. The survey also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium. Conclusions The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction. PMID:18297270

[Video-assisted thoracoscopic surgery as an alternative to urgent thoracotomy following open chest trauma in selected cases].

PubMed

Samiatina, Diana; Rubikas, Romaldas

2004-01-01

To prove that video-assisted thoracoscopic surgery in selected cases is an alternative to urgent thoracotomy following open chest trauma. Retrospective analysis of case reports of patients operated for open chest trauma during 1997-2002. Comparison of two methods of surgical treatment: urgent video-assisted thoracoscopy and urgent thoracotomy. Duration of drain presence in the pleural cavity, duration of postoperative treatment, pain intensity and cosmetic effect were evaluated. Data analysis was performed using SPSS statistical software. Statistical evaluation of differences between groups was performed using Mann-Whitney U test. The differences between groups were considered to be statistically significant when the probability of deviation was p<0.05. During 1997-2002, 121 patients with open chest trauma were operated. Thirty three patients underwent urgent video-assisted thoracoscopy, 88 patients were operated through thoracotomy incision: 69 due to isolated open chest trauma, 17 due to thoracoabdominal injury and 2 due to abdominothoracic injury. Almost thirteen percent (12.5%) of patients after urgent thoracotomy underwent urgent laparotomy due to damaged diaphragm and other organs of peritoneal cavity. Duration of drain presence in the pleural cavity after video-assisted thoracoscopy was 4.57 days and after urgent thoracotomy - 6.88 days (p<0.05). Duration of post-operative treatment after video-assisted thoracoscopy was 8.21 days and after urgent thoracotomy - 14.89 days (p<0.05). Amount of consumed non-narcotic analgesics after video-assisted thoracoscopy was 1056.98 mg and after urgent thoracotomy - 1966.70 mg (p<0.05). Video-assisted thoracoscopy is minimally invasive method of thoracic surgery allowing for the evaluation of the pathological changes in the lung, pericardium, diaphragm, mediastinum, thoracic wall and pleura, including the localization of these changes, and the type and severity of the injury. The number of early post-operative complications following video-assisted thoracoscopy is lower. Compared to operations through thoracotomy incision, video assisted thoracoscopies entail the shortening of the duration of drain presence in the pleural cavity and the duration of post-operative treatment. Video-assisted thoracoscopy should be performed on all patients with open chest trauma and stable hemodynamics and the respiration function. Video-assisted thoracoscopy is an informative diagnostic and treatment method allowing for the selection of patients for urgent thoracotomy.

Comparison of outcome between low and high thoracic trauma severity score in blunt trauma chest patients.

PubMed

Subhani, Shahzadi Samar; Muzaffar, Mohammad Sultan; Khan, Muhammad Imtiaz

2014-01-01

Blunt chest trauma is second leading cause of death among trauma patients. Early identification and aggressive management of blunt thoracic trauma is essential to reduce the significant rates of morbidity and mortality. Thoracic trauma severity score (TTS) is a better predictor of chest trauma related complications. The objective of the study was to compare outcomes between low-and high thoracic trauma severity score in blunt trauma chest patients. A cross sectional descriptive study was carried out in public and private sector hospitals of Rawalpindi, Pakistan from 2008 to 2012 and 264 patients with blunt trauma chest who reported to emergency department of the hospitals, within 48 hrs of trauma were recruited. All patients were subjected to detailed history and respiratory system examination to ascertain fracture ribs, flail segment and hemopneumothorax. Written and informed consent was taken from each patient. Permission was taken from ethical committee of the hospital. The patients with blunt chest trauma had an array of associated injuries; however there were 70.8% of patients in low TTS group and 29.2% in high TTS group. Outcome was assessed as post trauma course of the patient. Outcome in low and high TTS group was compared using Chi square test which shows a significant relationship (p=0.000) between outcome and TTS, i.e., outcome worsened with increase in TTS. It is concluded that there is a significant relationship between outcome and thoracic trauma severity. Outcome of the patient worsened with increase in thoracic trauma severity score.

Predictive value of focused assessment with sonography for trauma (FAST) for laparotomy in unstable polytrauma Egyptians patients.

PubMed

Elbaih, Adel Hamed; Abu-Elela, Sameh T

2017-12-01

The emergency physicians face significant clinical uncertainty when multiple trauma patients arrive in the emergency department (ED). The priorities for assessment and treatment of polytrauma patients are established in the primary survey. Focused assessment with sonography for trauma (FAST) is very essential clinical skill during trauma resuscitation. Use of point of care ultrasound among the trauma team working in the primary survey in emergency care settings is lacking in Suez Canal University Hospitals even ultrasound machine not available in ED. This study aims to evaluate the accuracy of FAST in hemodynamically unstable polytraumatized patients and to determine its role as an indication of laparotomy. This study is a cross-sectional study included 150 polytrauma patients with a blunt mechanism admitted in Suez Canal University Hospital. Firstly primary survey by airway check, cervical spine securing with neck collar, maintenance of breathing/circulation and management of life threading conditions if present were conducted accordingly to ATLS (advanced trauma life support) guidelines. The patients were assessed in the primary survey using the FAST as a tool to determine the presence of intra-abdominal collection. A total of 150 patients, and FAST scans were performed in all cases. The sensitivity and specificity were 92.6% and 100%, respectively. The negative predictive value was 92%, while the positive predictive value of FAST was 100%. The accuracy of FAST was 96%. FAST is an important method to detect intra-abdominal fluid in the initial assessment in hemodynamically unstable polytrauma patients with high accuracy. Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

Risk Factors for Vascular Occlusive Events and Death Due to Bleeding in Trauma Patients; an Analysis of the CRASH-2 Cohort

PubMed Central

Pealing, Louise; Perel, Pablo; Prieto-Merino, David; Roberts, Ian

2012-01-01

Background Vascular occlusive events can complicate recovery following trauma. We examined risk factors for venous and arterial vascular occlusive events in trauma patients and the extent to which the risk of vascular occlusive events varies with the severity of bleeding. Methods and Findings We conducted a cohort analysis using data from a large international, double-blind, randomised, placebo-controlled trial (The CRASH-2 trial) [1]. We studied the association between patient demographic and physiological parameters at hospital admission and the risk of vascular occlusive events. To assess the extent to which risk of vascular occlusive events varies with severity of bleeding, we constructed a prognostic model for the risk of death due to bleeding and assessed the relationship between risk of death due to bleeding and risk of vascular occlusive events. There were 20,127 trauma patients with outcome data including 204 (1.01%) patients with a venous event (pulmonary embolism or deep vein thrombosis) and 200 (0.99%) with an arterial event (myocardial infarction or stroke). There were 81 deaths due to vascular occlusive events. Increasing age, decreasing systolic blood pressure, increased respiratory rates, longer central capillary refill times, higher heart rates and lower Glasgow Coma Scores (all p<0.02) were strong risk factors for venous and arterial vascular occlusive events. Patients with more severe bleeding as assessed by predicted risk of haemorrhage death had a greatly increased risk for all types of vascular occlusive event (all p<0.001). Conclusions Patients with severe traumatic bleeding are at greatly increased risk of venous and arterial vascular occlusive events. Older age and blunt trauma are also risk factors for vascular occlusive events. Effective treatment of bleeding may reduce venous and arterial vascular occlusive complications in trauma patients. PMID:23251374

Comparative Analysis of the Paravertebral Analgesic Pump Catheter with the Epidural Catheter in Elderly Trauma Patients with Multiple Rib Fractures.

PubMed

Shapiro, Brian S; Wasfie, Tarik; Chadwick, Mathew; Barber, Kimberly R; Yapchai, Raquel

2017-04-01

Presently, trauma guidelines recommend epidural analgesia as the optimal modality of pain relief from rib fractures. They are not ideally suited for elderly trauma patients and have disadvantages including bleeding risk. The paravertebral analgesic pump (PVP) eliminates such disadvantages and includes ease of placement in the trauma setting. This study compares pain control in patients treated by EPI versus PVP. This is a retrospective, historical cohort study comparing two methods of pain management in the trauma setting. Before 2010, patients who had epidural catheters (EPI) placed for pain control were compared with patients after 2010 in which the PVP was used. All patients had multiple rib fractures as diagnosed by CT scan. Analysis was adjusted for age, number of fractures, and comorbid conditions. Multiple linear regression analysis was conducted to compare average reported pain. A total of 110 patients, 31 PVP and 79 epidural catheters, were included in the study. Overall mean age was 65 years. The mean Injury Severity Score was 12.0 (EPI) and 11.1 (PVP). Mean number rib fractures was 4.29 (EPI) and 4.71 (PVP). PVP was associated with a 30 per cent greater decrease in pain than that seen with EPI (6.0-1.9 vs 6.4-3.4). After controlling for age, Injury Severity Score, and number of rib fractures, there were no differences in intensive care unit or total length of stay (P = 0.35) or in pain score (3.76 vs 3.56, P = 0.64). In conclusion, the PVP compares well with epidural analgesia in older trauma patients yet is safe, well tolerated, and easily inserted.

The impact of patient volume on surgical trauma training in a Scandinavian trauma centre.

PubMed

Gaarder, Christine; Skaga, Nils Oddvar; Eken, Torsten; Pillgram-Larsen, Johan; Buanes, Trond; Naess, Paal Aksel

2005-11-01

Some of the problems faced in trauma surgery are increasing non-operative management of abdominal injuries, decreasing work hours and increasing sub-specialisation. We wanted to document the experience of trauma team leaders at the largest trauma centre in Norway, hypothesising that the patient volume would be inadequate to secure optimal trauma care. Patients registered in the hospital based Trauma Registry during the 2-year period from 1 August 2000 to 31 July 2002 were included. Of a total of 1667 patients registered, 645 patients (39%) had an Injury Severity Score (ISS)>15. Abdominal injuries were diagnosed in 205 patients with a median ISS of 30. An average trauma team leader assessed a total of 119 trauma cases a year (46 patients with ISS>15) and participated in 10 trauma laparotomies. Although the total number of trauma cases seems adequate, the experience of the trauma team leaders with challenging abdominal injuries is limited. With increasing sub-specialisation and general surgery vanishing, fewer surgical specialties provide operative competence in dealing with complicated torso trauma. A system of additional education and quality assurance measures is a prerequisite of high quality, and has consequently been introduced in our institution.

Reexperiencing symptoms, dissociation, and avoidance behaviors in daily life of patients with PTSD and patients with panic disorder with agoraphobia.

PubMed

Pfaltz, Monique C; Michael, Tanja; Meyer, Andrea H; Wilhelm, Frank H

2013-08-01

Panic attacks are frequently perceived as life threatening. Panic disorder (PD) patients may therefore experience symptoms of posttraumatic stress disorder (PTSD). The authors explored this in 28 healthy controls, 17 PTSD patients, and 24 PD patients with agoraphobia who completed electronic diaries 36 times during 1 week. Patient groups frequently reported dissociation as well as thoughts, memories, and reliving of their trauma or panic attacks. PTSD patients reported more trauma/panic attack thoughts (incidence rate ratio [IRR] = 2.9) and memories (IRR = 2.8) than PD patients. Patient groups relived their trauma or panic attacks equally frequently, and reported comparable bodily reactions and distress associated with trauma or panic attack memories. Clinical groups avoided trauma or panic attack reminders more often than healthy controls (avoidance of trauma- or panic attack-related thoughts (IRR = 8.0); avoidance of things associated with the trauma or panic attack (IRR = 40.7). PD patients avoided trauma or panic attack reminders less often than PTSD patients (avoidance of trauma- or panic attack-related thoughts [IRR = 2.5]; avoidance of things associated with the trauma or panic attack [IRR = 4.1]), yet these differences were nonsignificant when controlling for functional impairment. In conclusion, trauma-like symptoms are common in PD with agoraphobia and panic attacks may be processed similarly as trauma in PTSD. Copyright © 2013 International Society for Traumatic Stress Studies.

Minimally displaced clavicle fracture after high-energy injury: Are they likely to displace?

PubMed Central

Riehl, John T.; Athans, Bill J.; Munro, Mark W.; Langford, Joshua R.; Kupiszewski, Stanley J.; Haidukewych, George J.; Koval, Kenneth J.

2014-01-01

Background Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture. Methods We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded. Results Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission. Conclusion Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury. PMID:24869608

Patient-Reported Outcome Measures for Hand and Wrist Trauma

PubMed Central

Dacombe, Peter Jonathan; Amirfeyz, Rouin; Davis, Tim

2016-01-01

Background: Patient-reported outcome measures (PROMs) are important tools for assessing outcomes following injuries to the hand and wrist. Many commonly used PROMs have no evidence of reliability, validity, and responsiveness in a hand and wrist trauma population. This systematic review examines the PROMs used in the assessment of hand and wrist trauma patients, and the evidence for reliability, validity, and responsiveness of each measure in this population. Methods: A systematic review of Pubmed, Medline, and CINAHL searching for randomized controlled trials of patients with traumatic injuries to the hand and wrist was carried out to identify the PROMs. For each identified PROM, evidence of reliability, validity, and responsiveness was identified using a further systematic review of the Pubmed, Medline, CINAHL, and reverse citation trail audit procedure. Results: The PROM used most often was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; the Patient-Rated Wrist Evaluation (PRWE), Gartland and Werley score, Michigan Hand Outcomes score, Mayo Wrist Score, and Short Form 36 were also commonly used. Only the DASH and PRWE have evidence of reliability, validity, and responsiveness in patients with traumatic injuries to the hand and wrist; other measures either have incomplete evidence or evidence gathered in a nontraumatic population. Conclusions: The DASH and PRWE both have evidence of reliability, validity, and responsiveness in a hand and wrist trauma population. Other PROMs used to assess hand and wrist trauma patients do not. This should be considered when selecting a PROM for patients with traumatic hand and wrist pathology. PMID:27418884

Analysis of Otologic Injuries Due to Blast Trauma by Handmade Explosives

PubMed Central

Aslıer, Mustafa; Aslıer, Nesibe Gül Yüksel

2017-01-01

Objective The aim of this study is to identify the otologic injuries due to handmade explosive-welded blast travma in the law enforcement officers during the combat operations in the curfew security region and to specify the disorders that Otolaryngology and Head Neck Surgery (OHNS) physicians can face during such operations. Methods Medical records of patients in law enforcement who were initially treated by OHNS physicians of Silopi State Hospital during combat operations, between December 14, 2015 and January 15, 2016 were reviewed. Twenty-five patients with otologic injuries due to blast trauma were included in the study. Trauma characteristics, physical examination findings, and beginning treatments were identified. Results Primary blast injury (PBI) was identified as the major disorder in all 24 cases. Tinnitus and hearing loss were the most frequent complaints. In physical examination, tympanic membrane perforations were found in four ears of three patients. Oral methylprednisolone in decreasing doses for 10 days was commenced as an initial treatment in patients with PBI. Secondary blast injury presented in the form of soft tissue damage in the auricular helix due to shrapnel pieces in one patient and a minor surgery was performed. Conclusion Otologic injuries due to blast trauma may often develop during this type of combat operations. Otologic symptoms should be checked, otoscopic examination should be performed, and patients should consult OHNS physicians as soon as possible after trauma. PMID:29392057

Factors Affecting Morbidity in Solid Organ Injuries

PubMed Central

Baygeldi, Serdar; Karakose, Oktay; Özcelik, Kazım Caglar; Pülat, Hüseyin; Damar, Sedat; Eken, Hüseyin; Zihni, İsmail; Çalta, Alpaslan Fedai; Baç, Bilsel

2016-01-01

Background and Aim. The aim of this study was to investigate the effects of demographic characteristics, biochemical parameters, amount of blood transfusion, and trauma scores on morbidity in patients with solid organ injury following trauma. Material and Method. One hundred nine patients with solid organ injury due to abdominal trauma during January 2005 and October 2015 were examined retrospectively in the General Surgery Department of Dicle University Medical Faculty. Patients' age, gender, trauma interval time, vital status (heart rate, arterial tension, and respiratory rate), hematocrit (HCT) value, serum area aminotransferase (ALT) and aspartate aminotransferase (AST) values, presence of free abdominal fluid in USG, trauma mechanism, extra-abdominal system injuries, injured solid organs and their number, degree of injury in abdominal CT, number of blood transfusions, duration of hospital stay, time of operation (for those undergoing operation), trauma scores (ISS, RTS, Glasgow coma scale, and TRISS), and causes of morbidity and mortality were examined. In posttraumatic follow-up period, intra-abdominal hematoma infection, emboli, catheter infection, and deep vein thrombosis were monitored as factors of morbidity. Results. One hundred nine patients were followed up and treated due to isolated solid organ injury following abdominal trauma. There were 81 males (74.3%) and 28 females (25.7%), and the mean age was 37.6 ± 18.28 (15–78) years. When examining the mechanism of abdominal trauma in patients, the following results were obtained: 58 (53.3%) traffic accidents (22 out-vehicle and 36 in-vehicle), 27 (24.7%) falling from a height, 14 (12.9%) assaults, 5 (4.5%) sharp object injuries, and 5 (4.5%) gunshot injuries. When evaluating 69 liver injuries scaled by CT the following was detected: 14 (20.3%) of grade I, 32 (46.4%) of grade II, 22 (31.8%) of grade III, and 1 (1.5%) of grade IV. In 63 spleen injuries scaled by CT the following was present: grade I in 21 (33.3%), grade II in 27 (42.9%), grade III in 11 (17.5%), and grade IV in 4 (6.3%). The mean length of hospital stay after trauma was 6.46 days in the medically followed patients. This ratio was 8.13 days in 22 patients with morbidity and 5.98 days in 78 patients without morbidity. There was a morbidity in 22 (22%) patients medically followed after trauma. In this study, nonoperative treatment was observed to be performed safely in solid organ injuries after trauma in case of absence of hemodynamic stability and peritoneal irritation. It has been emphasized that injury of both liver and spleen (p < 0.01), high respiratory rate (p < 0.01), trauma scores (GKS, ISS, RTS) (p < 0.0001), and elevation of ALT AST values (p < 0.01) are stimulants for morbidity that may occur during follow-up. Conclusion. Medical follow-up can be considered in patients with high grade injuries similar to patients with low-grade solid organ injury after trauma. The injury of both liver and spleen, high respiratory rate, high GCS and ISS, low RTS, and elevation of ALT AST values were found to increase morbidity again in the follow-up of these patients. PMID:27375316

Factors Affecting Morbidity in Solid Organ Injuries.

PubMed

Baygeldi, Serdar; Karakose, Oktay; Özcelik, Kazım Caglar; Pülat, Hüseyin; Damar, Sedat; Eken, Hüseyin; Zihni, İsmail; Çalta, Alpaslan Fedai; Baç, Bilsel

2016-01-01

Background and Aim. The aim of this study was to investigate the effects of demographic characteristics, biochemical parameters, amount of blood transfusion, and trauma scores on morbidity in patients with solid organ injury following trauma. Material and Method. One hundred nine patients with solid organ injury due to abdominal trauma during January 2005 and October 2015 were examined retrospectively in the General Surgery Department of Dicle University Medical Faculty. Patients' age, gender, trauma interval time, vital status (heart rate, arterial tension, and respiratory rate), hematocrit (HCT) value, serum area aminotransferase (ALT) and aspartate aminotransferase (AST) values, presence of free abdominal fluid in USG, trauma mechanism, extra-abdominal system injuries, injured solid organs and their number, degree of injury in abdominal CT, number of blood transfusions, duration of hospital stay, time of operation (for those undergoing operation), trauma scores (ISS, RTS, Glasgow coma scale, and TRISS), and causes of morbidity and mortality were examined. In posttraumatic follow-up period, intra-abdominal hematoma infection, emboli, catheter infection, and deep vein thrombosis were monitored as factors of morbidity. Results. One hundred nine patients were followed up and treated due to isolated solid organ injury following abdominal trauma. There were 81 males (74.3%) and 28 females (25.7%), and the mean age was 37.6 ± 18.28 (15-78) years. When examining the mechanism of abdominal trauma in patients, the following results were obtained: 58 (53.3%) traffic accidents (22 out-vehicle and 36 in-vehicle), 27 (24.7%) falling from a height, 14 (12.9%) assaults, 5 (4.5%) sharp object injuries, and 5 (4.5%) gunshot injuries. When evaluating 69 liver injuries scaled by CT the following was detected: 14 (20.3%) of grade I, 32 (46.4%) of grade II, 22 (31.8%) of grade III, and 1 (1.5%) of grade IV. In 63 spleen injuries scaled by CT the following was present: grade I in 21 (33.3%), grade II in 27 (42.9%), grade III in 11 (17.5%), and grade IV in 4 (6.3%). The mean length of hospital stay after trauma was 6.46 days in the medically followed patients. This ratio was 8.13 days in 22 patients with morbidity and 5.98 days in 78 patients without morbidity. There was a morbidity in 22 (22%) patients medically followed after trauma. In this study, nonoperative treatment was observed to be performed safely in solid organ injuries after trauma in case of absence of hemodynamic stability and peritoneal irritation. It has been emphasized that injury of both liver and spleen (p < 0.01), high respiratory rate (p < 0.01), trauma scores (GKS, ISS, RTS) (p < 0.0001), and elevation of ALT AST values (p < 0.01) are stimulants for morbidity that may occur during follow-up. Conclusion. Medical follow-up can be considered in patients with high grade injuries similar to patients with low-grade solid organ injury after trauma. The injury of both liver and spleen, high respiratory rate, high GCS and ISS, low RTS, and elevation of ALT AST values were found to increase morbidity again in the follow-up of these patients.

Decision-Making in Management of the Complex Trauma Patient: Changing the Mindset of the non-trauma Surgeon.

PubMed

Sonesson, Linda; Boffard, Kenneth; Lundberg, Lars; Rydmark, Martin; Karlgren, Klas

2018-01-16

European surgeons are frequently subspecialized and trained primarily in elective surgical techniques. As trauma leaders, they may occasionally have to deal with complex polytrauma, advanced management techniques, differing priorities, and the need for multidisciplinary care. There is a lack of expertise, experience, and a low trauma volume, as well as a lack of research, with limited support as to the decision-making and teaching challenges present. We studied what experienced trauma experts describe as the challenges that are specific to the advanced surgical decision-making required, whether civilian, humanitarian, or military. Design-based research using combined methods including interviews, reviews of authentic trauma cases, and video-recorded resuscitations performed at a high-volume civilian academic trauma center. Several educational dilemmas were identified: (1) thinking physiologically, (2) the application of damage control resuscitation and surgery, (3) differing priorities and time management, (4) impact of environment, (5) managing limited resources, (6) lack of general surgical skills, (7) different cultural behavior, and (8) ethical issues. The challenges presented, and the educational domains identified, constitute a basis for improved development of education and training in complex surgical decision-making. This study contributes new knowledge about the mindset required for decision-making in patients with complex multisystem trauma and competing priorities of care. This is, especially important in countries having a low intensity of trauma in both military and civilian environments, and consequential limited skills, and lack of expertise. Guidelines focused on the same decision-making process, using virtual patients and blended learning, can be developed.

Task Shifting: The Use of Laypersons for Acquisition of Vital Signs Data for Clinical Decision Making in the Emergency Room Following Traumatic Injury.

PubMed

Haac, Bryce E; Gallaher, Jared R; Mabedi, Charles; Geyer, Andrew J; Charles, Anthony G

2017-12-01

In resource-limited settings, identification of successful and sustainable task-shifting interventions is important for improving care. To determine whether the training of lay people to take vital signs as trauma clerks is an effective and sustainable method to increase availability of vital signs in the initial evaluation of trauma patients. We conducted a quasi-experimental study of patients presenting with traumatic injury pre- and post-intervention. The study was conducted at Kamuzu Central Hospital, a tertiary care referral hospital, in Lilongwe, Malawi. All adult (age ≥ 18 years) trauma patients presenting to emergency department over a six-month period from January to June prior to intervention (2011), immediately post-intervention (2012), 1 year post-intervention (2013) and 2 years post-intervention (2014). Lay people were trained to take and record vital signs. The number of patients with recorded vital signs pre- and post-intervention and sustainability of the intervention as determined by time-series analysis. Availability of vital signs on initial evaluation of trauma patients increased significantly post-intervention. The percentage of patients with at least one vital sign recorded increased from 23.5 to 92.1%, and the percentage of patients with all vital signs recorded increased from 4.1 to 91.4%. Availability of Glasgow Coma Scale also increased from 40.3 to 88.6%. Increased documentation of vital signs continued at 1 year and 2 years post-intervention. However, the percentage of documented vital signs did decrease slightly after the US-trained medical student and surgeon who trained the trauma clerks were no longer available in country, except for Glasgow Coma Scale. Patients who died during emergency department evaluation were significantly less likely to have vital signs recorded. The training of lay people to collect vital signs and Glasgow Coma Scale is an effective and sustainable method of task shifting in a resource-limited setting.

Lost information during the handover of critically injured trauma patients: a mixed-methods study.

PubMed

Zakrison, Tanya Liv; Rosenbloom, Brittany; McFarlan, Amanda; Jovicic, Aleksandra; Soklaridis, Sophie; Allen, Casey; Schulman, Carl; Namias, Nicholas; Rizoli, Sandro

2016-12-01

Clinical information may be lost during the transfer of critically injured trauma patients from the emergency department (ED) to the intensive care unit (ICU). The aim of this study was to investigate the causes and frequency of information discrepancies with handover and to explore solutions to improving information transfer. A mixed-methods research approach was used at our level I trauma centre. Information discrepancies between the ED and the ICU were measured using chart audits. Descriptive, parametric and non-parametric statistics were applied, as appropriate. Six focus groups of 46 ED and ICU nurses and nine individual interviews of trauma team leaders were conducted to explore solutions to improve information transfer using thematic analysis. Chart audits demonstrated that injuries were missed in 24% of patients. Clinical information discrepancies occurred in 48% of patients. Patients with these discrepancies were more likely to have unknown medical histories (p<0.001) requiring information rescue (p<0.005). Close to one in three patients with information rescue had a change in clinical management (p<0.01). Participants identified challenges according to their disciplines, with some overlap. Physicians, in contrast to nurses, were perceived as less aware of interdisciplinary stress and their role regarding variability in handover. Standardising handover, increasing non-technical physician training and understanding unit cultures were proposed as solutions, with nurses as drivers of a culture of safety. Trauma patient information was lost during handover from the ED to the ICU for multiple reasons. An interprofessional approach was proposed to improve handover through cross-unit familiarisation and use of communication tools is proposed. Going beyond traditional geographical and temporal boundaries was deemed important for improving patient safety during the ED to ICU handover. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Evaluating the long-term impact of the Trauma Team Training course in Guyana: an explanatory mixed-methods approach.

PubMed

Pemberton, Julia; Rambaran, Madan; Cameron, Brian H

2013-02-01

We evaluated the retention of trauma knowledge and skills after an interprofessional Trauma Team Training (TTT) course in Guyana and explored the course impact on participants. A mixed-methods design evaluated knowledge using a multiple-choice quiz test, skills and trauma moulage simulation with checklists, and course impact with qualitative interviews. Participants were evaluated at 3 time points; before, after, and 4 months after TTT. Forty-seven course participants included 20 physicians, 17 nurses, and 10 paramedical providers. All participants had improved multiple-choice quiz test scores after the course and retained knowledge after 4 months, with nonphysicians showing the most improved scores. Trauma skill and moulage scores declined slightly after 4 months, with the greatest decline observed in complex skills. Qualitatively, course participants self-reported impact of the TTT course included improved empowerment, knowledge, teamwork, and patient care. Interprofessional team-based training led to the retention of trauma knowledge and skills as well as the empowerment of nonphysicians. The decline in performance of some trauma skills indicates the need for a regular trauma update course. Copyright © 2013 Elsevier Inc. All rights reserved.

Hepatic trauma: a 21-year experience.

PubMed

Zago, Thiago Messias; Pereira, Bruno Monteiro; Nascimento, Bartolomeu; Alves, Maria Silveira Carvalho; Calderan, Thiago Rodrigues Araujo; Fraga, Gustavo Pereira

2013-01-01

To evaluate the epidemiological aspects, behavior, morbidity and treatment outcomes for liver trauma. We conducted a retrospective study of patients over 13 years of age admitted to a university hospital from 1990 to 2010, submitted to surgery or nonoperative management (NOM). 748 patients were admitted with liver trauma. The most common mechanism of injury was penetrating trauma (461 cases, 61.6%), blunt trauma occurring in 287 patients (38.4%). According to the degree of liver injury (AAST-OIS) in blunt trauma we predominantly observed Grades I and II and in penetrating trauma, Grade III. NOM was performed in 25.7% of patients with blunt injury. As for surgical procedures, suturing was performed more frequently (41.2%). The liver-related morbidity was 16.7%. The survival rate for patients with liver trauma was 73.5% for blunt and 84.2% for penetrating trauma. Mortality in complex trauma was 45.9%. trauma remains more common in younger populations and in males. There was a reduction of penetrating liver trauma. NOM proved safe and effective, and often has been used to treat patients with penetrating liver trauma. Morbidity was high and mortality was higher in victims of blunt trauma and complex liver injuries.

Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: a retrospective review of 888 cases

PubMed Central

2012-01-01

Background Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this study, we present our 11-year experience in the management and clinical outcome of 888 chest trauma cases as a result of blunt and penetrating injuries in our university hospital in Damascus, Syria. Methods We reviewed files of 888 consequent cases of chest trauma between January 2000 and January 2011. The mean age of our patients was 31 ± 17 years mostly males with blunt injuries. Patients were evaluated and compared according to age, gender, etiology of trauma, thoracic and extra-thoracic injuries, complications, and mortality. Results The leading cause of the trauma was violence (41%) followed by traffic accidents (33%). Pneumothorax (51%), Hemothorax (38%), rib fractures (34%), and lung contusion (15%) were the most common types of injury. Associated injuries were documented in 36% of patients (extremities 19%, abdomen 13%, head 8%). A minority of the patients required thoracotomy (5.7%), and tube thoracostomy (56%) was sufficient to manage the majority of cases. Mean hospital LOS was 4.5 ± 4.6 days. The overall mortoality rate was 1.8%, and morbidity (n = 78, 8.7%). Conclusions New traffic laws (including seat belt enforcement) reduced incidence and severity of chest trauma in Syria. Violence was the most common cause of chest trauma rather than road traffic accidents in this series, this necessitates epidemiologic or multi-institutional studies to know to which degree violence contributes to chest trauma in Syria. The number of fractured ribs can be used as simple indicator of the severity of trauma. And we believe that significant neurotrauma, traffic accidents, hemodynamic status and GCS upon arrival, ICU admission, ventilator use, and complication of therapy are predictors of dismal prognosis. PMID:22515842

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.

Arterial Embolization in the Management of Mesenteric Bleeding Secondary to Blunt Abdominal Trauma

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

Ghelfi, Julien, E-mail: JGhelfi@chu-grenoble.fr; Frandon, Julien, E-mail: JFrandon2@chu-grenoble.fr; Barbois, Sandrine, E-mail: SBarbois@chu-grenoble.fr

IntroductionMesenteric bleeding is a rare but potentially life-threatening complication of blunt abdominal trauma. It can induce active hemorrhage and a compressive hematoma leading to bowel ischemia. Emergency laparotomy remains the gold standard treatment. We aimed to study the effectiveness and complications of embolization in patients with post-traumatic mesenteric bleeding.Materials and MethodsThe medical records of 7 consecutive patients with active mesenteric bleeding treated by embolization in a level-one trauma center from 2007 to 2014 were retrospectively reviewed. All patients presented with active mesenteric bleeding on CT scans without major signs of intestinal ischemia. We focused on technical success, clinical success, andmore » the complications of embolization.ResultsSix endovascular procedures were successful in controlling hemorrhage but 1 patient had surgery to stop associated arterial and venous bleeding. One patient suffered from bowel ischemia, a major complication of embolization, which was confirmed by surgery. No acute renal failure was noted after angiography. For 1 patient we performed combined management as the endovascular approach allowed an easier surgical exploration.ConclusionIn mesenteric trauma with active bleeding, embolization is a valuable alternative to surgery and should be considered, taking into account the risk of bowel ischemia.« less

Bayesian assessment of overtriage and undertriage at a level I trauma centre.

PubMed

DiDomenico, Paul B; Pietzsch, Jan B; Paté-Cornell, M Elisabeth

2008-07-13

We analysed the trauma triage system at a specific level I trauma centre to assess rates of over- and undertriage and to support recommendations for system improvements. The triage process is designed to estimate the severity of patient injury and allocate resources accordingly, with potential errors of overestimation (overtriage) consuming excess resources and underestimation (undertriage) potentially leading to medical errors.We first modelled the overall trauma system using risk analysis methods to understand interdependencies among the actions of the participants. We interviewed six experienced trauma surgeons to obtain their expert opinion of the over- and undertriage rates occurring in the trauma centre. We then assessed actual over- and undertriage rates in a random sample of 86 trauma cases collected over a six-week period at the same centre. We employed Bayesian analysis to quantitatively combine the data with the prior probabilities derived from expert opinion in order to obtain posterior distributions. The results were estimates of overtriage and undertriage in 16.1 and 4.9% of patients, respectively. This Bayesian approach, which provides a quantitative assessment of the error rates using both case data and expert opinion, provides a rational means of obtaining a best estimate of the system's performance. The overall approach that we describe in this paper can be employed more widely to analyse complex health care delivery systems, with the objective of reduced errors, patient risk and excess costs.

Assessment of the effects and limitations of the 1998 to 2008 Abbreviated Injury Scale map using a large population-based dataset

PubMed Central

2011-01-01

Background Trauma systems should consistently monitor a given trauma population over a period of time. The Abbreviated Injury Scale (AIS) and derived scores such as the Injury Severity Score (ISS) are commonly used to quantify injury severities in trauma registries. To reflect contemporary trauma management and treatment, the most recent version of the AIS (AIS08) contains many codes which differ in severity from their equivalents in the earlier 1998 version (AIS98). Consequently, the adoption of AIS08 may impede comparisons between data coded using different AIS versions. It may also affect the number of patients classified as major trauma. Methods The entire AIS98-coded injury dataset of a large population based trauma registry was retrieved and mapped to AIS08 using the currently available AIS98-AIS08 dictionary map. The percentage of codes which had increased or decreased in severity, or could not be mapped, was examined in conjunction with the effect of these changes to the calculated ISS. The potential for free text information accompanying AIS coding to improve the quality of AIS mapping was explored. Results A total of 128280 AIS98-coded injuries were evaluated in 32134 patients, 15471 patients of whom were classified as major trauma. Although only 4.5% of dictionary codes decreased in severity from AIS98 to AIS08, this represented almost 13% of injuries in the registry. In 4.9% of patients, no injuries could be mapped. ISS was potentially unreliable in one-third of patients, as they had at least one AIS98 code which could not be mapped. Using AIS08, the number of patients classified as major trauma decreased by between 17.3% and 30.3%. Evaluation of free text descriptions for some injuries demonstrated the potential to improve mapping between AIS versions. Conclusions Converting AIS98-coded data to AIS08 results in a significant decrease in the number of patients classified as major trauma. Many AIS98 codes are missing from the existing AIS map, and across a trauma population the AIS08 dataset estimates which it produces are of insufficient quality to be used in practice. However, it may be possible to improve AIS98 to AIS08 mapping to the point where it is useful to established registries. PMID:21214906

Positive and negative volume-outcome relationships in the geriatric trauma population.

PubMed

Matsushima, Kazuhide; Schaefer, Eric W; Won, Eugene J; Armen, Scott B; Indeck, Matthew C; Soybel, David I

2014-04-01

In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. In-hospital mortality, major complications, and mortality after major complications (failure to rescue). Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

Soccer-related Facial Trauma: Multicenter Experience in 2 Brazilian University Hospitals

PubMed Central

Dini, Gal M.; Pereira, Max D.; Gurgel, Augusto; Bastos, Endrigo O.; Nagarkar, Purushottam; Gemperli, Rolf; Ferreira, Lydia M.

2014-01-01

Background: Soccer is the most popular sport in Brazil and a high incidence of related trauma is reported. Maxillofacial trauma can be quite common, sometimes requiring prolonged hospitalization and invasive procedures. To characterize soccer-related facial fractures needing surgery in 2 major Brazilian Centers. Methods: A retrospective review of trauma medical records from the Plastic Surgery Divisions at the Universidade Federal de São Paulo–Escola Paulista de Medicina and the Hospital das Clinicas–Universidade de São Paulo was carried out to identify patients who underwent invasive surgical procedures due to acute soccer-related facial fractures. Data points reviewed included gender, date of injury, type of fracture, date of surgery, and procedure performed. Results: A total of 45 patients (31 from Escola Paulista de Medicina and 14 from Universidade de São Paulo) underwent surgical procedures to address facial fractures between March 2000 and September 2013. Forty-four patients were men, and mean age was 28 years. The fracture patterns seen were nasal bones (16 patients, 35%), orbitozygomatic (16 patients, 35%), mandibular (7 patients, 16%), orbital (6 patients, 13%), frontal (1 patient, 2%), and naso-orbito-ethmoid (1 patient, 2%). Mechanisms of injury included collisions with another player (n = 39) and being struck by the ball (n = 6). Conclusions: Although it is less common than orthopedic injuries, soccer players do sustain maxillofacial trauma. Knowledge of its frequency is important to first responders, nurses, and physicians who have initial contact with patients. Missed diagnosis or delayed treatment can lead to facial deformities and functional problems in the physiological actions of breathing, vision, and chewing. PMID:25289361

The relationship between patient volume and mortality in American trauma centres: a systematic review of the evidence.

PubMed

Caputo, Lisa M; Salottolo, Kristin M; Slone, Denetta Sue; Mains, Charles W; Bar-Or, David

2014-03-01

To synthesise published and unpublished findings examining the relationship between institutional trauma centre volume or trauma patient volume per surgeon and mortality. Evidence on the relationship between patient volume and survival in trauma patients is inconclusive in the literature and remains controversial. A literature search was performed to identify studies published between 1976 and 2013 via MEDLINE (Pubmed) and the Cumulative Index to Nursing and Allied Health Literature (EbscoHost) as well as footnote chasing. Abstracts from appropriate conferences and ProQuest Dissertations and Theses were also searched. Inclusion criteria required studies to be original research published in English that examined the relationship between mortality and either institutional or per surgeon volume in American trauma centres. We employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement checklist and flowchart. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was employed to rate the quality of the evidence. Of 1392 studies reviewed, 19 studies met defined inclusion criteria; all studies were retrospective. The definition of volume was heterogeneous across the studies. Patient population and analysis methods also varied across the studies. Sixteen studies (84%) examined the relationship between institutional trauma centre volume and mortality. Of the 16 studies, 12 examined the volume of severely injured patients and eight examined overall trauma patient volume. High institutional volume was associated with at least somewhat improved mortality in ten of 16 studies (63%); however, nearly half of these studies found only some subpopulations experienced benefits. In the remaining six studies, volume was not associated with any benefits. Four studies (25%) analysed the impact of surgeon volume on mortality. High volume per surgeon was associated with improved mortality in only one of four studies (25%). The studies were extremely heterogeneous, thus definitive conclusions cannot be drawn regarding optimal volume before a clear advantage in survival is observed. A prospective study defining volume as a continuous variable is warranted to support current admission criteria for American trauma patients. Copyright © 2013 Elsevier Ltd. All rights reserved.

Determining the hospital trauma financial impact in a statewide trauma system.

PubMed

Mabry, Charles D; Kalkwarf, Kyle J; Betzold, Richard D; Spencer, Horace J; Robertson, Ronald D; Sutherland, Michael J; Maxson, Robert T

2015-04-01

There have been no comprehensive studies across an organized statewide trauma system using a standardized method to determine cost. Trauma financial impact includes the following costs: verification, response, and patient care cost (PCC). We conducted a survey of participating trauma centers (TCs) for federal fiscal year 2012, including separate accounting for verification and response costs. Patient care cost was merged with their trauma registry data. Seventy-five percent of the 2012 state trauma registry had data submitted. Each TC's reasonable cost from the Medicare Cost Report was adjusted to remove embedded costs for response and verification. Cost-to-charge ratios were used to give uniform PCC across the state. Median (mean ± SD) costs per patient for TC response and verification for Level I and II centers were $1,689 ($1,492 ± $647) and $450 ($636 ± $431) for Level III and IV centers. Patient care cost-median (mean ± SD) costs for patients with a length of stay >2 days rose with increasing Injury Severity Score (ISS): ISS <9: $6,787 ($8,827 ± $8,165), ISS 9 to 15: $10,390 ($14,340 ± $18,395); ISS 16 to 25: $15,698 ($23,615 ± $21,883); and ISS 25+: $29,792 ($41,407 ± $41,621), and with higher level of TC: Level I: $13,712 ($23,241 ± $29,164); Level II: $8,555 ($13,515 ± $15,296); and Levels III and IV: $8,115 ($10,719 ± $11,827). Patient care cost rose with increasing ISS, length of stay, ICU days, and ventilator days for patients with length of stay >2 days and ISS 9+. Level I centers had the highest mean ISS, length of stay, ICU days, and ventilator days, along with the highest PCC. Lesser trauma accounted for lower charges, payments, and PCC for Level II, III, and IV TCs, and the margin was variable. Verification and response costs per patient were highest for Level I and II TCs. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Spectrum and outcome of pancreatic trauma.

PubMed

Kantharia, Chetan V; Prabhu, R Y; Dalvi, A N; Raut, Abhijit; Bapat, R D; Supe, Avinash N

2007-01-01

Pancreatic trauma is associated with high morbidity and mortality. Diagnosis is often difficult and surgery poses a formidable challenge. Data from 17 patients of pancreatic trauma gathered from a prospectively maintained database were analysed and the following parameters were considered: mode of injury, diagnostic modalities, associated injury, grade of pancreatic trauma and management. Pancreatic trauma was graded from I through IV, as per Modified Lucas Classification. The median age was 39 years (range 19-61). The aetiology of pancreatic trauma was blunt abdominal trauma in 14 patients and penetrating injury in 3. Associated bowel injury was present in 4 cases (3 penetrating injury and 1 blunt trauma) and 1 case had associated vascular injury. 5 patients had grade I, 3 had grade II, 7 had grade III and 2 had grade IV pancreatic trauma. Contrast enhanced computed tomography scan was used to diagnose pancreatic trauma in all patients with blunt abdominal injury. Immediate diagnosis could be reached in only 4 (28.5%) patients. 7 patients responded to conservative treatment. Of the 10 patients who underwent surgery, 6 required it for the pancreas and the duodenum. (distal pancreatectomy with splenectomy-3, pylorus preserving pancreatoduodenectomy-1, debridement with external drainage-1, associated injuries-duodenum-1). Pancreatic fistula, recurrent pancreatitis and pseudocyst formation were seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patient respectively. Death occurred in 4 cases (23.5%), 2 each in grades III and IV pancreatic trauma. Contrast enhanced computed tomography scan is a useful modality for diagnosing, grading and following up patients with pancreatic trauma. Although a majority of cases with pancreatic trauma respond to conservative treatment, patients with penetrating trauma, and associated bowel injury and higher grade pancreatic trauma require surgical intervention and are also associated with higher morbidity and mortality.

Accuracy and Coverage of Diagnosis and Procedural Coding of Severely Injured Patients in the Finnish Hospital Discharge Register: Comparison to Patient Files and the Helsinki Trauma Registry.

PubMed

Heinänen, M; Brinck, T; Handolin, L; Mattila, V M; Söderlund, T

2017-09-01

The Finnish Hospital Discharge Register data are frequently used for research purposes. The Finnish Hospital Discharge Register has shown excellent validity in single injuries or disease groups, but no studies have assessed patients with multiple trauma diagnoses. We aimed to evaluate the accuracy and coverage of the Finnish Hospital Discharge Register but at the same time validate the data of the trauma registry of the Helsinki University Hospital's Trauma Unit. We assessed the accuracy and coverage of the Finnish Hospital Discharge Register data by comparing them to the original patient files and trauma registry files from the trauma registry of the Helsinki University Hospital's Trauma Unit. We identified a baseline cohort of patients with severe thorax injury from the trauma registry of the Helsinki University Hospital's Trauma Unit of 2013 (sample of 107 patients). We hypothesized that the Finnish Hospital Discharge Register would lack valuable information about these patients. Using patient files, we identified 965 trauma diagnoses in these 107 patients. From the Finnish Hospital Discharge Register, we identified 632 (65.5%) diagnoses and from the trauma registry of the Helsinki University Hospital's Trauma Unit, 924 (95.8%) diagnoses. A total of 170 (17.6%) trauma diagnoses were missing from the Finnish Hospital Discharge Register data and 41 (4.2%) from the trauma registry of the Helsinki University Hospital's Trauma Unit data. The coverage and accuracy of diagnoses in the Finnish Hospital Discharge Register were 65.5% (95% confidence interval: 62.5%-68.5%) and 73.8% (95% confidence interval: 70.4%-77.2%), respectively, and for the trauma registry of the Helsinki University Hospital's Trauma Unit, 95.8% (95% confidence interval: 94.5%-97.0%) and 97.6% (95% confidence interval: 96.7%-98.6%), respectively. According to patient records, these patients were subjects in 249 operations. We identified 40 (16.1%) missing operation codes from the Finnish Hospital Discharge Register and 19 (7.6%) from the trauma registry of the Helsinki University Hospital's Trauma Unit. The validity of the Finnish Hospital Discharge Register data is unsatisfactory in terms of the accuracy and coverage of diagnoses in patients with multiple trauma diagnoses. Procedural codes provide greater accuracy. We found the coverage and accuracy of the trauma registry of the Helsinki University Hospital's Trauma Unit to be excellent. Therefore, a special trauma registry, such as the trauma registry of the Helsinki University Hospital's Trauma Unit, provides much more accurate data and should be the preferred registry when extracting data for research or for administrative use, such as resource prioritizing.

Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases

PubMed Central

Chughtai, Talat; Ali, Syed; Sharkey, Phillip; Lins, Marcelo; Rizoli, Sandro

2009-01-01

Background Blunt diaphragmatic rupture (BDR) is a rare event and represents a diagnostic challenge. The purpose of our study was to review our experience with BDR at the Sunnybrook Health Sciences Centre (Sunnybrook), the largest trauma centre in Canada, and to highlight recent changes in the diagnosis and management of the condition. Methods We retrospectively reviewed the cases of patients with BDR who were admitted to Sunnybrook between January 1986 and December 2003 using our trauma registry. We performed Student t and Fisher exact tests to compare our findings on patients with BDR with those on the entire cohort of blunt trauma patients admitted to our centre. Results Most patients with BDR were men (64.4%) with a mean age of 42 years. Left-sided tears were most common (65.0%). Patients with BDR had a very high Injury Severity Score (38) and very high mortality (28.8%). Of those who were injured as a result of motor vehicle collisions (MVCs), a significantly greater percentage of patients in the BDR group than in the entire cohort of blunt trauma patients were drivers or front-seat passengers. Patients with BDR were also significantly less likely to be pedestrians, to have experienced a fall or to be involved in a motorcycle collision. Patients with BDR had a higher chest, abdomen, pelvis and extremity Abbreviated Injury Scale score than all blunt trauma patients in general. Most of our patients underwent laparotomy (93.3%). The most common causes of death among patients with BDR were head injury (25.0%), intra-abdominal bleeding (23.3%) and pelvic hemorrhage (18.3%). Conclusion Blunt diaphragmatic rupture is rare and difficult to diagnose; however, certain MVC characteristics along with severe associated injuries should raise the index of suspicion. These associated injuries include injuries to the head, chest (including the aorta), abdomen and pelvis. Computed tomographic angiography is essential to rule out associated aortic injury and to increase the diagnostic accuracy of BDR. PMID:19503660

Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma

PubMed Central

Fu, Chen-Ju; Wong, Yon-Cheong; Tsang, Yuk-Ming; Wang, Li-Jen; Chen, Huan-Wu; Ku, Yi-Kang; Wu, Cheng-Hsien; Chen, Huan-Wen; Kang, Shih-Ching

2015-01-01

PURPOSE Intrahepatic portal vein injuries secondary to blunt abdominal trauma are difficult to diagnose and can result in insidious bleeding. We aimed to compare computed tomography arterial portography (CTAP), reperfusion CTAP (rCTAP), and conventional computed tomography (CT) for diagnosing portal vein injuries after blunt hepatic trauma. METHODS Patients with blunt hepatic trauma, who were eligible for nonoperative management, underwent CTAP, rCTAP, and CT. The number and size of perfusion defects observed using the three methods were compared. RESULTS A total of 13 patients (seven males/six females) with a mean age of 34.5±14.1 years were included in the study. A total of 36 hepatic segments had perfusion defects on rCTAP and CT, while there were 47 hepatic segments with perfusion defects on CTAP. The size of perfusion defects on CT (239 cm3; interquartile range [IQR]: 129.5, 309.5) and rCTAP (238 cm3; IQR: 129.5, 310.5) were significantly smaller compared with CTAP (291 cm3; IQR: 136, 371) (both, P = 0.002). CONCLUSION Perfusion defects measured by CTAP were significantly greater than those determined by either rCTAP or CT in cases of blunt hepatic trauma. This finding suggests that CTAP is superior to rCTAP and CT in evaluating portal vein injuries after blunt liver trauma. PMID:26268303

Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank☆,☆☆

PubMed Central

Englum, Brian R.; Gulack, Brian C.; Rice, Henry E.; Scarborough, John E.; Adibe, Obinna O.

2016-01-01

Purpose This study aims to examine the current management strategies and outcomes after blunt pancreatic trauma in children using a national patient registry. Methods Using the National Trauma Data Bank (NTDB) from 2007–2011, we identified all patients ≤18 years old who suffered blunt pancreatic trauma. Patients were categorized as undergoing nonoperative pancreatic management (no abdominal operation, abdominal operation without pancreatic-specific procedure, or pancreatic drainage alone) or operative pancreatic management (pancreatic resection/repair). Patient characteristics, operative details, clinical outcomes, and factors associated with operative management were examined. Results Of 610,402 pediatric cases in the NTDB, 1653 children (0.3%) had blunt pancreatic injury and 674 had information on specific location of pancreatic injury. Of these 674 cases, 514 (76.3%) underwent nonoperative pancreatic management. The groups were similar in age, gender, and race; however, pancreatic injury grade > 3, moderate to severe injury severity, and bicycle accidents were associated with operative management in multivariable analysis. Children with pancreatic head injuries or GCS motor score < 6 were less likely to undergo pancreatic operation. Overall morbidity and mortality rates were 26.5% and 5.3%, respectively. Most outcomes were similar between treatment groups, including mortality (2.5% vs. 6.7% in operative vs. nonoperative cohorts respectively; p = 0.07). Conclusion Although rare, blunt pancreatic trauma in children continues to be a morbid injury. In the largest analysis of blunt pancreatic trauma in children, we provide data on which to base future prospective studies. Operative management of pancreatic trauma occurs most often in children with distal ductal injuries, suggesting that prospective studies may want to focus on this group. PMID:27577183

Negative pressure wound therapy management of the “open abdomen” following trauma: a prospective study and systematic review

PubMed Central

2013-01-01

Introduction The use of Negative Pressure Wound Therapy (NPWT) for temporary abdominal closure of open abdomen (OA) wounds is widely accepted. Published outcomes vary according to the specific nature and the aetiology that resulted in an OA. The aim of this study was to evaluate the effectiveness of a new NPWT system specifically used OA resulting from abdominal trauma. Methods A prospective study on trauma patients requiring temporary abdominal closure (TAC) with grade 1or 2 OA was carried out. All patients were treated with NPWT (RENASYS AB Smith & Nephew) to achieve TAC. The primary outcome measure was time taken to achieve fascial closure and secondary outcomes were complications and mortality. Results A total of 20 patients were included. Thirteen patients (65%) achieved fascial closure following a median treatment period of 3 days. Four patients (20%) died of causes unrelated to NPWT. Complications included fistula formation in one patient (5%) with spontaneous resolution during NPWT), bowel necrosis in a single patient (5%) and three cases of infection (15%). No fistulae were present at the end of NPWT. Conclusion This new NPWT kit is safe and effective and results in a high rate of fascial closure and low complication rates in the severely injured trauma patient. PMID:23305306

Differences in Risk Factors for Rotator Cuff Tears between Elderly Patients and Young Patients.

PubMed

Watanabe, Akihisa; Ono, Qana; Nishigami, Tomohiko; Hirooka, Takahiko; Machida, Hirohisa

2018-02-01

It has been unclear whether the risk factors for rotator cuff tears are the same at all ages or differ between young and older populations. In this study, we examined the risk factors for rotator cuff tears using classification and regression tree analysis as methods of nonlinear regression analysis. There were 65 patients in the rotator cuff tears group and 45 patients in the intact rotator cuff group. Classification and regression tree analysis was performed to predict rotator cuff tears. The target factor was rotator cuff tears; explanatory variables were age, sex, trauma, and critical shoulder angle≥35°. In the results of classification and regression tree analysis, the tree was divided at age 64. For patients aged≥64, the tree was divided at trauma. For patients aged<64, the tree was divided at critical shoulder angle≥35°. The odds ratio for critical shoulder angle≥35° was significant for all ages (5.89), and for patients aged<64 (10.3) while trauma was only a significant factor for patients aged≥64 (5.13). Age, trauma, and critical shoulder angle≥35° were related to rotator cuff tears in this study. However, these risk factors showed different trends according to age group, not a linear relationship.

Cost Savings Associated with the Adoption of a Cloud Computing Data Transfer System for Trauma Patients.

PubMed

Feeney, James M; Montgomery, Stephanie C; Wolf, Laura; Jayaraman, Vijay; Twohig, Michael

2016-09-01

Among transferred trauma patients, challenges with the transfer of radiographic studies include problems loading or viewing the studies at the receiving hospitals, and problems manipulating, reconstructing, or evalu- ating the transferred images. Cloud-based image transfer systems may address some ofthese problems. We reviewed the charts of patients trans- ferred during one year surrounding the adoption of a cloud computing data transfer system. We compared the rates of repeat imaging before (precloud) and af- ter (postcloud) the adoption of the cloud-based data transfer system. During the precloud period, 28 out of 100 patients required 90 repeat studies. With the cloud computing transfer system in place, three out of 134 patients required seven repeat films. There was a statistically significant decrease in the proportion of patients requiring repeat films (28% to 2.2%, P < .0001). Based on an annualized volume of 200 trauma patient transfers, the cost savings estimated using three methods of cost analysis, is between $30,272 and $192,453.

The impact of childhood sexual abuse on the outcome of intensive trauma-focused treatment for PTSD.

PubMed

Wagenmans, Anouk; Van Minnen, Agnes; Sleijpen, Marieke; De Jongh, Ad

2018-01-01

Background : It is assumed that PTSD patients with a history of childhood sexual abuse benefit less from trauma-focused treatment than those without such a history. Objective : To test whether the presence of a history of childhood sexual abuse has a negative effect on the outcome of intensive trauma-focused PTSD treatment. Method : PTSD patients, 83% of whom suffered from severe PTSD, took part in a therapy programme consisting of 2 × 4 consecutive days of Prolonged Exposure (PE) and EMDR therapy (eight of each). In between sessions, patients participated in sport activities and psycho-education sessions. No prior stabilization phase was implemented. PTSD symptom scores of clinician-administered and self-administered measures were analysed using the data of 165 consecutive patients. Pre-post differences were compared between four trauma groups; patients with a history of childhood sexual abuse before age 12 (CSA), adolescent sexual abuse (ASA; i.e. sexual abuse between 12 and 18 years of age), sexual abuse (SA) at age 18 and over, or no history of sexual abuse (NSA). Results : Large effect sizes were achieved for PTSD symptom reduction for all trauma groups (Cohen's d  = 1.52-2.09). For the Clinical Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES), no differences in treatment outcome were found between the trauma (age) groups. For the PTSD Symptom Scale Self Report (PSS-SR), there were no differences except for one small effect between CSA and NSA. Conclusions : The results do not support the hypothesis that the presence of a history of childhood sexual abuse has a detrimental impact on the outcome of first-line (intensive) trauma-focused treatments for PTSD.

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

The impact of childhood sexual abuse on the outcome of intensive trauma-focused treatment for PTSD

PubMed Central

Wagenmans, Anouk; Van Minnen, Agnes; Sleijpen, Marieke; De Jongh, Ad

2018-01-01

ABSTRACT Background: It is assumed that PTSD patients with a history of childhood sexual abuse benefit less from trauma-focused treatment than those without such a history. Objective: To test whether the presence of a history of childhood sexual abuse has a negative effect on the outcome of intensive trauma-focused PTSD treatment. Method: PTSD patients, 83% of whom suffered from severe PTSD, took part in a therapy programme consisting of 2 × 4 consecutive days of Prolonged Exposure (PE) and EMDR therapy (eight of each). In between sessions, patients participated in sport activities and psycho-education sessions. No prior stabilization phase was implemented. PTSD symptom scores of clinician-administered and self-administered measures were analysed using the data of 165 consecutive patients. Pre-post differences were compared between four trauma groups; patients with a history of childhood sexual abuse before age 12 (CSA), adolescent sexual abuse (ASA; i.e. sexual abuse between 12 and 18 years of age), sexual abuse (SA) at age 18 and over, or no history of sexual abuse (NSA). Results: Large effect sizes were achieved for PTSD symptom reduction for all trauma groups (Cohen’s d = 1.52–2.09). For the Clinical Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES), no differences in treatment outcome were found between the trauma (age) groups. For the PTSD Symptom Scale Self Report (PSS-SR), there were no differences except for one small effect between CSA and NSA. Conclusions: The results do not support the hypothesis that the presence of a history of childhood sexual abuse has a detrimental impact on the outcome of first-line (intensive) trauma-focused treatments for PTSD. PMID:29441153

Validity of Caregivers’ Reports on Head Trauma Due to Falls in Young Children Aged Less than 2 Years

PubMed Central

Fujiwara, Takeo; Nagase, Hiroaki; Okuyama, Makiko; Hoshino, Takahiro; Aoki, Kazunori; Nagashima, Tastuya; Nakamura, Hajime

2010-01-01

Objective: The clinical presentations of head trauma due to falls among young children aged less than 2 years are controversial, particularly in Japan, as the history of trauma recounted by a caretaker is not always reliable. The purpose of this study was to assess the validity of caregiver’s reports on head trauma due to falls in young children aged less than 2 years in Japan. Methods: All patients <2 years of age presenting with head trauma resulting from a fall who were admitted to 3 children’s hospitals in Japan from January 2001 to December 2005 were retrospectively reviewed (N = 58). The clinical presentations were compared among groups categorized by the heights from which the patient fell (short (≤120 cm) or long (>120 cm)) and the surface on which the patient landed (carpet, tatami (Japanese mattress), hardwood floor, or concrete). Results: Patients who suffered short falls were more likely to present with subdural hemorrhage (SDH) than those who suffered long falls (74% and 40%, respectively, P = 0.027). More specifically, 62% of short falls showed SDH indicative of shaken baby syndrome (e.g. multilayer SDH). Neurological symptoms, cyanosis, and SDH were more commonly observed in patients who landed on carpeted or tatami surfaces than in those who landed on hardwood or concrete floors. Conclusions: Short falls and landing on soft surfaces resulted in the presentation of severer clinical symptoms than did long falls and landing on hard surfaces, suggesting that the validity of caretakers’ reports on infant or young children’s head trauma due to falls is low. Further research is warranted to investigate the cause of infant head trauma due to falls. PMID:23761991

Implementing screening, brief intervention, and referral for alcohol and drug use: the trauma service perspective.

PubMed

Sise, Michael J; Sise, C Beth; Kelley, Dorothy M; Simmons, Charles W; Kelso, Dennis J

2005-09-01

Most trauma surgeons are unfamiliar with screening, brief intervention, and referral (SBIR) programs for substance use disorders, and few trauma centers provide them. This report describes how an urban private-teaching hospital adapted a protocol from an existing emergency department-based program to include patients treated by the trauma service. We recorded the rates of SBIR completion and reasons for failure during each phase of the implementation, interviewed trauma service staff and health educators to assess attitudes toward the program, and evaluated patient satisfaction surveys. By adding SBIR staff to the trauma outpatient clinic and to trauma morning rounds, the capture rate increased from 12 to 71%. Most screened patients (59%) were found at risk for problems or probably dependent on alcohol or drugs. Trauma service staff and health educators reported high satisfaction with the program. Patients reported higher satisfaction with SBIR. SBIR services can be effectively integrated into all components of a busy, urban trauma service by adding specially trained health educators to the trauma service staff. This collaboration provides effective SBIR services to both trauma and emergency service patients without interfering with patient flow or medical procedures. The relatively high percentage of patients at risk for alcohol or drug problems supports the inclusion of routine alcohol and drug screening for all eligible trauma patients.

Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service

PubMed Central

Clarke, D; Laing, G

2017-01-01

INTRODUCTION This audit of traumatic diaphram injury (TDI) from a busy South African trauma service reviews the spectrum of disease and highlights current approaches to these injuries. METHODS The Pietermaritzburg Metropolitan Trauma Service (PMTS) has maintained an Electronic Surgical Registry (ESR) and a Hybrid Electronic Medical Record (HEMR) system since January 1st 2012. RESULTS A total of 105 TDIs were identified and repaired during the study period. The mean patient age was 30 years (range 15-68 years - SD 9.7). The majority (92.4%) of patients were male (97/105). Penetrating trauma was the leading mechanism of injury (94%). 75 patients sustained a TDI from a stab wound, and the remaining 24 injuries resulted from gunshot wounds. Multiple associated injuries and high morbidity was seen with right diaphragm injury, blunt trauma, gunshot wounds and chronic diaphragmatic hernias. CONCLUSIONS TDI is a fairly uncommon injury with a local incidence of 1.6%. It presents in a spectrum from the obvious to the occult. Multiple associated injuries and high morbidity occur following blunt trauma or gunshot wounds, right diaphragm injury and chronic diaphragmatic hernias. Diagnostic laparoscopy offers a diagnostic and therapeutic tool to prevent progression of occult TDI to chronic diaphragmatic hernias. PMID:28462659

Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service.

PubMed

D'Souza, N; Clarke, D; Laing, G

2017-05-01

INTRODUCTION This audit of traumatic diaphram injury (TDI) from a busy South African trauma service reviews the spectrum of disease and highlights current approaches to these injuries. METHODS The Pietermaritzburg Metropolitan Trauma Service (PMTS) has maintained an Electronic Surgical Registry (ESR) and a Hybrid Electronic Medical Record (HEMR) system since January 1 st 2012. RESULTS A total of 105 TDIs were identified and repaired during the study period. The mean patient age was 30 years (range 15-68 years - SD 9.7). The majority (92.4%) of patients were male (97/105). Penetrating trauma was the leading mechanism of injury (94%). 75 patients sustained a TDI from a stab wound, and the remaining 24 injuries resulted from gunshot wounds. Multiple associated injuries and high morbidity was seen with right diaphragm injury, blunt trauma, gunshot wounds and chronic diaphragmatic hernias. CONCLUSIONS TDI is a fairly uncommon injury with a local incidence of 1.6%. It presents in a spectrum from the obvious to the occult. Multiple associated injuries and high morbidity occur following blunt trauma or gunshot wounds, right diaphragm injury and chronic diaphragmatic hernias. Diagnostic laparoscopy offers a diagnostic and therapeutic tool to prevent progression of occult TDI to chronic diaphragmatic hernias.

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

Factors affecting planned return to work after trauma: A prospective descriptive qualitative and quantitative study.

PubMed

Folkard, S S; Bloomfield, T D; Page, P R J; Wilson, D; Ricketts, D M; Rogers, B A

2016-12-01

The use of patient reported outcome measures (PROMs) in trauma is limited. The aim of this pilot study is to evaluate qualitative responses and factors affecting planned return to work following significant trauma, for which there is currently a poor evidence base. National ethical approval was obtained for routine prospective PROMs data collection, including EQ-5D, between Sept 2013 and March 2015 for trauma patients admitted to the Sussex Major Trauma Centre (n=92). 84 trauma patients disclosed their intended return to work at discharge. Additional open questions asked 'things done well' and 'things to be improved'. EQ-5D responses were valued using the time trade-off method. Statistical analysis between multiple variables was completed by ANOVA, and with categorical categories by Chi squared analysis. Only 18/68 of patients working at admission anticipated returning to work within 14days post-discharge. The injury severity scores (ISS) of those predicting return to work within two weeks and those predicting return to work longer than two weeks were 14.17 and 13.59, respectively. Increased physicality of work showed a trend towards poorer return to work outcomes, although non-significant in Chi-squared test in groups predicting return in less than or greater than two weeks (4.621, p=0.2017ns). No significant difference was demonstrated in the comparative incomes of patients with different estimated return to work outcomes (ANOVA r 2 =0.001, P=0.9590ns). EQ-5D scores were higher in those predicting return to work within two weeks when compared to greater than two weeks. Qualitative thematic content analysis of open responses was possible for 66/92 of respondents. Prominent positive themes were: care, staff, professionalism, and communication. Prominent negative themes were: food, ward response time, and communication. This pilot study highlights the importance of qualitative PROMs analysis in leading patient-driven improvements in trauma care. We provide standard deviations for ISS scores and EQ-5D scores in our general trauma cohort, for use in sample size calculations for further studies analysing factors affecting return to work after trauma. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.

Critical care considerations in the management of the trauma patient following initial resuscitation

PubMed Central

2012-01-01

Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients. PMID:22989116

New technology in the management of liver trauma

PubMed Central

Chatoupis, Konstantinos; Papadopoulou, Glikeria; Kaskarelis, Ioannis

2013-01-01

The liver is the second most frequently injured solid organ in patients with blunt abdominal trauma. Hence the diagnosis and clinical assessment of hepatic trauma is of great importance because of the relationship of the liver to high morbidity and mortality. Multi detector-row computed tomography is the main diagnostic modality for the examination of hepatic parenchyma and other associated organ injuries, such as acute or delayed complications. Based on clinical and radiological findings, the majority of patients are managed conservatively, with the most important criterion of surgical therapy being hemodynamic instability. Radiologists must demonstrate a high knowledge of imaging recommendations and standardization of reporting to enable the selection of the appropriate treatment algorithm. Transcatheter embolization therapy is a method of great potential for the management of patients with traumatic hepatic injuries. PMID:24714662

The outcomes of 1120 severe multiple trauma patients with hemorrhagic shock in an emergency department: a retrospective study.

PubMed

Wen, Yin; Yang, Huang; Wei, Wang; Shan-shou, Liu

2013-01-01

Uncontrolled hemorrhagic shock is a significant factor in death of severe multiple trauma patients. The acute management of injured bleeding in emergency department (ED) may improve patient outcomes. The medical records of severe multiple trauma patients with hemorrhagic shock in our ED were reviewed to summarize an evidence-based approach to the management of critically injured bleeding trauma patients. A retrospective study was carried out from January 2002 to December 2011 in a Chinese tertiary hospital. Clinical data from major trauma patients with hemorrhagic shock admitted to ED were evaluated. The patients were stratified based on the characteristics of traumatic condition and resuscitation strategies. The medical treatments and the outcomes of these severe multiple trauma patients were described. A total of 1120 major trauma patients, consisting of 832 males and 288 females, were enrolled. 906 of the patients (80.9%) were injured in traffic accidents, 104 (9.3%) from falling, and 100 from other reasons. The number of injured sites varied from 2 to 6, 616(55.0%) more than 3. 902 (80.5%) trauma patients have recovered and been discharged from hospital. Uncontrolled hemorrhagic shock is a main reason of trauma patients' death. The resuscitation strategy should center upon permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy. The current approach to the management of critically injured bleeding trauma patients is able to improve patient outcomes.

The application of MDCT in the diagnosis of chest trauma.

PubMed

Błasińska-Przerwa, Katarzyna; Pacho, Ryszard; Bestry, Iwona

2013-01-01

Traumas are the third most common cause of death worldwide, after cardiovascular diseases and neoplasms, and the main cause of death of patients under 40 years of age. Contemporary image diagnosis of chest trauma uses chest X-ray (CXR), multidetector computed tomography (MDCT), transthoracic and transoesophageal ultrasound (USG), X-ray angiography and magnetic resonance. The aim of the present study was to evaluate MDCT results in the examination of posttraumatic chest injuries and to compare the results of CXR and MDCT in chosen chest traumatic injuries. The sixty patients with chest trauma included in the study were diagnosed at the Department of Radiology of the Institute of Tuberculosis and Lung Diseases between May 2004 and October 2007. MDCT was performed in all patients. Two groups with different types of injury (blunt or penetrating chest trauma) were distinguished. The analysis of injuries in both groups was conducted depending on the mechanism of trauma. The detection of 20 selected injuries at CXR and MDCT was compared. Moreover, the compatibility of MDCT with the results of intraoperative assessment and bronchoscopy was analysed. The influence of MDCT on the treatment modality was also assessed. History of blunt chest trauma was found in 51 patients (group 1) and of penetrating trauma in 9 patients (group 2). The most frequent injuries among group 1 were lung contusion and rib fractures, and among group 2 it was pericardial hematoma. Compared to MDCT, the sensitivity and specificity of CXR were 66.7 and 58%, respectively. Change of treatment modality was observed after MDCT in 83% of patients. The sensitivity and specificity of MDCT in diagnosing tracheobronchial injury, compared to bronchoscopy, were 72.7% and 100%, respectively. Compatibility of MDCT results and intraoperative assessment was observed in 43% of patients, and the main reason for discrepancy was underdiagnosis of diaphragm injury in MDCT. MDCT was a valuable diagnostic method in recognition of chest trauma, characterized by high sensitivity and specificity in the assessment of life-threatening injures and for depicting tracheal and bronchial injuries. The diagnostic value of CXR was low. The compatibility of MCTD and intraoperative assessment was confirmed, with the exception of diaphragm injures and lung laceration. Change of treatment modality was certified after MDCT in 83% of patients.

[Prevention and treatment of post-traumatic pancreatic necrosis in patients with blunt abdominal trauma].

PubMed

Cherdantsev, D V; Pervova, O V; Vinnik, Iu S; Kurbanov, D Sh

2016-01-01

High incidence of necrotic and suppurative complications is feature of acute post-traumatic pancreatitis. Severe trauma of the pancreas and post-traumatic pancreatitis lead to depressurization of ductal system that requires adequate drainage of damaged area and retroperitoneal fat. 95 patients in group 1 received standardized treatment. The victims of the 2nd group (44 patients) were treated using immunoreactive therapy (roncoleukin) and octreotide (the dose depended on the severity of pancreatitis) at early stages. The efficacy of treatment was assessed based on clinical, laboratory and instrumental parameters. Regardless severity of pancreatic injury overall mortality in groups 1 and 2 was 41% and 20.5% respectively. The main causes of adverse outcomes are severe destructive pancreatitis, postnecrotic suppurative complications. Adequacy rather radicalism of surgery should be preferred for blunt pancreatic trauma management. Minimally invasive surgical techniques and new methods of biological hemostasis may be applied. Timely use of anti-enzymatic and immunoactive therapy reduces the risk of severe post-traumatic pancreatitis, suppurative complications and improves outcomes in patients with blunt pancreatic trauma.

Orthopedics nursing patients' profile of a public hospital in Salvador-Bahia

PubMed Central

de Castro, Renata Reis Matutino; Ribeiro, Natália Fonseca; de Andrade, Aline Mendonça; Jaques, Bruno Dórea

2013-01-01

OBJECTIVES: To describe the profile of patients treated in the trauma and orthopedics nursing of a trauma care referral public hospital of in the state of Bahia. METHODS: Cross-sectional study in which data were collected from medical records of patients in the period from July to December 2008. RESULTS: The profile of the patients involved was formed by subjects mostly male young subjects, victims of trauma from accidents, especially those with motorcycles or car runover. On the other hand,the most frequent traumas associated with urban violence were perforations by gunshot and stab wounds. The primary injury presented by these individuals was exposed fracture of the femur and the most common treatment was external fixation. The most frequent in-hospital complication was wound infection, which required another surgical approach. Most inpatients were discharged and only one death was reported during this period. CONCLUSION: The results of this study corroborate those from other institutions in the country, which may contribute to elaborate public policies for accidents and violence prevention. Level of Evidence IV, Case Series. PMID:24453666

Evaluation of the criteria for angiotomography indications in the diagnosis of carotid and vertebral arterial injury associated with blunt trauma

PubMed Central

2010-01-01

Background Blunt carotid and vertebral artery injury (BCVI) occur infrequently. The incidence of this type of injury is difficult to determine as many emergency room patients are neurologically asymptomatic. The statistics have not been reported in Brazil. The objectives of the current study were: To evaluate the accuracy of criteria used to recommend angiotomography in the diagnosis of cervical BCVI in 100 patients with blunt cervical trauma in the trauma services section of a Brazilian quaternary care hospital. Methods During a 30-month (2006-2008), all patients admitted to the emergency room of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo with blunt cervical trauma and potential risk of cervical vessel injury, were subjected to cervical angiotomography to diagnose BCVI. The data analyzed are presented as mean ± standard deviation, and statistical analyses included Chi-square and Fisher's exact tests, and the Mann-Whitney test. Results During the study period 2467 blunt trauma patients were admitted. In 100 patients that met the criteria for inclusion in the study, angiotomography identified 23 with BCVI, including 17 males and six females. The mean patient age was 34.81 ± 14.84 years. Car crash (49%) and car-pedestrian accidents (24%) were the most frequent causes of injury. Ten patients had internal carotid artery injuries, two patients had common carotid artery injuries, and 11 patients had vertebral artery injuries. Seven patients presented with Degree I arterial injuries, 10 patients presented with Degree II artery injuries, four patients presented with Degree IV artery injuries, one patient presented with a Degree V artery injury, and one patient had a carotid fistula. Seven out of the 23 patients with BCVI (30.4%) presented with cervical vertebrae fractures, and 11 out of the 23 patients with BCVI (47.8%) presented with facial fractures (LeFort II and III). Conclusions Although there is no consensus regarding the criteria that should be used to indicate angiotomography for BCVI diagnosis, we conclude that the criteria used in the current study led to a diagnosis of BCVI in 0.93% of 2,467 trauma patients, BCVI injuries were associated with more severe traumas and did not affect mortality. PMID:20579381

Revisiting the Pancreaticoduodenectomy for Trauma: a Single Institution’s Experience

PubMed Central

Thompson, Callie M.; Shalhub, Sherene; DeBoard, Zachary M.; Maier, Ronald V.

2013-01-01

STRUCTURED ABSTRACT Background Major pancreaticoduodenal injury can be devastating even if identified and controlled early. To date, both morbidity and mortality have resisted the improvements achieved with many other life-threatening injuries, with reported mortalities of 31–50%. We sought to elucidate the impact of the initial operation in the management of severe pancreaticoduodenal injury. Methods A retrospective review of all patients presenting to a single level-one trauma center who required pancreaticoduodenectomy for trauma from 1996–2010. We collected demographic and in-hospital data and compared subjects based on their initial operation. Results Fifteen patients (median age 29 yrs, 93% male, median ISS=35) underwent pancreaticoduodenectomy following blunt (n =5) or penetrating trauma (n=10). Twelve (80%) underwent damage control surgery (DCS) +/− the initial stage of Whipple resection as their first operation. Three (20%) underwent a complete Whipple procedure, including reconstruction, as their first operation. Overall, 87% of patients (13 of 15) were acidotic, hypothermic and coagulopathic during their first operation. Average operative time was longer for the completion pancreaticoduodenectomy vs. DCS (460±98 mins vs. 243±112 mins). There were no overall differences in complication rates, although the two patients that did not suffer a complication had DCS. In-hospital mortality was 13% (n=2). Conclusions We present both the largest series of patients to date who underwent a DCS or staged-Whipple procedure for complex pancreaticoduodenal trauma and the largest series due to blunt trauma. Using a staged approach, we report the lowest mortality rate for such injuries in the literature; less than half of that reported in the most recent series (33%). Given the frequent occurrence and recognized detrimental impact of acidosis, hypothermia and coagulopathy in patients with severe pancreaticoduodenal trauma, and proven benefits of DCS, we propose that these patients should undergo initial damage control surgery and staged reconstruction. PMID:23823615

A systematic review of technology-based interventions for co-occurring substance use and trauma symptoms.

PubMed

Gilmore, Amanda K; Wilson, Sarah M; Skopp, Nancy A; Osenbach, Janyce E; Reger, Greg

2017-09-01

Introduction Technology-based mental health interventions are becoming increasingly common, and several have begun to target multiple outcomes in a single intervention. Recent developments in the treatment of co-occurring posttraumatic stress disorder and substance use disorder has led to the development and testing of technology-based interventions for these disorders. The current systematic review examined technology-based interventions designed to improve mental health outcomes among patients with co-occurring trauma symptoms and substance use. Methods Of 601 articles reviewed, 14 included a technology-based intervention for patients with these co-occurring problems. Results Seven of these studies provided preliminary evidence that technology-based interventions are likely to be efficacious in reducing either trauma symptoms or substance use. The seven remaining studies demonstrated that technology-based interventions for co-occurring trauma symptoms and substance use are feasible. Discussion This review suggests that technology-based interventions for co-occurring trauma symptoms and substance use are feasible, but more work is needed to assess efficacy using scientifically rigorous studies.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma

PubMed Central

Stengel, Dirk; Ottersbach, Caspar; Matthes, Gerrit; Weigeldt, Moritz; Grundei, Simon; Rademacher, Grit; Tittel, Anja; Mutze, Sven; Ekkernkamp, Axel; Frank, Matthias; Schmucker, Uli; Seifert, Julia

2012-01-01

Background: Contrast-enhanced whole-body computed tomography (also called “pan-scanning”) is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results. Methods: Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care. Results: A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7–490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%–8.0%). Interpretation: We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma. PMID:22392949

Prevalence of Domestic Violence Among Trauma Patients.

PubMed

Joseph, Bellal; Khalil, Mazhar; Zangbar, Bardiya; Kulvatunyou, Narong; Orouji, Tahereh; Pandit, Viraj; O'Keeffe, Terence; Tang, Andrew; Gries, Lynn; Friese, Randall S; Rhee, Peter; Davis, James W

2015-12-01

Domestic violence is an extremely underreported crime and a growing social problem in the United States. However, the true burden of the problem remains unknown. To assess the reported prevalence of domestic violence among trauma patients. A 6-year (2007-2012) retrospective analysis of the prospectively maintained National Trauma Data Bank. Trauma patients who experienced domestic violence and who presented to trauma centers participating in the National Trauma Data Bank were identified using International Classification of Diseases, Ninth Revision diagnosis codes (995.80-995.85, 995.50, 995.52-995.55, and 995.59) and E codes (E967.0-E967.9). Patients were stratified by age into 3 groups: children (≤18 years), adults (19-54 years), and elderly patients (≥55 years). Trend analysis was performed on April 10, 2014, to assess the reported prevalence of domestic violence over the years. Trauma patients presenting to trauma centers participating in the National Trauma Data Bank. To assess the reported prevalence of domestic violence among trauma patients. A total of 16 575 trauma patients who experienced domestic violence were included. Of these trauma patients, 10 224 (61.7%) were children, 5503 (33.2%) were adults, and 848 (5.1%) were elderly patients. The mean (SD) age was 15.9 (20.6), the mean (SD) Injury Severity Score was 10.9 (9.6), and 8397 (50.7%) were male patients. Head injuries (46.8% of patients) and extremity fractures (31.2% of patients) were the most common injuries. A total of 12 515 patients (75.1%) were discharged home, and the overall mortality rate was 5.9% (n = 980). The overall reported prevalence of domestic violence among trauma patients was 5.7 cases per 1000 trauma center discharges. The prevalence of domestic violence increased among children (14.0 cases per 1000 trauma center discharges in 2007 to 18.5 case per 1000 trauma center discharges in 2012; P = .001) and adults (3.2 cases per 1000 discharges in 2007 to 4.5 cases per 1000 discharges in 2012; P = .001) over the 6-year period and remained unchanged for elderly patients (0.8 cases per 1000 discharges in 2007 to 0.96 cases per 1000 discharges in 2012; P = .09). On subanalysis of adults and elderly patients, the prevalence of domestic violence increased among both female (4.6 cases per 1000 discharges in 2007 to 5.3 cases per 1000 discharges in 2012; P = .001) and male patients (1.5 cases per 1000 discharges in 2007 to 2.8 cases per 1000 discharges in 2012; P = .001). Domestic violence is prevalent among trauma patients. Over the years, the reported prevalence of domestic violence has been increasing among children and adults, and continues to remain high among female trauma patients. A robust mandatory screening for evaluating domestic violence among trauma patients, along with a focused national intervention, is warranted.

Management of bleeding following major trauma: an updated European guideline

PubMed Central

2010-01-01

Introduction Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes. Methods The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. Results Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. Conclusions This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients. PMID:20370902

Retrospective evaluation of canine and feline maxillomandibular trauma cases. A comparison of signalment with non-maxillomandibular traumatic injuries (2003-2012).

PubMed

Mulherin, B L; Snyder, C J; Soukup, J W; Hetzel, S

2014-01-01

To determine differences in signalment between maxillomandibular (MM) and non-maxillomandibular (non-MM) trauma patients to help predict the type of injury sustained. A medical records database was searched from December 2003 to September 2012 to identify all MM trauma patients. A random sample of non-MM trauma patients was generated for comparison. Patient species, age, sex, weight, and injury aetiology were recorded for both populations. Sixty-seven MM trauma patients and 129 non-MM trauma patients were identified. Feline patients were almost twice as likely to be presented for MM trauma compared with non-MM trauma. The median weight of canine patients suffering MM injury was significantly less than that of non-MM patients (p = 0.025). A significant association existed between the causes of injuries associated with MM and non-MM trauma populations (p = 0.000023). The MM trauma patients were more likely to sustain injury as a result of an animal altercation (Bonferroni p = 0.001) while non-MM injuries were more likely to result from motor vehicle accidents (Bonferroni p = 0.001). Overall, animals that were less than one year of age with traumatic injuries were overrepresented (65/196) in comparison to the entire patient population. The results of this study may help guide clinicians in the evaluation and screening of trauma patients that are presented as an emergency. Cats, small dogs and animals suffering from animal altercations should all be closely evaluated for MM injury.

Eliminating log rolling as a spine trauma order.

PubMed

Conrad, Bryan P; Rossi, Gianluca Del; Horodyski, Mary Beth; Prasarn, Mark L; Alemi, Yara; Rechtine, Glenn R

2012-01-01

Currently, up to 25% of patients with spinal cord injuries may experience neurologic deterioration during the initial management of their injuries. Therefore, more effective procedures need to be established for the transportation and care of these to reduce the risk of secondary neurologic damage. Here, we present more acceptable methods to minimize motion in the unstable spine during the management of patients with traumatic spine injuries. This review summarizes more than a decade of research aimed at evaluating different methods of caring for patients with spine trauma. The most commonly utilized technique to transport spinal cord injured patients, the log rolling maneuver, produced more motion than placing a patient on a spine board, removing a spine board, performing continuous lateral therapy, and positioning a patient prone for surgery. Alternative maneuvers that produced less motion included the straddle lift and slide, 6 + lift and slide, scoop stretcher, mechanical kinetic therapy, mechanical transfers, and the use of the operating table to rotate the patient to the prone position for surgical stabilization. The log roll maneuver should be removed from the trauma response guidelines for patients with suspected spine injuries, as it creates significantly more motion in the unstable spine than the readily available alternatives. The only exception is the patient who is found prone, in which case the patient should then be log rolled directly on to the spine board utilizing a push technique.

Outcome of Concurrent Occult Hemothorax and Pneumothorax in Trauma Patients Who Required Assisted Ventilation

PubMed Central

Mahmood, Ismail; Tawfeek, Zainab; El-Menyar, Ayman; Zarour, Ahmad; Afifi, Ibrahim; Kumar, Suresh; Latifi, Rifat; Al-Thani, Hassan

2015-01-01

Background. The management and outcomes of occult hemopneumothorax in blunt trauma patients who required mechanical ventilation are not well studied. We aimed to study patients with occult hemopneumothorax on mechanical ventilation who could be carefully managed without tube thoracostomy. Methods. Chest trauma patients with occult hemopneumothorax who were on mechanical ventilation were prospectively evaluated. The presence of hemopneumothorax was confirmed by CT scanning. Hospital length of stay, complications, and outcome were recorded. Results. A total of 56 chest trauma patients with occult hemopneumothorax who were on ventilatory support were included with a mean age of 36 ± 13 years. Hemopneumothorax was managed conservatively in 72% cases and 28% underwent tube thoracostomy as indicated. 29% of patients developed pneumonia, 16% had Acute Respiratory Distress Syndrome (ARDS), and 7% died. Thickness of hemothorax, duration of mechanical ventilation, and development of ARDS were significantly associated with tube thoracostomy in comparison to no-chest tube group. Conclusions. The majority of occult hemopneumothorax can be carefully managed without tube thoracostomy in patients who required positive pressure ventilation. Tube thoracotomy could be restricted to those who had evidence of increase in the size of the hemothorax or pneumothorax on follow-up chest radiographs or developed respiratory compromise. PMID:25785199

A joint latent class model for classifying severely hemorrhaging trauma patients.

PubMed

Rahbar, Mohammad H; Ning, Jing; Choi, Sangbum; Piao, Jin; Hong, Chuan; Huang, Hanwen; Del Junco, Deborah J; Fox, Erin E; Rahbar, Elaheh; Holcomb, John B

2015-10-24

In trauma research, "massive transfusion" (MT), historically defined as receiving ≥10 units of red blood cells (RBCs) within 24 h of admission, has been routinely used as a "gold standard" for quantifying bleeding severity. Due to early in-hospital mortality, however, MT is subject to survivor bias and thus a poorly defined criterion to classify bleeding trauma patients. Using the data from a retrospective trauma transfusion study, we applied a latent-class (LC) mixture model to identify severely hemorrhaging (SH) patients. Based on the joint distribution of cumulative units of RBCs and binary survival outcome at 24 h of admission, we applied an expectation-maximization (EM) algorithm to obtain model parameters. Estimated posterior probabilities were used for patients' classification and compared with the MT rule. To evaluate predictive performance of the LC-based classification, we examined the role of six clinical variables as predictors using two separate logistic regression models. Out of 471 trauma patients, 211 (45 %) were MT, while our latent SH classifier identified only 127 (27 %) of patients as SH. The agreement between the two classification methods was 73 %. A non-ignorable portion of patients (17 out of 68, 25 %) who died within 24 h were not classified as MT but the SH group included 62 patients (91 %) who died during the same period. Our comparison of the predictive models based on MT and SH revealed significant differences between the coefficients of potential predictors of patients who may be in need of activation of the massive transfusion protocol. The traditional MT classification does not adequately reflect transfusion practices and outcomes during the trauma reception and initial resuscitation phase. Although we have demonstrated that joint latent class modeling could be used to correct for potential bias caused by misclassification of severely bleeding patients, improvement in this approach could be made in the presence of time to event data from prospective studies.

Thoracic Injuries in earthquake-related versus non-earthquake-related trauma patients: differentiation via Multi-detector Computed Tomography

PubMed Central

Dong, Zhi-hui; Yang, Zhi-gang; Chen, Tian-wu; Chu, Zhi-gang; Deng, Wen; Shao, Heng

2011-01-01

PURPOSE: Massive earthquakes are harmful to humankind. This study of a historical cohort aimed to investigate the difference between earthquake-related crush thoracic traumas and thoracic traumas unrelated to earthquakes using a multi-detector Computed Tomography (CT). METHODS: We retrospectively compared an earthquake-exposed cohort of 215 thoracic trauma crush victims of the Sichuan earthquake to a cohort of 215 non-earthquake-related thoracic trauma patients, focusing on the lesions and coexisting injuries to the thoracic cage and the pulmonary parenchyma and pleura using a multi-detector CT. RESULTS: The incidence of rib fracture was elevated in the earthquake-exposed cohort (143 vs. 66 patients in the non-earthquake-exposed cohort, Risk Ratio (RR) = 2.2; p<0.001). Among these patients, those with more than 3 fractured ribs (106/143 vs. 41/66 patients, RR = 1.2; p<0.05) or flail chest (45/143 vs. 11/66 patients, RR = 1.9; p<0.05) were more frequently seen in the earthquake cohort. Earthquake-related crush injuries more frequently resulted in bilateral rib fractures (66/143 vs. 18/66 patients, RR = 1.7; p<0.01). Additionally, the incidence of non-rib fracture was higher in the earthquake cohort (85 vs. 60 patients, RR = 1.4; p<0.01). Pulmonary parenchymal and pleural injuries were more frequently seen in earthquake-related crush injuries (117 vs. 80 patients, RR = 1.5 for parenchymal and 146 vs. 74 patients, RR = 2.0 for pleural injuries; p<0.001). Non-rib fractures, pulmonary parenchymal and pleural injuries had significant positive correlation with rib fractures in these two cohorts. CONCLUSIONS: Thoracic crush traumas resulting from the earthquake were life threatening with a high incidence of bony thoracic fractures. The ribs were frequently involved in bilateral and severe types of fractures, which were accompanied by non-rib fractures, pulmonary parenchymal and pleural injuries. PMID:21789386

Ocular trauma from land mines among soldiers treated at a University Hospital in Medellín, Colombia

PubMed Central

Velasquez, Luis F; Restrepo, Carlos A; Paulo, Jose D; Donado, Jorge; Muñoz, Marta L; Aristizabal, John J

2013-01-01

Introduction: Currently ocular combat injuries are complex and associated with poor visual outcomes. Our objective is to characterize the military population that suffer land mine combat ocular trauma in Colombia and identify the type of wound, treatment and visual outcomes. Methods: Retrospectively review of medical history of soldiers evaluated in Pablo Tobon Uribe Hospital, whom had land mine trauma during January of 2004 and December 2012. Results: 635 soldiers had land mine trauma, 153 of them had ocular trauma (226 eyes). Open ocular trauma was observed in 29.6%. The Ocular Trauma Score was calculated in 183 eyes, the initial visual acuity was not possible to be reported in the rest of them; the 45% of the eyes were classified in category 3. Three patients had no light perception in both eyes. 97.3% of the eyes received medical treatment and 49.1% had surgery also. Primary evisceration was made in 5.8% and enucleation in 1.8%. Intraocular foreign body was observed by ultrasonography in 11.1% and in 5.8% by orbital tomography. Eleven patients were legally blind at discharge. Conclusions: The ocular trauma related to a land mine is highly destructive at an ocular level. The treatments associated with better visual outcomes are primary closure of globe and systemic antibiotics; although the characteristics of the wound itself are the main prognostic factor. The Ocular trauma score is a useful tool for determining visual outcome in combat ocular trauma. PMID:24892238

Trauma-related self-defining memories and future goals in Dissociative Identity Disorder.

PubMed

Huntjens, Rafaële J C; Wessel, Ineke; Ostafin, Brian D; Boelen, Paul A; Behrens, Friederike; van Minnen, Agnes

2016-12-01

This study examined the content of self-defining autobiographical memories in different identities in patients with Dissociative Identity Disorder (DID) and comparison groups of patients with PTSD, healthy controls, and DID simulators. Consistent with the DID trauma model, analyses of objective ratings showed that DID patients in trauma identities retrieved more negative and trauma-related self-defining memories than DID patients in avoidant identities. Inconsistent with the DID trauma model, DID patients' self-rated trauma-relatedness of self-defining memories and future life goals did not differ between trauma identities and trauma avoidant identities. That is, the DID patients did not seem to be "shut off" from their trauma while in their avoidant identity. Furthermore, DID patients in both identities reported a higher proportion of avoidance goals compared to PTSD patients, with the latter group scoring comparably to healthy controls. The simulators behaved according to the instructions to respond differently in each identity (i.e., to report memories and goals consistent with the identity tested). The discrepant task behavior by DID patients and simulators indicated that DID patients did not seem to intentionally produce the hypothesized differences in performance between identities. In conclusion, for patients with DID (i.e., in both identities) and patients with PTSD, trauma played a central role in the retrieval of self-defining memories and in the formulation of life goals. Copyright © 2016 Elsevier Ltd. All rights reserved.

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

Acute Lung Injury in Patients with Traumatic Injuries: Utility of a Panel of Biomarkers for Diagnosis and Pathogenesis

PubMed Central

Fremont, Richard D.; Koyama, Tatsuki; Calfee, Carolyn S.; Wu, William; Dossett, Lesly A.; Bossert, Fred R.; Mitchell, Daphne; Wickersham, Nancy; Bernard, Gordon R.; Matthay, Michael A.; May, Addison K.; Ware, Lorraine B.

2012-01-01

Background The diagnosis of acute lung injury (ALI) is based on a consensus clinical definition. Despite the simplicity of this definition, ALI remains underdiagnosed and undertreated. Severe trauma is a well-described cause of ALI that represents a relatively homogeneous subset of ALI patients. The goals of this study were to develop a panel of plasma biomarkers to facilitate diagnosis of trauma-induced ALI and to enhance our understanding of the pathogenesis of human ALI. Methods A retrospective nested case control of 192 patients admitted to the trauma intensive care unit (ICU) at a university hospital between 2002 and 2006. We compared 107 patients with ALI to 85 patients without ALI. Plasma was collected within 72 h of ICU admission. Twenty-one plasma biomarkers were measured in duplicate in each plasma sample. Results Patients with ALI had higher severity of illness scores, more days of mechanical ventilation, longer hospital stays and higher mortality versus controls. Seven biomarkers (RAGE, PCPIII, BNP, ANG2, IL10, TNF-α, and IL8) had a high diagnostic accuracy as reflected by the area under the receiver operating characteristic curve of 0.86 (95% CI 0.82 – 0.92) in differentiating ALI from controls. Conclusions A model utilizing seven plasma biomarkers had a high diagnostic accuracy in differentiating patients with trauma-induced ALI from trauma patients without ALI. In addition, use of a panel of biomarkers provides insight into the likely importance of alveolar epithelial injury in the pathogenesis of early acute lung injury. PMID:20038857

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

A trauma outreach program provided by a level I trauma center is an effective way to initiate peer review at referring hospitals and foster process improvements.

PubMed

Byrnes, Matthew C; Irwin, Eric; Becker, Leslie; Thorson, Melissa; Beilman, Greg; Horst, Patrick; Croston, Kevin

2010-04-01

The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement. We hypothesized that an outreach program would stimulate peer review and identify systematic deficiencies in the care of patients with injuries. We developed a quality improvement program aimed at providing educational feedback to hospitals that referred patients to our American College of Surgeons-verified level I trauma center. We traveled to each referral center to provide feedback on the initial treatment and ultimate outcome of patients that were transferred to us. These feedback sessions were presented in the format of case presentations and case discussions. The outreach program was presented at each hospital every 3 months to 6 months. Nine hospitals were included in our program. We received 334 patients in transfer from these hospitals during the study period. Formal peer review that focused on trauma patients increased from 14% of hospitals to 100% of hospitals after institution of the program. Eighty-five percent of hospitals thought that the care of patients with injuries was improved as a result of the program. Eighty-five percent of hospitals developed process improvement initiatives as a result of the program. A formal outreach program can stimulate peer review at rural hospitals, provide continuing education in the care of patients with injuries, and foster process improvements at referring hospitals.

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.

[Forensic Psychiatric Assessment for Organic Personality Disorders after Craniocerebral Trauma].

PubMed

Li, C H; Huang, L N; Zhang, M C; He, M

2017-04-01

To explore the occurrence and the differences of clinical manifestations of organic personality disorder with varying degrees of craniocerebral trauma. According to the International Classification of Diseases-10, 396 subjects with craniocerebral trauma caused by traffic accidents were diagnosed, and the degrees of craniocerebral trauma were graded. The personality characteristics of all patients were evaluated using the simplified Neuroticism Extraversion Openness Five-Factor Inventory （NEO-FFI）. The occurrence rate of organic personality disorder was 34.6% while it was 34.9% and 49.5% in the patients with moderate and severe craniocerebral trauma, respectively, which significantly higher than that in the patients （18.7%） of mild craniocerebral trauma （ P <0.05）. Compared with the patients without personality disorder, the neuroticism, extraversion and agreeableness scores all showed significantly differences （ P <0.05） in the patients of mild craniocerebral trauma with personality disorder; the neuroticism, extraversion, agreeableness and conscientiousness scores showed significantly differences （ P >0.05） in the patients of moderate and severe craniocerebral trauma with personality disorder. The agreeableness and conscientiousness scores in the patients of moderate and severe craniocerebral trauma with personality disorder were significantly lower than that of mild craniocerebral trauma, and the patients of severe craniocerebral trauma had a lower score in extraversion than in the patients of mild craniocerebral trauma. The severity of craniocerebral trauma is closely related to the incidence of organic personality disorder, and it also affects the clinical features of the latter, which provides a certain significance and help for forensic psychiatric assessment. Copyright© by the Editorial Department of Journal of Forensic Medicine

The outcome of trauma patients with do-not-resuscitate orders.

PubMed

Matsushima, Kazuhide; Schaefer, Eric W; Won, Eugene J; Armen, Scott B

2016-02-01

Institutional variation in outcome of patients with do-not-resuscitate (DNR) orders has not been well described in the setting of trauma. The purpose of this study was to assess the impact of trauma center designation on outcome of patients with DNR orders. A statewide trauma database (Pennsylvania Trauma Outcome Study) was used for the analysis. Characteristics of patients with DNR orders were compared between state-designated level 1 and 2 trauma centers. Inhospital mortality and major complication rates were compared using hierarchical logistic regression models that included a random effect for trauma centers. We adjusted for a number of potential confounders and allowed for nonlinearity in injury severity score and age in these models. A total of 106,291 patients (14 level 1 and 11 level 2 trauma centers) were identified in the Pennsylvania Trauma Outcome Study database between 2007 and 2011. We included 5953 patients with DNR orders (5.6%). Although more severely injured patients with comorbid disease were made DNR in level 1 trauma centers, trauma center designation level was not a significant factor for inhospital mortality of patients with DNR orders (odds ratio, 1.33; 95% confidence interval, 0.81-2.18; P = 0.26). Level 1 trauma centers were significantly associated with a higher rate of major complications (odds ratio, 1.75; 95% confidence interval, 1.11-2.75; P = 0.016). Inhospital mortality of patients with DNR orders was not significantly associated with trauma designation level after adjusting for case mix. More aggressive treatment or other unknown factors may have resulted in a significantly higher complication rate at level 1 trauma centers. Copyright © 2016 Elsevier Inc. All rights reserved.

The potential of blended learning in education and training for advanced civilian and military trauma care.

PubMed

Sonesson, Linda; Boffard, Kenneth; Lundberg, Lars; Rydmark, Martin; Karlgren, Klas

2018-01-01

In the field of advanced care of the complex trauma patient, there is an emerging need for focused education and training. However, several hospitals do not support further education and training in this field, and the challenge of releasing time for physicians and nurses is well-known. Educational strategies using blended learning, which combines traditional classroom methods with modern computer-assisted methods and media, have not yet been widely used. This study analysed the educational challenges and areas for improvement, according to senior physicians and nurses, and investigated the potential use of blended learning. The setting was an international course, Definitive Surgical Trauma Care (DSTC) - Military Version, part of a programme which prepares health professionals for work during extreme conditions. The sample consisted of senior physicians and nurses, participating in the course in September 2015. A survey was completed, interviews were performed and a post-course survey was conducted 18 months later in March 2017. The most difficult aspect of learning how to manage the complex trauma patient, was the lack of real practice. Even though the respondents were knowledgeable in advanced trauma, they lacked personal experience in managing complex trauma cases. Cases presented during the course represented significantly greater complexity of injury compared to those usually seen in hospitals and during military deployment. The following educational challenges were identified from the study: (1) Lack of experience and knowledge of advanced trauma care. (2) Lack of the use of blended learning as support for education and training. (3) Limited time available for preparation and reflection in the education and training process. (4) Lack of support for such education and training from home hospitals. (5) The unfulfilled requirement for multidisciplinary team-training in the military medical environment. Educational strategies and methods, such as blended learning can support education and training, and the learning process by unlimited practice in reasoning and decision making in virtual patients. It can also provide flexibility and mobility for senior health professionals and their home hospitals, and contribute to an improved military pre-deployment training with less time strain on the civilian home hospitals. Copyright © 2017 Elsevier Ltd. All rights reserved.

Should bedside sonography be used first to diagnose pneumothorax secondary to blunt trauma?

PubMed

Donmez, Halil; Tokmak, Turgut Tursem; Yildirim, Afra; Buyukoglan, Hakan; Ozturk, Mehmet; Yaşar Ayaz, Umit; Mavili, Ertugrul

2012-01-01

BACKGROUND.: Our purpose was to evaluate the effectiveness of bedside sonography (US) in the detection of pneumothorax secondary to blunt thoracic trauma. METHODS.: In this prospective study, 240 hemithoraces of 120 consecutive patients with multiple trauma were evaluated with chest radiographs (CXR) and bedside thoracic US for the diagnosis of pneumothorax. CT examinations were performed in 68 patients. Fifty-two patients who did not undergo CT examinations were excluded from the study. US examinations were performed independently at bedside by two radiologists who were not informed about CXR and CT findings. CXRs were interpreted by two radiologists who were unaware of the US and CT results. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CXR and US were calculated. RESULTS.: One hundred thirty-six hemithoraces were assessed in 68 patients. A total of 35 pneumothoraces were detected in 33 patients. On US, the diagnosis of pneumothorax was correct in 32 hemithoraces. In 98 hemithoraces without pneumothorax, US was normal. With US examination, there were three false-positive and three false-negative results. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of US were 91.4%, 97%, 91.4%, 97%, and 97%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CXR were 82.7%, 89.7%, 68.5%, 95%, and 89.5%, respectively. CONCLUSIONS.: Bedside thoracic US is an accurate method that can be used in trauma patients instead of CXR for the detection of pneumothorax. Copyright © 2012 Wiley Periodicals, Inc.

911 Emergency Medical Services and Re-Triage to Level I Trauma Centers.

PubMed

Kuncir, Eric; Spencer, Dean; Feldman, Kelly; Barrios, Cristobal; Miller, Kenneth; Lush, Stephanie; Dolich, Matthew; Lekawa, Michael

2018-01-01

Interfacility transfer of undertriaged patients to higher-level trauma centers has been found to result in a delay of appropriate care and an increase in mortality. To address this, for the last 10 years our region has used 911 emergency medical services (EMS) paramedics for rapid re-triage of undertriaged patients to our institution's Level I trauma center. We sought to determine whether using 911 EMS for re-triage to our institution was associated with worse outcomes-with mortality as the primary end point-compared with direct EMS transport from point of injury. We retrospectively reviewed all trauma activations to our institution during a 16-month period; 3,394 active traumas were analyzed. Two hundred and seventy patients (8%) arrived via 911 EMS re-triage and 3,124 (92%) arrived via direct EMS transport. Total EMS transport time was significantly longer (122.5 minutes vs 33.7 minutes; p < 0.001) between the 2 groups, but there was no significant difference in mortality rates (4.1% vs 3.6%; p = 0.67). These data show that although using 911 EMS for re-triage is associated with an increase in total transport time, it does not result in an increase in mortality compared with direct EMS transport. We conclude that the use of 911 EMS can be considered a safe method to re-triage patients to higher-level trauma centers. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Epidemiological Characteristics of Work-Related Ocular Trauma in Southwest Region of China

PubMed Central

Cai, Mingming; Zhang, Jie

2015-01-01

Purpose: To determine the epidemiological characteristics of work-related eye injury in representative southwest region of China. Methods: Patients with eye injuries treated at the Ninth People’s Hospital of Chongqing from 1 January 2014 to 31 December 2014 were included in the current study. All patients completed a comprehensive examination and interview. Demographic characteristics and injury details were recorded. The International Classification of Diseases (ICD-10) and Birmingham Eye Trauma Terminology (BETT) were used. Results: The average age of eye injury patients was 37.52 years and the majority were male. Among the 1055 total patients, approximately 42.9% of the injuries were work-related. The highest proportion of occupational eye trauma was observed in the group between 36 and 45 years of age. Occupational ocular trauma occurred more frequently in summer, with most from 16:00 to 18:00. Metal was the most common injury cause. Foreign body on external eye was the most common diagnosis. Workers in the manufacturing industry without pre-work safety training or eye protection were far more likely to suffer from occupational ocular trauma than those with training and protection. Conclusions: This study provides insight into the epidemiological characteristics of occupational ocular trauma in southwest region of China. The current findings might be considered as a baseline for future research on regional work-related eye injuries. Our findings will provide valuable information for further development of preventive strategies. PMID:26295403

ABO Blood Type A Is Associated With Increased Risk of ARDS in Whites Following Both Major Trauma and Severe Sepsis

PubMed Central

Meyer, Nuala J.; Shashaty, Michael G. S.; Feng, Rui; Lanken, Paul N.; Gallop, Robert; Kaplan, Sandra; Herlim, Maximilian; Oz, Nathaniel L.; Hiciano, Isabel; Campbell, Ana; Holena, Daniel N.; Reilly, Muredach P.; Christie, Jason D.

2014-01-01

Background: ABO glycosyltransferases catalyze antigen modifications on various glycans and glycoproteins and determine the ABO blood types. Blood type A has been associated with increased risk of vascular diseases and differential circulating levels of proteins related to inflammation and endothelial function. The objective of this study was to determine the association of ABO blood types with ARDS risk in patients with major trauma and severe sepsis. Methods: We conducted prospective cohort studies in two populations at an urban tertiary referral, level I trauma center. Critically ill patients (n = 732) presenting after major trauma were followed for 5 days for ARDS development. Additionally, 976 medical patients with severe sepsis were followed for 5 days for ARDS. Multivariable logistic regression was used to adjust for confounders. Results: ARDS developed in 197 of the 732 trauma patients (27%). Blood type A was associated with increased ARDS risk among whites (37% vs 24%; adjusted OR, 1.88; 95% CI, 1.14-3.12; P = .014), but not blacks (adjusted OR, 0.61; 95% CI, 0.33-1.13; P = .114). ARDS developed in 222 of the 976 patients with severe sepsis (23%). Blood type A was also associated with an increased ARDS risk among whites (31% vs 21%; adjusted OR, 1.67; 95% CI, 1.08-2.59; P = .021) but, again, not among blacks (adjusted OR, 1.17; 95% CI, 0.59-2.33; P = .652). Conclusions: Blood type A is associated with an increased risk of ARDS in white patients with major trauma and severe sepsis. These results suggest a role for ABO glycans and glycosyltransferases in ARDS susceptibility. PMID:24385226

The impact of major trauma network triage systems on patients with major burns.

PubMed

Nizamoglu, Metin; O'Connor, Edmund Fitzgerald; Bache, Sarah; Theodorakopoulou, Evgenia; Sen, Sankhya; Sherren, Peter; Barnes, David; Dziewulski, Peter

2016-12-01

Trauma is a leading cause of death and disability worldwide. Patients presenting with severe trauma and burns benefit from specifically trained multidisciplinary teams. Regional trauma systems have shown improved outcomes for trauma patients. The aim of this study is to determine whether the development of major trauma systems have improved the management of patients with major burns. A retrospective study was performed over a four-year period reviewing all major burns in adults and children received at a regional burns centre in the UK before and after the implementation of the regional trauma systems and major trauma centres (MTC). Comparisons were drawn between three areas: (1) Patients presenting before the introduction of MTC and after the introduction of MTC. (2) Patients referred from MTC and non-MTC within the region, following the introduction of MTC. (3) Patients referred using the urban trauma protocol and the rural trauma protocol. Following the introduction of regional trauma systems and major trauma centres (MTC), isolated burn patients seen at our regional burns centre did not show any significant improvement in transfer times, admission resuscitation parameters, organ dysfunction or survival when referred from a MTC compared to a non-MTC emergency department. There was also no significant difference in survival when comparing referrals from all hospitals pre and post establishment of the major trauma network. No significant outcome benefit was demonstrated for burns patients referred via MTCs compared to non-MTCs. We suggest further research is needed to ascertain whether burns patients benefit from prolonged transfer times to a MTC compared to those seen at their local hospitals prior to transfer to a regional burns unit for further specialist care. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.

Combating terror: a new paradigm in student trauma education.

PubMed

Rivkind, Avraham I; Faroja, Mouhammad; Mintz, Yoav; Pikarsky, Alon J; Zamir, Gideon; Elazary, Ram; Abu-Gazala, Mahmoud; Bala, Miklosh

2015-02-01

Other than the Advanced Trauma Life Support course, usually run for postgraduate trainees, there are few trauma courses available for medical students. It has been shown that trauma teaching for medical students is sadly lacking within the undergraduate curriculum. We stated that students following formal teaching, even just theory and some practice in basic skills significantly improved their management of trauma patients. Hadassah-Hebrew University in Israel runs an annual 2-week trauma course for final-year medical students. The focus is on hands-on practice in resuscitation, diagnosis, procedures, and decision making. After engaging a combination of instructional and interactive teaching methods including practice on simulated injuries that students must assess and treat through the 2 weeks, the course culminates in a disaster drill where students work alongside the emergency services to rescue, assess, treat, and transfer patients. The course is evaluated with a written precourse and postcourse test, an Objective Structured Clinical Examination and detailed feedback from the drill. We analyzed student feedback at the end of each course during a 6-year period from 2007 to 2012. Correct answers for the posttest results were higher each year with good reliability as assessed by Chronbach's α and with significant variation from pretest scores assessed using paired-samples t tests. Best scores were achieved in knowledge acquisition and practical skills gained. Students were also asked whether the course contributed to self-preparedness in treating trauma patients, and this consistently achieved high scores. We believe that students benefit substantially from the course and gain lasting skills and confidence in trauma management, decision making, and organizational skills. The course provides students with the opportunity to learn and ingrain trauma principles along Advanced Trauma Life Support guidelines and prepares them for practice as safe doctors. We advocate the global implementation of a student trauma training course as a mandatory educational initiative and propose our course format as a model for similar courses.

Dose reduction in whole-body computed tomography of multiple injuries (DoReMI): protocol for a prospective cohort study

PubMed Central

2014-01-01

Background Single-pass, contrast-enhanced whole body multidetector computed tomography (MDCT) emerged as the diagnostic standard for evaluating patients with major trauma. Modern iterative image algorithms showed high image quality at a much lower radiation dose in the non-trauma setting. This study aims at investigating whether the radiation dose can safely be reduced in trauma patients without compromising the diagnostic accuracy and image quality. Methods/Design Prospective observational study with two consecutive cohorts of patients. Setting: A high-volume, academic, supra-regional trauma centre in Germany. Study population: Consecutive male and female patients who 1. had been exposed to a high-velocity trauma mechanism, 2. present with clinical evidence or high suspicion of multiple trauma (predicted Injury Severity Score [ISS] ≥16) and 3. are scheduled for primary MDCT based on the decision of the trauma leader on call. Imaging protocols: In a before/after design, a consecutive series of 500 patients will undergo single-pass, whole-body 128-row multi-detector computed tomography (MDCT) with a standard, as low as possible radiation dose. This will be followed by a consecutive series of 500 patients undergoing an approved ultra-low dose MDCT protocol using an image processing algorithm. Data: Routine administrative data and electronic patient records, as well as digital images stored in a picture archiving and communications system will serve as the primary data source. The protocol was approved by the institutional review board. Main outcomes: (1) incidence of delayed diagnoses, (2) diagnostic accuracy, as correlated to the reference standard of a synopsis of all subsequent clinical, imaging, surgical and autopsy findings, (3) patients’ safety, (4) radiation exposure (e.g. effective dose), (5) subjective image quality (assessed independently radiologists and trauma surgeons on a 100-mm visual analogue scale), (6) objective image quality (e.g., contrast-to-noise ratio). Analysis: Multivariate regression will be employed to adjust and correct the findings for time and cohort effects. An exploratory interim analysis halfway after introduction of low-dose MDCT will be conducted to assess whether this protocol is clearly inferior or superior to the current standard. Discussion Although non-experimental, this study will generate first large-scale data on the utility of imaging-enhancing algorithms in whole-body MDCT for major blunt trauma. Trial registration Current Controlled Trials ISRCTN74557102. PMID:24589310

[Surgical selection and efficacy assessment for membranous urethral trauma caused by pelvic fracture].

PubMed

Zhu, Li-Zhen; Liu, Liang-Le; Cai, Chun-Yuan; Yang, Guo-Jing; Zhang, Li-Cheng; Zhu, Qi

2012-08-01

To explore selection and efficacy assessment for membranous urethral trauma caused by pelvic fracture. From June 2000 to August 2010, 72 patients with membranous urethral trauma caused by pelvic fracture were selected. There were 46 males and 26 females,ranging age from 26 to 62 years (averaged 35.2 years). The time from injury to hospitalization time was 1 to 3 hours. According to Tile pelvic fracture classification, there were 8 patients with type A, 45 patients with type B, 19 patients with type C. Thirty of the 35 patients with partial rupture of posterior urethral were treated by catheterization,5 patients treated by rupture anastomosis on the stage I combined with cystostomy; 25 of the 37 patients with complete rupture of posterior urethra were treated by early realignment, and 12 patients were treated by cystostomy. Urinary incontinence, impotence and urethrostenosis were evaluated. All patients were followed up for 5 to 10 years (mean 7.7 years). Incidence of urethrostenosis, impotence and urinary incontinence in patients treated by cystostomy were significantly higher than rupture anastomosis on the stage I and early realignment (P < 0.05); while incidence in patients treated by catheterization was significantly lower than other groups (P < 0.05). For patients with partial rupture of posterior urethral, catheterization and rupture anastomosis on the stage I are preferred methods; while patients with complete rupture of posterior urethra, early realignment is a preferred method with advantages of simple operation and less complications.

An epidemiological study of the burden of trauma in Makurdi, Nigeria

PubMed Central

Elachi, Itodo C; Yongu, Williams T; Odoyoh, Odatuwa-Omagbemi D; Mue, Daniel D; Ogwuche, Edwin I; Ahachi, Chukwukadibia N

2015-01-01

Background: Trauma leads to considerable morbidity and mortality. The aim of this study is to elucidate the pattern and characteristics of trauma at Benue State University Teaching Hospital (BSUTH), Makurdi, Nigeria. Materials and Methods: Case records of all patients who presented to the Accident and Emergency (A and E) Department with trauma between January and December 2013 were analyzed for demographic data, types of injuries sustained, causes and circumstances of injuries, as well as outcome of treatment were extracted from the case files and entered onto a computerized questionnaire. Data were analyzed using the software Statistical Package for Social Sciences for Windows version 15.0 (SPSS Inc; Chicago, Illinois). Results: A total of 250 traumatized patients were studied consisting of 203 (81.2%) males and 47 (18.8%) females with a modal age group of 21–30 years. Unintentional injuries were the most predominant form of trauma (n = 209, 83.6%) with road traffic accidents being the leading cause (n = 180, 72.0%). Open wounds (n = 95, 28.2%) were the most common form of injury sustained and the extremities (n = 148, 43.5%), the most frequently injured body region. Most patients (n = 133, 53.2%) were treated and discharged home without permanent disabilities, while death occurred in 15.2%. Conclusion: Trauma in Makurdi is a predominantly young adult male occurrence with road traffic accidents being the leading etiological factor. Reducing road traffic accidents will likely reduce mortality and morbidity due to trauma. PMID:26157653

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.

Risk factors for ventilator-associated pneumonia: among trauma patients with and without brain injury.

PubMed

Gianakis, Anastasia; McNett, Molly; Belle, Josie; Moran, Cristina; Grimm, Dawn

2015-01-01

Ventilator-associated pneumonia (VAP) rates remain highest among trauma and brain injured patients; yet, no research compares VAP risk factors between the 2 groups. This retrospective, case-controlled study identified risk factors for VAP among critically ill trauma patients with and without brain injury. Data were abstracted on trauma patients with (cases) and without (controls) brain injury. Data gathered on n = 157 subjects. Trauma patients with brain injury had more emergent and field intubations. Age was strongest predictor of VAP in cases, and ventilator days predicted VAP in controls. Trauma patients with brain injury may be at higher risk for VAP.

Changes in the pattern of plasma extracellular vesicles after severe trauma

PubMed Central

Kuravi, Sahithi J.; Yates, Clara M.; Foster, Mark; Hampson, Peter; Watson, Chris; Midwinter, Mark

2017-01-01

Background Extracellular vesicles (EV) released into the circulation after traumatic injury may influence complications. We thus evaluated the numbers of EV in plasma over 28 days after trauma and evaluated their pro-coagulant and inflammatory effects. Methods and findings 37 patients suffering trauma with an injury severity score >15 were studied along with 24 healthy controls. Plasma samples were isolated by double centrifugation (2000g 20min; 13000g 2min) from blood collected from within an hour up to 28 days after injury. Plasma EV were counted and sized using nanoparticle tracking analysis (NTA); counts and cellular origins were also determined by flow cytometry (FC) using cell-specific markers. Functional effects were tested in a procoagulant phospholipid assay and in flow-based, leukocyte adhesion assay after endothelial cells (EC) were treated with EV. We found that EV concentrations measured by NTA were significantly increased in trauma patients compared to healthy controls, and remained elevated over days. In addition, or FC showed that patients with trauma had higher numbers of EV derived from platelets (CD41+), leukocytes (CD45+) and endothelial EC (CD144+). The increases were evident throughout the 28-day follow-up. However, the FC count represented <1% of the count detected by NTA, and only 1–2% of EV identified using NTA had a diameter >400nm. The procoagulant phospholipid activity assay showed that patient plasma accelerated coagulation on day 1 and day 3 after trauma, with coagulation times correlated with EV counts. Furthermore, treatment of EC for 24 hours with plasma containing EV tended to increase the recruitment of peripheral flowing blood mononuclear cells. Conclusions EV counted by FC represent a small sub-population of the total load detected by NTA. Both methods however indicate a significant increase in plasma EV after severe traumatic injury that have pro-coagulant and pro-inflammatory effects that may influence outcomes. PMID:28837705

A Multi-Method Treatment for Child Survivors of Sexual Abuse: An Intervention Informed by Relational and Trauma Theories.

ERIC Educational Resources Information Center

Levendosky, Alytia A.; Buttenheim, Margaret

2002-01-01

Presents a case study of the treatment of a pre-adolescent female survivor of incest. The treatment integrated relational and trauma theory perspectives in focusing on reducing self-blame, preventing further isolation, creating a safe, secure environment, and helping the patient develop positive connections with others and feelings of…

Reliable Real-time Calculation of Heart-rate Complexity in Critically Ill Patients Using Multiple Noisy Waveform Sources

DTIC Science & Technology

2014-01-01

systems Machine learning Automatic data processing 1 Introduction Heart-rate complexity (HRC) is a method of quantifying the amount of complex...5. Batchinsky AI, Skinner J, Necsoiu C, et al. New measures of heart-rate complexity: effect of chest trauma and hemorrhage. J Trauma. 2010;68:1178–85

Muscle oxygenation as an early predictor of shock severity in trauma patients

PubMed Central

Arakaki, Lorilee S. L.; Bulger, Eileen M.; Ciesielski, Wayne A.; Carlbom, David J.; Fisk, Dana M.; Sheehan, Kellie L.; Asplund, Karin M.; Schenkman, Kenneth A.

2016-01-01

Introduction We evaluated the potential utility of a new prototype noninvasive muscle oxygenation (MOx) measurement for the identification of shock severity in a population of patients admitted to the trauma resuscitation rooms of a Level I regional trauma center. The goal of this project was to correlate MOx with shock severity as defined by standard measures of shock: systolic blood pressure, heart rate, and lactate. Methods Optical spectra were collected from subjects by placement of a custom-designed optical probe over the first dorsal interosseous muscles on the back of the hand. Spectra were acquired from trauma patients as soon as possible upon admission to the trauma resuscitation room. Patients with any injury were eligible for study. MOx was determined from the collected optical spectra with a multi-wavelength analysis that used both visible and near-infrared regions of light. Shock severity was determined in each patient by a scoring system based on combined degrees of hypotension, tachycardia, and lactate. MOx values of patients in each shock severity group (mild, moderate, and severe) were compared using two-sample t-tests. Results In 17 healthy control patients, the mean MOx value was 91.0 ± 5.5%. A total of 69 trauma patients were studied. Patients classified as having mild shock had a mean MOx of 62.5 ± 26.2% (n = 33), those classified as in moderate shock had a mean MOx of 56.9 ± 26.9% (n = 25) and those classified as in severe shock had a MOx of 31.0 ± 17.1% (n = 11). Mean MOx for each of these groups was statistically different from the healthy control group (p<0.05). Receiver operating characteristic (ROC) analyses show that MOx and shock index (heart rate/systolic blood pressure) identified shock similarly well (area under the curves (AUC) = 0.857 and 0.828, respectively). However, MOx identified mild shock better than shock index in the same group of patients (AUC = 0.782 and 0.671, respectively). Conclusions The results obtained from this pilot study indicate that MOx correlates with shock severity in a population of trauma patients. Noninvasive and continuous MOx holds promise to aid in patient triage and to evaluate patient condition throughout the course of resuscitation. PMID:27820776

Maryland's Helicopter Emergency Medical Services Experience From 2001 to 2011: System Improvements and Patients' Outcomes.

PubMed

Hirshon, Jon Mark; Galvagno, Samuel M; Comer, Angela; Millin, Michael G; Floccare, Douglas J; Alcorta, Richard L; Lawner, Benjamin J; Margolis, Asa M; Nable, Jose V; Bass, Robert R

2016-03-01

Helicopter emergency medical services (EMS) has become a well-established component of modern trauma systems. It is an expensive, limited resource with potential safety concerns. Helicopter EMS activation criteria intended to increase efficiency and reduce inappropriate use remain elusive and difficult to measure. This study evaluates the effect of statewide field trauma triage changes on helicopter EMS use and patient outcomes. Data were extracted from the helicopter EMS computer-aided dispatch database for in-state scene flights and from the state Trauma Registry for all trauma patients directly admitted from the scene or transferred to trauma centers from July 1, 2000, to June 30, 2011. Computer-aided dispatch flights were analyzed for periods corresponding to field triage protocol modifications intended to improve system efficiency. Outcomes were separately analyzed for trauma registry patients by mode of transport. The helicopter EMS computer-aided dispatch data set included 44,073 transports. There was a statewide decrease in helicopter EMS usage for trauma patients of 55.9%, differentially affecting counties closer to trauma centers. The Trauma Registry data set included 182,809 patients (37,407 helicopter transports, 128,129 ambulance transports, and 17,273 transfers). There was an increase of 21% in overall annual EMS scene trauma patients transported; ground transports increased by 33%, whereas helicopter EMS transports decreased by 49%. Helicopter EMS patient acuity increased, with an attendant increase in patient mortality. However, when standardized with W statistics, both helicopter EMS- and ground-transported trauma patients showed sustained improvement in mortality. Modifications to state protocols were associated with decreased helicopter EMS use and overall improved trauma patient outcomes. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Trauma care at rural level III trauma centers in a state trauma system.

PubMed

Helling, Thomas S

2007-02-01

Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care. During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail. A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5. Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.

Subjective safety and self-confidence in prehospital trauma care and learning progress after trauma-courses: part of the prospective longitudinal mixed-methods EPPTC-trial.

PubMed

Häske, David; Beckers, Stefan K; Hofmann, Marzellus; Lefering, Rolf; Grützner, Paul A; Stöckle, Ulrich; Papathanassiou, Vassilios; Münzberg, Matthias

2017-08-14

Prehospital trauma care is stressful and requires multi-professional teamwork. A decrease in the number of accident victims ultimately affects the routine and skills and underlines the importance of effective training. Standardized courses, like PHTLS, are established for health care professionals to improve the prehospital care of trauma patients. The aim of the study was to investigate the subjective safety in prehospital trauma care and learning progress by paramedics in a longitudinal analysis. This was a prospective intervention trial and part of the mixed-method longitudinal EPPTC-trial, evaluating subjective and objective changes among participants and real patient care as a result of PHTLS courses. Participants were evaluated with pre/post questionnaires as well as one year after the course. We included 236 datasets. In the pre/post comparison, an increased performance could be observed in nearly all cases. The result shows that the expectations of the participants of the course were fully met even after one year (p = 0.002). The subjective safety in trauma care is significantly better even one year after the course (p < 0.001). Regression analysis showed that (ABCDE)-structure is decisive (p = 0.036) as well as safety in rare and common skills (both p < 0.001). Most skills are also rated better after one year. Knowledge and specific safety are assessed as worse after one year. The courses meet the expectations of the participants and increase the subjective safety in the prehospital care of trauma patients. ABCDE-structure and safety in skills are crucial. In the short term, both safety in skills and knowledge can be increased, but the courses do not have the power to maintain knowledge and specific subjective safety issues over a year. German Clinical Trials Register, ID DRKS00004713 , registered 14. February 2014.

Effects of closure of an urban level I trauma centre on adjacent hospitals and local injury mortality: a retrospective, observational study.

PubMed

Crandall, Marie; Sharp, Douglas; Wei, Xiong; Nathens, Avery; Hsia, Renee Y

2016-05-10

To determine the association of the Martin Luther King Jr Hospital (MLK) closure on the distribution of admissions on adjacent trauma centres, and injury mortality rates in these centres and within the county. Observational, retrospective study. Non-public patient-level data from the state of California were obtained for all trauma patients from 1999 to 2009. Geospatial analysis was used to visualise the redistribution of trauma patients to other hospitals after MLK closed. Variance of observed to expected injury mortality using multivariate logistic regression was estimated for the study period. A total of 37 131 trauma patients were admitted to the five major south Los Angeles trauma centres from the MLK service area between 1999 and 2009. (1) Number and type of trauma admissions to trauma centres in closest proximity to MLK; (2) inhospital injury mortality of trauma patients after the trauma centre closure. During and after the MLK closure, trauma admissions increased at three of the four nearby hospitals, particularly admissions for gunshot wounds (GSWs). This redistribution of patient load was accompanied by a dramatic change in the payer mix for surrounding hospitals; one hospital's share of uninsured more than tripled from 12.9% in 1999 to 44.6% by 2009. Overall trauma mortality did not significantly change, but GSW mortality steadily and significantly increased after the closure from 5.0% in 2007 to 7.5% in 2009. Though local hospitals experienced a dramatic increase in trauma patient volume, overall mortality for trauma patients did not significantly change after MLK closed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Electronic Versus Manual Data Processing: Evaluating the Use of Electronic Health Records in Out-of-Hospital Clinical Research

PubMed Central

Newgard, Craig D.; Zive, Dana; Jui, Jonathan; Weathers, Cody; Daya, Mohamud

2011-01-01

Objectives To compare case ascertainment, agreement, validity, and missing values for clinical research data obtained, processed, and linked electronically from electronic health records (EHR), compared to “manual” data processing and record abstraction in a cohort of out-ofhospital trauma patients. Methods This was a secondary analysis of two sets of data collected for a prospective, population-based, out-of-hospital trauma cohort evaluated by 10 emergency medical services (EMS) agencies transporting to 16 hospitals, from January 1, 2006 through October 2, 2007. Eighteen clinical, operational, procedural, and outcome variables were collected and processed separately and independently using two parallel data processing strategies, by personnel blinded to patients in the other group. The electronic approach included electronic health record data exports from EMS agencies, reformatting and probabilistic linkage to outcomes from local trauma registries and state discharge databases. The manual data processing approach included chart matching, data abstraction, and data entry by a trained abstractor. Descriptive statistics, measures of agreement, and validity were used to compare the two approaches to data processing. Results During the 21-month period, 418 patients underwent both data processing methods and formed the primary cohort. Agreement was good to excellent (kappa 0.76 to 0.97; intraclass correlation coefficient 0.49 to 0.97), with exact agreement in 67% to 99% of cases, and a median difference of zero for all continuous and ordinal variables. The proportions of missing out-of-hospital values were similar between the two approaches, although electronic processing generated more missing outcomes (87 out of 418, 21%, 95% CI = 17% to 25%) than the manual approach (11 out of 418, 3%, 95% CI = 1% to 5%). Case ascertainment of eligible injured patients was greater using electronic methods (n = 3,008) compared to manual methods (n = 629). Conclusions In this sample of out-of-hospital trauma patients, an all-electronic data processing strategy identified more patients and generated values with good agreement and validity compared to traditional data collection and processing methods. PMID:22320373

Laparotomy for blunt abdominal trauma in a civilian trauma service.

PubMed

Howes, N; Walker, T; Allorto, N L; Oosthuizen, G V; Clarke, D L

2012-03-29

This report looks at the group of patients who required a laparotomy for blunt torso trauma at a busy metropolitan trauma service in South Africa. Methods. A prospective trauma registry is maintained by the surgical services of the Pietermaritzburg metropolitan complex. This registry is interrogated retrospectively. All patients who required admission for blunt torso trauma over the period September 2006 - September 2007 were included for review. Proformas documenting mechanism of injury, age, vital signs, blood gas, delay in presentation, length of hospital stay, intensive care unit stay and operative details were completed. Results. A total of 926 patients were treated for blunt trauma by the Pietermaritzburg metropolitan services during the period under consideration. A cohort of 65 (8%) required a laparotomy for blunt trauma during this period. There were 17 females in this group. The mechanisms of injury were motor vehicle accident (MVA) (27), pedestrian vehicle accident (PVA) (21), assault (5), fall from a height (3), bicycle accident (6), quad bike accident (1) and tractor-related accident (2). The following isolated injuries were discovered at laparotomy: liver (9), spleen (5), diaphragm (1), duodenum (2), small bowel (8), mesentery (8) bladder (10), gallbladder (1), stomach (2), colon/rectum (2) and retrohepatic vena cava (1). The following combined injuries were discovered: liver and diaphragm (2), spleen and pancreas (1), spleen and liver (2), spleen, aorta and diaphragm (1), spleen and bladder (1) and small bowel and bladder (2). Eighteen patients in the series (26%) required relaparotomy. In 10 patients temporary abdominal containment was needed. The mortality rate was 26% (18 patients). There were 6 deaths from massive bleeding, all within 6 hours of operation, and 3 deaths from renal failure; the remaining 9 patients died of multiple organ failure. There were 8 negative laparotomies (7%). In the negative laparotomy group false-positive computed tomography (CT) scan findings were a problem in 3 cases, in 1 case hypotension and a fractured pelvis on admission prompted laparotomy, and in the other cases clinical findings prompted laparotomy. All patients who underwent negative laparotomy survived. There were 10 pelvic fractures, 5 lower limb fractures, 2 spinal injuries, 4 femur fractures and 2 upper limb fractures. CT scans were done in 25 patients. In 20 patients the systolic blood pressure on presentation was <90 mmHg and in 41 the pulse rate was >110 beats/min. In 16 patients there was a base excess of <-4 on presentation. Conclusion. Laparotomy is needed in less than 10% of patients who sustain blunt abdominal trauma. Solid visceral injury requiring laparotomy presents with haemodynamic instability. Hollow visceral injury has a more insidious presentation and is associated with a delay in diagnosis. CT scan is the most widely used investigation in blunt abdominal trauma. It is both sensitive and specific for solid visceral injury, but its accuracy for the diagnosis of hollow visceral injury is less well defined. Clinical suspicion must be high, and hollow visceral injury needs to be actively excluded.

Prehospital Helicopter Transport and Survival of Patients With Traumatic Brain Injury

PubMed Central

Mackenzie, Todd A.

2015-01-01

Objective To investigate the association of helicopter transport with survival of patients with traumatic brain injury (TBI), in comparison with ground emergency medical services (EMS). Background Helicopter utilization and its effect on the outcomes of TBI remain controversial. Methods We performed a retrospective cohort study involving patients with TBI who were registered in the National Trauma Data Bank between 2009 and 2011. Regression techniques with propensity score matching were used to investigate the association of helicopter transport with survival of patients with TBI, in comparison with ground EMS. Results During the study period, there were 209,529 patients with TBI who were registered in the National Trauma Data Bank and met the inclusion criteria. Of these patients, 35,334 were transported via helicopters and 174,195 via ground EMS. For patients transported to level I trauma centers, 2797 deaths (12%) were recorded after helicopter transport and 8161 (7.8%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival [OR (odds ratio), 1.95; 95% confidence interval (CI), 1.81–2.10; absolute risk reduction (ARR), 6.37%]. This persisted after propensity score matching (OR, 1.88; 95% CI, 1.74–2.03; ARR, 5.93%). For patients transported to level II trauma centers, 1282 deaths (10.6%) were recorded after helicopter transport and 5097 (7.3%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival (OR, 1.81; 95% CI, 1.64–2.00; ARR 5.17%). This again persisted after propensity score matching (OR, 1.73; 95% CI, 1.55–1.94; ARR, 4.69). Conclusions Helicopter transport of patients with TBI to level I and II trauma centers was associated with improved survival, in comparison with ground EMS. PMID:24743624

Prospective Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk Elderly Fall Patients

PubMed Central

Tran, John; Jeanmonod, Donald; Agresti, Darin; Hamden, Khalief; Jeanmonod, Rebecca K.

2016-01-01

Introduction The National Emergency X-radiography Utilization Study (NEXUS) criteria are used extensively in emergency departments to rule out C-spine injuries (CSI) in the general population. Although the NEXUS validation set included 2,943 elderly patients, multiple case reports and the Canadian C-Spine Rules question the validity of applying NEXUS to geriatric populations. The objective of this study was to validate a modified NEXUS criteria in a low-risk elderly fall population with two changes: a modified definition for distracting injury and the definition of normal mentation. Methods This is a prospective, observational cohort study of geriatric fall patients who presented to a Level I trauma center and were not triaged to the trauma bay. Providers enrolled non-intoxicated patients at baseline mental status with no lateralizing neurologic deficits. They recorded midline neck tenderness, signs of trauma, and presence of other distracting injury. Results We enrolled 800 patients. One patient fall event was excluded due to duplicate enrollment, and four were lost to follow up, leaving 795 for analysis. Average age was 83.6 (range 65–101). The numbers in parenthesis after the negative predictive value represent confidence interval. There were 11 (1.4%) cervical spine injuries. One hundred seventeen patients had midline tenderness and seven of these had CSI; 366 patients had signs of trauma to the face/neck, and 10 of these patients had CSI. Using signs of trauma to the head/neck as the only distracting injury and baseline mental status as normal alertness, the modified NEXUS criteria was 100% sensitive (CI [67.9–100]) with a negative predictive value of 100 (98.7–100). Conclusion Our study suggests that a modified NEXUS criteria can be safely applied to low-risk elderly falls. PMID:27330655

Endovascular repair of thoracic aortic traumatic transections is a safe method in patients with complicated injuries.

PubMed

Rahimi, Saum A; Darling, R Clement; Mehta, Manish; Roddy, Sean P; Taggert, John B; Sternbach, Yaron

2010-10-01

Historically thoracic aortic rupture secondary to trauma was treated with cardiopulmonary bypass and open surgery. With the advent of endovascular grafting, physicians have the ability to reconstruct the thoracic aortic transection using a less invasive technique. In this study, we examine our experience with stent graft repair of thoracic transections secondary to trauma. The medical records of patients treated at a level I trauma center from 2005 to 2008 were reviewed. Those patients who had an aortic transection treated with an endograft were identified and evaluated for in-hospital mortality and morbidity and concurrent injuries. Demographics, procedural details, and outcomes were analyzed. Over a 3-year period, 18 thoracic aortic transections secondary to trauma were identified in patients with a mean age of 43 (range, 16-80). Primary technical success was 100%. None of the patients required explant or open repair during this time period. In-hospital mortality was 2 of 18 (11%); all patients had multiple trauma including long bone fractures. The subclavian artery origin was covered by the stent graft in 9 of the 18 patients. The mean estimated blood loss per procedure was 222 cc. No patient in this series had postoperative paraplegia. Follow-up ranged from 1 to 50 months with an average of 13 months. There have been no late explantation or device failures identified. Endovascular repair of traumatic thoracic aortic transections can be performed safely with a relatively low mortality and morbidity and should be the procedure of choice for patients presenting with traumatic thoracic aortic ruptures. Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Impact of STAT/SOCS mRNA Expression Levels after Major Injury

PubMed Central

Brumann, M.; Matz, M.; Kusmenkov, T.; Stegmaier, J.; Biberthaler, P.; Kanz, K.-G.; Mutschler, W.; Bogner, V.

2014-01-01

Background. Fulminant changes in cytokine receptor signalling might provoke severe pathological alterations after multiple trauma. The aim of this study was to evaluate the posttraumatic imbalance of the innate immune system with a special focus on the STAT/SOCS family. Methods. 20 polytraumatized patients were included. Blood samples were drawn 0 h–72 h after trauma; mRNA expression profiles of IL-10, STAT 3, SOCS 1, and SOCS 3 were quantified by qPCR. Results. IL-10 mRNA expression increased significantly in the early posttraumatic period. STAT 3 mRNA expressions showed a significant maximum at 6 h after trauma. SOCS 1 levels significantly decreased 6 h–72 h after trauma. SOCS 3 levels were significantly higher in nonsurvivors 6 h after trauma. Conclusion. We present a serial, sequential investigation in human neutrophil granulocytes of major trauma patients evaluating mRNA expression profiles of IL-10, STAT 3, SOCS 1, and SOCS 3. Posttraumatically, immune disorder was accompanied by a significant increase of IL-10 and STAT 3 mRNA expression, whereas SOCS 1 mRNA levels decreased after injury. We could demonstrate that death after trauma was associated with higher SOCS 3 mRNA levels already at 6 h after trauma. To support our results, further investigations have to evaluate protein levels of STAT/SOCS family in terms of posttraumatic immune imbalance. PMID:24648661

Mortality factors in geriatric blunt trauma patients.

PubMed

Knudson, M M; Lieberman, J; Morris, J A; Cushing, B M; Stubbs, H A

1994-04-01

To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma. In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score. Three urban trauma centers. Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989). The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure, < 90 mm Hg); hypoventilation (respiratory rate, < 10 breaths per minute); or a Glasgow Coma Scale score equal to 3. Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.

Laparoscopic surgery for trauma: the realm of therapeutic management.

PubMed

Zafar, Syed N; Onwugbufor, Michael T; Hughes, Kakra; Greene, Wendy R; Cornwell, Edward E; Fullum, Terrence M; Tran, Daniel D

2015-04-01

The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients. We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups. Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001). Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Injury mechanisms, patterns and outcomes of older polytrauma patients—An analysis of the Dutch Trauma Registry

PubMed Central

Reininga, Inge H. F.; Pieske, Oliver; Lefering, Rolf; El Moumni, Mostafa; Wendt, Klaus

2018-01-01

Background Polytrauma patients nowadays tend to be older due to the growth of the elderly population and its improved mobility. The aim of this study was to compare demographics, injury patterns, injury mechanisms and outcomes between younger and older polytrauma patients. Methods Data from polytrauma (ISS≥16) patients between 2009 and 2014 were extracted from the Dutch trauma registry (DTR). Younger (Group A: ages 18–59) and older (Group B: ages ≥60) polytrauma patients were compared. Differences in injury severity, trauma mechanism (only data for the year 2014), vital signs, injury patterns, ICU characteristics and hospital mortality were analyzed. Results Data of 25,304 polytrauma patients were analyzed. The older patients represented 47.8% of the polytrauma population. Trauma mechanism in the older patients was more likely to be a bicycle accident (A: 17%; B: 21%) or a low-energy fall (A: 13%; B: 43%). Younger polytrauma patients were more likely to have the worst scores on the Glasgow coma scale (EMV = 3, A: 20%, B: 13%). However, serious head injuries were seen more often in the older patients (A: 53%; B: 69%). The hospital mortality was doubled for the older polytrauma patients (19.8% vs. 9.6%). Conclusion Elderly are involved more often in polytrauma. Although injury severity did not differ between groups, the older polytrauma patients were at a higher risk of dying than their younger counterparts despite sustaining less high-energy accidents. PMID:29304054

Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study.

PubMed

Stelfox, Henry Thomas; Joshipura, Manjul; Chadbunchachai, Witaya; Ellawala, Ranjith N; O'Reilly, Gerard; Nguyen, Thai Son; Gruen, Russell L

2012-08-01

Quality Improvement (QI) programs have been shown to be a valuable tool to strengthen care of severely injured patients, but little is known about them in low and middle income countries (LMIC). We sought to explore opportunities to improve trauma QI activities in LMIC, focusing on the Asia-Pacific region. We performed a mixed methods research study using both inductive thematic analysis of a meeting convened at the Royal Australasian College of Surgeons, Melbourne, Australia, November 21-22, 2010 and a pre-meeting survey to explore experiences with trauma QI activities in LMIC. Purposive sampling was employed to invite participants with demonstrated leadership in trauma care to provide diverse representation of organizations and countries within Asia-Pacific. A total of 22 experts participated in the meeting and reported that trauma QI activities varied between countries and organizations: morbidity and mortality conferences (56 %), monitoring complications (31 %), preventable death studies (25 %), audit filters (19 %), and statistical methods for analyzing morbidity and mortality (6 %). Participants identified QI gaps to include paucity of reliable/valid injury data, lack of integrated trauma QI activities, absence of standards of care, lack of training in QI methods, and varying cultures of quality and safety. The group highlighted barriers to QI: limited engagement of leaders, organizational diversity, limited resources, heavy clinical workload, and medico-legal concerns. Participants proposed establishing the Asia-Pacific Trauma Quality Improvement Network (APTQIN) as a tool to facilitate training and dissemination of QI methods, injury data management, development of pilot QI projects, and advocacy for quality trauma care. Our study provides the first description of trauma QI practices, gaps in existing practices, and barriers to QI in LMIC of the Asia-Pacific region. In this study we identified opportunities for addressing these challenges, and that work will be supported by APTQIN.

Gender differences among recidivist trauma patients.

PubMed

Kwan, Rita O; Cureton, Elizabeth L; Dozier, Kristopher C; Victorino, Gregory P

2011-01-01

Gender differences among trauma recidivist patients are not well-understood. We hypothesized that males are more likely to be repeatedly involved in the trauma system and have a shorter time to recurrence between repeat episodes of injury compared with females. A retrospective analysis of trauma patients treated at an urban university-based trauma center was performed. Variables including gender, race, insurance status, age, mechanism of injury, outcomes, and injury secondary to domestic violence were compared. Differences were compared using χ(2) tests and log-rank (Mantel-Cox) Kaplan-Meier cumulative event curves. We identified 689 trauma recidivist patients (4.0% of all trauma visits) over a 10-y period. Compared to single-visit patients, recidivist patients were more likely to be male (87% versus 73%), uninsured (78% versus 66%), and have injuries secondary to assaults (54% versus 37%) (P < 0.05). Time from the first to second trauma visit was shorter for females compared with males (23 ± 2.5 versus 30 ± 1.2 mo, P < 0.02). Additionally, female recidivists were more likely to be involved in blunt trauma than were male recidivists (69% versus 43%, P < 0.001). Furthermore, domestic violence was identified in a higher proportion of female recidivist patients than female single-visit patients (3.5% versus 1.6%, P < 0.0003). Contrary to our hypothesis, female recidivist trauma patients have a much shorter time to recurrence for a second traumatic injury than do males. Female recidivists have a high likelihood of assault-associated injuries and domestic violence. Trauma centers should screen for domestic violence among trauma patients to aid in preventing further repeat episodes of injury. Copyright © 2011 Elsevier Inc. All rights reserved.

Whole-body multislice computed tomography (MSCT) improves trauma care in patients requiring surgery after multiple trauma.

PubMed

Wurmb, T E; Quaisser, C; Balling, H; Kredel, M; Muellenbach, R; Kenn, W; Roewer, N; Brederlau, J

2011-04-01

Whole-body multislice helical CT becomes increasingly important as a diagnostic tool in patients with multiple injuries. Time gain in multiple-trauma patients who require emergency surgery might improve outcome. The authors hypothesised that whole-body multislice computed tomography (MSCT) (MSCT trauma protocol) as the initial diagnostic tool reduces the interval to start emergency surgery (tOR) if compared to conventional radiography, combined with abdominal ultrasound and organ-focused CT (conventional trauma protocol). The second goal of the study was to investigate whether the diagnostic approach chosen has an impact on outcome. The authors' level 1 trauma centre uses whole-body MSCT for initial radiological diagnostic work-up for patients with suspected multiple trauma. Before the introduction of MSCT in 2004, a conventional approach was used. Group I: data of trauma patients treated with conventional trauma protocol from 2001 to 2003. Group II: data from trauma patients treated with whole-body MSCT trauma protocol from 2004 to 2006. tOR in group I (n=155) was 120 (90-150) min (median and IQR) and 105 (85-133) min (median and IQR) in group II (n=163), respectively (p<0.05). Patients of group II had significantly more serious injuries. No difference in outcome data was found. 14 patients died in both groups within the first 30 days; five of these died within the first 24 h. A whole-body MSCT-based diagnostic approach to multiple trauma shortens the time interval to start emergency surgery in patients with multiple injuries. Mortality remained unchanged in both groups. Patients of group II were more seriously injured; an improvement of outcome might be assumed.

Evolution of a Multidisciplinary Clinical Pathway for the Management of Unstable Patients With Pelvic Fractures

PubMed Central

Biffl, Walter L.; Smith, Wade R.; Moore, Ernest E.; Gonzalez, Ricardo J.; Morgan, Steven J.; Hennessey, Theresa; Offner, Patrick J.; Ray, Charles E.; Franciose, Reginald J.; Burch, Jon M.

2001-01-01

Objective To determine whether the evolution of the authors’ clinical pathway for the treatment of hemodynamically compromised patients with pelvic fractures was associated with improved patient outcome. Summary Background Data Hemodynamically compromised patients with pelvic fractures present a complex challenge. The multidisciplinary trauma team must control hemorrhage, restore hemodynamics, and rapidly identify and treat associated life-threatening injuries. The authors developed a clinical pathway consisting of five primary elements: immediate trauma attending surgeon’s presence in the emergency department, early simultaneous transfusion of blood and coagulation factors, prompt diagnosis and management of associated life-threatening injuries, stabilization of the pelvic girdle, and timely insinuation of pelvic angiography and embolization. The addition of two orthopedic pelvic fracture specialists led to a revision of the pathway, emphasizing immediate emergency department presence of the orthopedic trauma attending to provide joint decision making with the trauma surgeon, closing the pelvic volume in the emergency department, and using alternatives to traditional external fixation devices. Methods Using trauma registry and blood bank records, the authors identified pelvic fracture patients receiving blood transfusions in the emergency department. They analyzed patients treated before versus after the May 1998 revision of the clinical pathway. Results A higher proportion of patients in the late period had blood pressure less than 90 mmHg (52% vs. 35%). In the late period, diagnostic peritoneal lavage was phased out in favor of torso ultrasound as a primary triage tool, and pelvic binding and C-clamp application largely replaced traditional external fixation devices. The overall death rate decreased from 31% in the early period to 15% in the later period, as did the rate of deaths from exsanguination (9% to 1%), multiple organ failure (12% to 1%), and death within 24 hours (16% to 5%). Conclusions The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed by joint decision making between trauma surgeons and orthopedic traumatologists, has resulted in improved patient survival. The primary benefits appear to be in reducing early deaths from exsanguination and late deaths from multiple organ failure. PMID:11407336

Trauma facilities in Denmark - a nationwide cross-sectional benchmark study of facilities and trauma care organisation.

PubMed

Weile, Jesper; Nielsen, Klaus; Primdahl, Stine C; Frederiksen, Christian A; Laursen, Christian B; Sloth, Erik; Mølgaard, Ole; Knudsen, Lars; Kirkegaard, Hans

2018-03-27

Trauma is a leading cause of death among adults aged < 44 years, and optimal care is a challenge. Evidence supports the centralization of trauma facilities and the use multidisciplinary trauma teams. Because knowledge is sparse on the existing distribution of trauma facilities and the organisation of trauma care in Denmark, the aim of this study was to identify all Danish facilities that care for traumatized patients and to investigate the diversity in organization of trauma management. We conducted a systematic observational cross-sectional study. First, all hospitals in Denmark were identified via online services and clarifying phone calls to each facility. Second, all trauma care manuals on all facilities that receive traumatized patients were gathered. Third, anesthesiologists and orthopedic surgeons on call at all trauma facilities were contacted via telephone for structured interviews. A total of 22 facilities in Denmark were found to receive traumatized patients. All facilities used a trauma care manual and all had a multidisciplinary trauma team. The study found three different trauma team activation criteria and nine different compositions of teams who participate in trauma care. Training was heterogeneous and, beyond the major trauma centers, databases were only maintained in a few facilities. The study established an inventory of the existing Danish facilities that receive traumatized patients. The trauma team activation criteria and the trauma teams were heterogeneous in both size and composition. A national database for traumatized patients, research on nationwide trauma team activation criteria, and team composition guidelines are all called for.

Effects of eye movement desensitization and reprocessing (EMDR) on non-specific chronic back pain: a randomized controlled trial with additional exploration of the underlying mechanisms

PubMed Central

2013-01-01

Background Non-specific chronic back pain (CBP) is often accompanied by psychological trauma, but treatment for this associated condition is often insufficient. Nevertheless, despite the common co-occurrence of pain and psychological trauma, a specific trauma-focused approach for treating CBP has been neglected to date. Accordingly, eye movement desensitization and reprocessing (EMDR), originally developed as a treatment approach for posttraumatic stress disorders, is a promising approach for treating CBP in patients who have experienced psychological trauma. Thus, the aim of this study is to determine whether a standardized, short-term EMDR intervention added to treatment as usual (TAU) reduces pain intensity in CBP patients with psychological trauma vs. TAU alone. Methods/design The study will recruit 40 non-specific CBP patients who have experienced psychological trauma. After a baseline assessment, the patients will be randomized to either an intervention group (n = 20) or a control group (n = 20). Individuals in the EMDR group will receive ten 90-minute sessions of EMDR fortnightly in addition to TAU. The control group will receive TAU alone. The post-treatment assessments will take place two weeks after the last EMDR session and six months later. The primary outcome will be the change in the intensity of CBP within the last four weeks (numeric rating scale 0–10) from the pre-treatment assessment to the post-treatment assessment two weeks after the completion of treatment. In addition, the patients will undergo a thorough assessment of the change in the experience of pain, disability, trauma-associated distress, mental co-morbidities, resilience, and quality of life to explore distinct treatment effects. To explore the mechanisms of action that are involved, changes in pain perception and pain processing (quantitative sensory testing, conditioned pain modulation) will also be assessed. The statistical analysis of the primary outcome will be performed on an intention-to-treat basis. The secondary outcomes will be analyzed in an explorative, descriptive manner. Discussion This study adapts the standard EMDR treatment for traumatized patients to patients with CBP who have experienced psychological trauma. This specific, mechanism-based approach might benefit patients. Trial registration This trial has been registered with ClinicalTrials.gov (NCT01850875). PMID:23987561

Penile fracture and associated urethral injury: Experience at a tertiary care hospital

PubMed Central

Amit, Attam; Arun, Kerketta; Bharat, Behera; Navin, Ram; Sameer, Trivedi; Shankar, Dwivedi Udai

2013-01-01

Introduction: Penile fracture may be associated with urethral trauma in 1% to 38% of cases. We present our experience in treating 8 such cases. Methods: Data were collected retrospectively from hospital records and from out-patient department follow-up visits. Results: The mean age of the patients was 30.4 years; trauma during coitus was the most common cause of the penile fracture. One patient presented after 7 days. Two patients had normal examination of their penis despite typical history. All fractures were repaired on an emergency basis via subcoronal incision. In 2 patients with normal findings, the urethra had to be mobilized to locate the site of the injury. In 1 patient, the site of the urethral trauma was 1 cm away from the site of the corporal injury, which was localized by injecting sterile methylene blue per urethra. Postoperatively, all patients voided with good flow and had erections with adequate rigidity. Conclusion: A high level of suspicion for urethral injury during surgical exploration is warranted, especially in the presence of suggestive history and examination. PMID:23589751

Outcomes of truncal vascular injuries in children

PubMed Central

Allison, Nathan D.; Anderson, Christopher M.; Shah, Shinil K.; Lally, Kevin P.; Hayes-Jordan, Andrea; Tsao, Kuo-Jen; Andrassy, Richard J.; Cox, Charles S.

2011-01-01

Background Pediatric truncal vascular injuries occur infrequently and have a reported mortality rate of 30% to 50%. This report examines the demographics, mechanisms of injury, associated trauma, and outcome of patients presenting for the past 10 years at a single institution with truncal vascular injuries. Methods A retrospective review (1997-2006) of a pediatric trauma registry at a single institution was undertaken. Results Seventy-five truncal vascular injuries occurred in 57 patients (age, 12 ± 3 years); the injury mechanisms were penetrating in 37%. Concomitant injuries occurred with 76%, 62%, and 43% of abdominal, thoracic, and neck vascular injuries, respectively. Nonvascular complications occurred more frequently in patients with abdominal vascular injuries who were hemodynamically unstable on presentation. All patients with thoracic vascular injuries presenting with hemodynamic instability died. In patients with neck vascular injuries, 1 of 2 patients who were hemodynamically unstable died, compared to 1 of 12 patients who died in those who presented hemodynamically stable. Overall survival was 75%. Conclusions Survival and complications of pediatric truncal vascular injury are related to hemodynamic status at the time of presentation. Associated injuries are higher with trauma involving the abdomen. PMID:19853755

Trauma with Injury Severity Score of 75: Are These Unsurvivable Injuries?

PubMed Central

Peng, Jin; Wheeler, Krista; Shi, Junxin; Groner, Jonathan Ira; Haley, Kathryn Jo; Xiang, Huiyun

2015-01-01

Trauma patients with an ISS=75 have been deliberately excluded from some trauma studies because they were assumed to have "unsurvivable injuries." This study aimed to assess the true mortality among patients with an ISS=75, and to examine the characteristics and primary diagnoses of these patients. Retrospective review of the 2006-2010 U.S. Nationwide Emergency Department Sample (NEDS) generated 2,815 patients with an ISS=75 for analysis, representing an estimated 13,569 patients in the country. Dispositions from the emergency department and hospital for these patients were tabulated by trauma center level. Survivors and non-survivors were compared using Pearson's chi-square test. Primary diagnosis codes of these patients were tabulated by mortality status. Overall, about 48.6% of patients with an ISS=75 were discharged alive, 25.8% died and 25.6% had unknown mortality status. The mortality risks of these patients did not vary significantly across different levels of trauma centers (15.6% vs. 13.0%, P = 0.16). Non-survivors were more likely than survivors to: be male (81.2% vs. 74.4%, P < 0.0001), be over 65 years (20.3% vs. 10.2%, P < 0.0001), be uninsured (33.8% vs. 19.1%), have at least one chronic condition (58.0% vs. 43.7%, P <0.0001), sustain life-threatening injuries (79.2% vs. 49.4%, P<0.0001), sustain penetrating injuries (42.0% vs. 25.9%, P<0.0001), and have injuries caused by motor vehicle crashes (32.9% vs. 21.1%, P<0.0001) or firearms (21.9% vs. 4.4%, P<0.0001). The most frequent diagnosis code was 862.8 (injury to multiple and unspecified intrathoracic organs, without mention of open wound into cavity). Our results revealed that at least half of patients with an ISS=75 survived, demonstrating that the rationale for excluding patients with an ISS=75 from analysis is not always justified. To avoid bias and inaccurate results, trauma researchers should examine the mortality status of patients with an ISS=75 before exclusion, and explicitly describe their method of generating ISS scores. PMID:26230931

The relationship of trauma severity and mortality with cardiac enzymes and cytokines at multiple trauma patients.

PubMed

Karakuş, Ali; Kekeç, Zeynep; Akçan, Ramazan; Seydaoğlu, Gülşah

2012-07-01

In this study, we aimed to determine the effects of trauma severity on cardiac involvement through evaluating the trauma severity score together with diagnostic tests in multiple trauma patients. A trauma score was determined using various trauma severity scales. After obtaining the approval of the ethics committee of the faculty, this prospective study was performed through evaluating 100 multiple trauma patients, aged over 15 years, who applied to our Emergency Department (ED). After determining the trauma severity score using instruments such as the Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS), the cardiac condition was evaluated using biochemical and radiological diagnostic tests. During the study period, 100 patients were evaluated (78 male, 22 female; mean age: 33.2±15.4; range 15 to 70 years). It was determined that 92 (92%) were blunt trauma cases, and 77 (77%) of them were due to traffic accidents. The majority of cases showed electrocardiogram (ECG) abnormalities (63%) and sinus tachycardia (36%). Abnormal echocardiogram (ECHO) findings, mostly accompanied by ventricular defects (n=24), were determined in 31 of the cases. Nineteen cases with high trauma severity score resulted in death, and 14 of all deaths were secondary to traffic accidents. Trauma scores were found to show a significant difference between the two groups. The ISS trauma scale was determined to be the most effective in terms of indicating heart involvement in patients with multiple traumas. Close follow-up and cardiac monitoring should be applied to patients with high trauma severity scores considering possible cardiac rhythm changes and hemodynamic disturbances due to cardiac involvement.

Early physical and functional rehabilitation of trauma patients in the Médecins Sans Frontières trauma centre in Kunduz, Afghanistan: luxury or necessity?

PubMed Central

Gohy, Bérangère; Ali, Engy; Van den Bergh, Rafael; Schillberg, Erin; Nasim, Masood; Naimi, Muhammad Mahmood; Cheréstal, Sophia; Falipou, Pauline; Weerts, Eric; Skelton, Peter; Van Overloop, Catherine; Trelles, Miguel

2016-01-01

Background In Afghanistan, Médecins Sans Frontières provided specialised trauma care in Kunduz Trauma Centre (KTC), including physiotherapy. In this study, we describe the development of an adapted functional score for patient outcome monitoring, and document the rehabilitation care provided and patient outcomes in relation to this functional score. Methods A descriptive cohort study was done, including all patients admitted in the KTC inpatient department (IPD) between January and June 2015. The adapted functional score was collected at four points in time: admission and discharge from both IPD and outpatient department (OPD). Results Out of the 1528 admitted patients, 92.3% (n = 1410) received at least one physiotherapy session. A total of 1022 patients sustained either lower limb fracture, upper limb fracture, traumatic brain injury or multiple injury. Among them, 966 patients received physiotherapy in IPD, of whom 596 (61.7%) received IPD sessions within 2 days of admission; 696 patients received physiotherapy in OPD. Functional independence increased over time; among patients having a functional score taken at admission and discharge from IPD, 32.2% (172/535) were independent at discharge, and among patients having a functional score at OPD admission and discharge, 79% (75/95) were independent at discharge. Conclusions The provision of physiotherapy was feasible in this humanitarian setting, and the tailored functional score appeared to be relevant. PMID:27738078

Changes of procalcitonin level in multiple trauma patients.

PubMed

Wojtaszek, Marek; Staśkiewicz, Grzegorz; Torres, Kamil; Jakubowski, Krzysztof; Rácz, Oliver; Cipora, Elżbieta

2014-01-01

Some aspects of the pathophysiology of complications in multiple-trauma patients still remain unclear. Mediators of inflammation have been postulated as playing a key role in being responsible for life threatening complications of multiple trauma patients. The objective of this study was to evaluate the prognostic value of procalcitonin (PCT) level in multiple trauma patients. A prospective study took place including patients with multiple trauma hospitalised in several hospital units. PCT level was measured in blood from 45 patients, aged 18-70 years using enzyme-linked immunoassay. The patients were divided into three groups: group I - individuals with multiple trauma with central nervous system injury; group II - those with multiple trauma without CNS injury; and group III - patients with isolated central nervous system injury. Initial PCT levels were below 0.5 ng mL(-1) regardless of the cause of trauma. In the 24th hour of observation, a statistically significant increase of PCT concentration vs. initial levels was recorded in all groups of patients. Then PCT levels decreased significantly at the 3rd measurement point in all groups, and they remained unchanged until the last measurement. The highest levels of PCT were observed in multiple trauma patients without CNS injury (group II). In this group of patients, a significantly longer duration of surgery in the post-trauma period affected PCT levels. PCT concentrations in patients who died were significantly greater than in survivors. A long lasting elevated concentration of procalcitonin in the post-traumatic period, or its repeated increase, is a good marker of developing complications observed earlier than clinical manifestations.

Leadership and Teamwork in Trauma and Resuscitation.

PubMed

Ford, Kelsey; Menchine, Michael; Burner, Elizabeth; Arora, Sanjay; Inaba, Kenji; Demetriades, Demetrios; Yersin, Bertrand

2016-09-01

Leadership skills are described by the American College of Surgeons' Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders. We searched the PubMed database using the keywords "leadership" and then either "trauma" or "resuscitation" as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders. We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance. Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership's effect on patient-level outcome.

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

PubMed

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

2018-01-27

In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients. A systematic search of Pubmed/MEDLINE, Embase, and Cochrane Library databases was performed, using "trauma", "trauma center," or "trauma system", combined with "triage", "undertriage," or "overtriage", as search terms. All studies describing ground transport and actual destination hospital of patients with and without severe injuries, using prehospital triage, published before November 2017, were eligible for inclusion. To assess the quality of these studies, a critical appraisal tool was developed. A total of 33 articles were included. The percentage of undertriage ranged from 1% to 68%; overtriage from 5% to 99%. Older age and increased geographical distance were associated with undertriage. Mortality was lower for severely injured patients transferred to a higher-level trauma center. The majority of the included studies were of poor methodological quality. The studies of good quality showed poor performance of the triage protocol, but additional value of EMS provider judgment in the identification of severely injured patients. In most of the evaluated trauma systems, a substantial part of the severely injured patients is not transported to the appropriate level trauma center. Future research should come up with new innovative ways to improve the quality of prehospital triage in trauma patients. Copyright © 2018. Published by Elsevier Inc.

Leadership and Teamwork in Trauma and Resuscitation

PubMed Central

Ford, Kelsey; Menchine, Michael; Burner, Elizabeth; Arora, Sanjay; Inaba, Kenji; Demetriades, Demetrios; Yersin, Bertrand

2016-01-01

Introduction Leadership skills are described by the American College of Surgeons’ Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders. Methods We searched the PubMed database using the keywords “leadership” and then either “trauma” or “resuscitation” as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders. Results We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance. Conclusion Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership’s effect on patient-level outcome. PMID:27625718

Genetic Variation in Complement Component 2 of the Classical Complement Pathway is Associated with Increased Mortality and Infection: A Study of 627 Trauma Patients

PubMed Central

Morris, John A.; Francois, Cedric; Olson, Paul K.; Cotton, Bryan A.; Summar, Marshall; Jenkins, Judith M.; Norris, Patrick R.; Moore, Jason H.; Williams, Anna E.; McNew, Brent S.; Canter, Jeffrey A.

2009-01-01

Trauma is a disease of inflammation. Complement Component 2 (C2) is a protease involved in activation of complement through the classical pathway and has been implicated in a variety of chronic inflammatory diseases. We hypothesized that genetic variation in C2 (E318D) identifies a high-risk subgroup of trauma patients reflecting increased mortality and infection (Ventilator associated pneumonia: VAP). Consequently, genetic variation in C2 may stratify patient risk and illuminate underlying mechanisms for therapeutic intervention. Methods DNA samples from 702 trauma patients were genotyped for C2 E318D and linked with covariates (age: mean 42.8 years, gender: 74% male, ethnicity: 80% Caucasian, mechanism: 84% blunt, ISS: mean 25.0, admission lactate: mean 3.13 mEq/L) and outcomes: mortality 9.9% and VAP: 18.5%. VAP was defined by quantitative bronchoalveolar lavage (>104). Multivariate regression determined the relationship of genotype and covariates to risk of death and VAP. However, patients with ISS ≥ 45 were excluded from the multivariate analysis, as magnitude of injury overwhelms genetics and covariates in determining outcome. Results 52 patients (8.3%) had the high-risk heterozygous genotype, associated with a significant increase in mortality and VAP. Conclusion In 702 trauma patients, 8.3% had a high-risk genetic variation in C2 associated with increased mortality (OR=2.65) and infection (OR=2.00). This variation: 1) Identifies a previously unknown high risk group for infection and mortality; 2) Can be determined on admission; 3) May provide opportunity for early therapeutic intervention; and 4) Requires validation in a distinct cohort of patients. PMID:19430225

Are first rib fractures a marker for other life-threatening injuries in patients with major trauma? A cohort study of patients on the UK Trauma Audit and Research Network database

PubMed Central

Sammy, Ian Ayenga; Chatha, Hridesh; Lecky, Fiona; Bouamra, Omar; Fragoso-Iñiguez, Marisol; Sattout, Abdo; Hickey, Michael; Edwards, John E

2017-01-01

Background First rib fractures are considered indicators of increased morbidity and mortality in major trauma. However, this has not been definitively proven. With an increased use of CT and the potential increase in detection of first rib fractures, re-evaluation of these injuries as a marker for life-threatening injuries is warranted. Methods Patients sustaining rib fractures between January 2012 and December 2013 were investigated using data from the UK Trauma Audit and Research Network. The prevalence of life-threatening injuries was compared in patients with first rib fractures and those with other rib fractures. Multivariate logistic regression was performed to determine the association between first rib fractures, injury severity, polytrauma and mortality. Results There were 1683 patients with first rib fractures and 8369 with fractures of other ribs. Life-threatening intrathoracic and extrathoracic injuries were more likely in patients with first rib fractures. The presence of first rib fractures was a significant predictor of injury severity (Injury Severity Score >15) and polytrauma, independent of mechanism of injury, age and gender with an adjusted OR of 2.64 (95% CI 2.33 to 3.00) and 2.01 (95% CI 1.80 to 2.25), respectively. Risk-adjusted mortality was the same in patients with first rib fractures and those with other rib fractures (adjusted OR 0.97, 95% CI 0.79 to 1.19). Conclusion First rib fractures are a marker of life-threatening injuries in major trauma, though they do not independently increase mortality. Management of patients with first rib fractures should focus on identification and treatment of associated life-threatening injuries. PMID:28119351

Epidemiology of Patients Hospitalized for Ocular Trauma in the Chaoshan Region of China, 2001–2010

PubMed Central

Cao, He; Li, Liping; Zhang, Mingzhi

2012-01-01

Background The burden and pattern of ocular trauma in China are poorly known and not well studied. We aimed at studying the epidemiological characteristics of patients hospitalized for ocular trauma at major ophthalmology departments in the largest industrial base of plastic toys in China. Methods A retrospective study of ocular trauma cases admitted to 3 tertiary hospitals in China from 1st January 2001 to 31st December 2010 was performed. Results The study included a total of 3,644 injured eyes from 3,559 patients over the 10-year period: 2,008 (55.1%) open-globe injuries, 1,580 (43.4%) closed-globe injuries, 41 (1.1%) chemical injuries, 15 (0.4%) thermal injuries and 678 (18.6%) ocular adnexal injuries. The mean age of the patients was 29.0±16.8 years with a male-to-female ratio of 5.2∶1 (P = 0.007). The most frequent types of injury were work-related injuries (1,656, 46.5%) and home-related injuries (715, 20.1%). The majority of injuries in males (56.2%) and females (36.0%) occurred in the 15–44 age group and 0–14 age group, respectively. The final visual acuity correlated with the initial visual acuity (Spearman’s correlation coefficient = 0.659; P<0.001). The Ocular Trauma Score also correlated with the final visual acuity (Spearman’s correlation coefficient = 0.655; P<0.001). Conclusions This analysis provides an epidemiological study of patients who were hospitalized for ocular trauma. Preventive efforts are important for both work-related and home-related eye injuries. PMID:23118997

An overview of New Zealand's trauma system.

PubMed

Paice, Rhondda

2007-01-01

Patterns of trauma and trauma systems in New Zealand are similar to those in Australia. Both countries have geographical considerations, terrain and distance, that can cause delay to definitive care. There are only 7 hospitals in New Zealand that currently manage major trauma patients, and consequently, trauma patients are often hospitalized some distance from their homes. The prehospital services are provided by one major provider throughout the country, with a high level of volunteers providing these services in the rural areas. New Zealand has a national no-fault accident insurance system, the Accident Compensation Corporation, which funds all trauma-related healthcare from the roadside to rehabilitation. This insurance system provides 24-hour no-fault personal injury insurance coverage. The Accident Compensation Corporation provides bulk funding to hospitals for resources to manage the care of trauma patients. Case managers are assigned for major trauma patients. This national system also has a rehabilitation focus. The actual funds are managed by the hospitals, and this allows hospital staff to provide optimum care for trauma patients. New Zealand works closely with Australia in the development of a national trauma registry, research, and education in trauma care for patients in Australasia (the islands of the southern Pacific Ocean, including Australia, New Zealand, and New Guinea).

Digital radiography of crush thoracic trauma in the Sichuan earthquake

PubMed Central

Dong, Zhi-Hui; Shao, Heng; Chen, Tian-Wu; Chu, Zhi-Gang; Deng, Wen; Tang, Si-Shi; Chen, Jing; Yang, Zhi-Gang

2011-01-01

AIM: To investigate the features of crush thoracic trauma in Sichuan earthquake victims using chest digital radiography (CDR). METHODS: We retrospectively reviewed 772 CDR of 417 females and 355 males who had suffered crush thoracic trauma in the Sichuan earthquake. Patient age ranged from 0.5 to 103 years. CDR was performed between May 12, 2008 and June 7, 2008. We looked for injury to the thoracic cage, pulmonary parenchyma and the pleura. RESULTS: Antero-posterior (AP) and lateral CDR were obtained in 349 patients, the remaining 423 patients underwent only AP CDR. Thoracic cage fractures, pulmonary contusion and pleural injuries were noted in 331 (42.9%; 95% CI: 39.4%-46.4%), 67 and 135 patients, respectively. Of the 256 patients with rib fractures, the mean number of fractured ribs per patient was 3. Rib fractures were mostly distributed from the 3rd through to the 8th ribs and the vast majority involved posterior and lateral locations along the rib. Rib fractures had a significant positive association with non-rib thoracic fractures, pulmonary contusion and pleural injuries (P < 0.001). The number of rib fractures and pulmonary contusions were significant factors associated with patient death. CONCLUSION: Earthquake-related crush thoracic trauma has the potential for multiple fractures. The high number of fractured ribs and pulmonary contusions were significant factors which needed appropriate medical treatment. PMID:22132298

The Effect of Trauma Center Designation and Trauma Volume on Outcome in Specific Severe Injuries

PubMed Central

Demetriades, Demetrios; Martin, Mathew; Salim, Ali; Rhee, Peter; Brown, Carlos; Chan, Linda

2005-01-01

Objective: The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries. Background: Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated. Methods: The National Trauma Data Bank study, which included patients >14 years of age and had injury severity score (ISS) >15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and II trauma centers and between centers within the same level designation but different volumes of severe trauma (<240 vs ≥240 trauma admissions with ISS >15 per year). The outcomes were adjusted for age (<65 ≥65), gender, mechanism of injury, hypotension on admission, and ISS (≤25 and >25). Results: A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71–0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44–0.69; P < 0.001) than level II centers. Subgroup analysis showed that cardiovascular injuries (N = 2004) and grades IV–V liver injuries (N = 1415) had a significantly better survival in level I than level II trauma centers (adjusted P = 0.017 and 0.023, respectively). Overall, there was a significantly better functional outcome in level I centers (adjusted P < 0.001). Subgroup analysis showed level I centers had significantly better functional outcomes in complex pelvic fractures (P < 0.001) and a trend toward better outcomes in the rest of the subgroups. The volume of trauma admissions with ISS >15 (<240 vs ≥240 cases per year) had no effect on outcome in either level I or II centers. Conclusions: Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation. PMID:16192811

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.

Major trauma: the unseen financial burden to trauma centres, a descriptive multicentre analysis.

PubMed

Curtis, Kate; Lam, Mary; Mitchell, Rebecca; Dickson, Cara; McDonnell, Karon

2014-02-01

This research examines the existing funding model for in-hospital trauma patient episodes in New South Wales (NSW), Australia and identifies factors that cause above-average treatment costs. Accurate information on the treatment costs of injury is needed to guide health-funding strategy and prevent inadvertent underfunding of specialist trauma centres, which treat a high trauma casemix. Admitted trauma patient data provided by 12 trauma centres were linked with financial data for 2008-09. Actual costs incurred by each hospital were compared with state-wide Australian Refined Diagnostic Related Groups (AR-DRG) average costs. Patient episodes where actual cost was higher than AR-DRG cost allocation were examined. There were 16693 patients at a total cost of AU$178.7million. The total costs incurred by trauma centres were $14.7million above the NSW peer-group average cost estimates. There were 10 AR-DRG where the total cost variance was greater than $500000. The AR-DRG with the largest proportion of patients were the upper limb injury categories, many of whom had multiple body regions injured and/or a traumatic brain injury (P<0.001). AR-DRG classifications do not adequately describe the trauma patient episode and are not commensurate with the expense of trauma treatment. A revision of AR-DRG used for trauma is needed. WHAT IS KNOWN ABOUT THIS TOPIC? Severely injured trauma patients often have multiple injuries, in more than one body region and the determination of appropriate AR-DRG can be difficult. Pilot research suggests that the AR-DRG do not accurately represent the care that is required for these patients. WHAT DOES THIS PAPER ADD? This is the first multicentre analysis of treatment costs and coding variance for major trauma in Australia. This research identifies the limitations of the current AR-DRGS and those that are particularly problematic. The value of linking trauma registry and financial data within each trauma centre is demonstrated. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Further work should be conducted between trauma services, clinical coding and finance departments to improve the accuracy of clinical coding, review funding models and ensure that AR-DRG allocation is commensurate with the expense of trauma treatment.

[Chest Injury and its Surgical Treatment in Polytrauma Patients. Five-Year Experience].

PubMed

Vodička, J; Doležal, J; Vejvodová, Š; Šafránek, J; Špidlen, V; Třeška, V

2016-01-01

PURPOSE OF THE STUDY Thoracic trauma, one of the most frequent injuries in patients with multiple traumata, is found in 50 to 80% of these patients and it is crucial for the patient's prognosis. It accounts for 25% of all death from polytraumatic injuries. The aim of this retrospective study was an analysis of the occurrence of chest injuries in polytrauma patients and their surgical treatment in the Trauma Centre or Department of Surgery of the University Hospital Pilsen in a five-year period. MATERIAL AND METHODS Patients with injuries meeting the definition of polytrauma and an Injury Severity Score (ISS) ≥16 were included. The demographic characteristics, mechanism of multiple trauma, ISS value and chest injury were recorded in each patient. The number of injured patients in each year of the study was noted. In the patients with chest injury, the type of injury and method of treatment were assessed. The therapy was further analysed including its timing. The number of deaths due to polytrauma involving chest injury, the cause of death and its time in relation to the patient's admission to the Trauma Centre were evaluated. RESULTS In the period 2010-14, 513 polytrauma patients were treated; of them 371 (72.3%) were men with an average age of 40.5 years. The most frequent cause of injury was a traffic accident (74%). The average ISS of the whole group was 35 points. Chest injury was diagnosed in 469 patients (91.4%) of whom only five (1.1%) had penetrating injury. Pulmonary contusion was most frequent (314 patients; 67%). A total of 212 patients with chest injury underwent surgery (45.2%); urgent surgery was performed in 143 (67.5%), acute surgery in 49 (23.1%) and delayed surgery in 63 (29.7%) patients. Chest drainage was the major surgical procedure used in the whole group. Of 61 patients who died, 52 had chest injury. In this subgroup the most frequent cause of death was decompensated traumatic shock (26 patients; 50%). In the whole group, 32 polytrauma patients died within 24 hours of injury (61.5%). CONCLUSIONS Chest injury, almost always blunt, is often diagnosed in polytrauma patients. A prevalent cause of multiple trauma is a traffic accident. Chest injury most frequently involves pulmonary contusion. Nearly half of chest injuries require surgery, of which 2/3 are urgent procedures. The procedure most frequently performed in polytrauma patients with chest injury is chest drainage and this is also a sufficient procedure in 75% of surgically treated patients. polytrauma, chest injury, pulmonary contusion, surgical treatment, chest drainage.

Comparison of trauma care systems in Asian countries: A systematic literature review.

PubMed

Choi, Se Jin; Oh, Moon Young; Kim, Na Rae; Jung, Yoo Joong; Ro, Young Sun; Shin, Sang Do

2017-12-01

The study aims to compare the trauma care systems in Asian countries. Asian countries were categorised into three groups; 'lower middle-income country', 'upper middle-income country' and 'high-income country'. The Medline/PubMed database was searched for articles published from January 2005 to December 2014 using relevant key words. Articles were excluded if they examined a specific injury mechanism, referred to a specific age group, and/or did not have full text available. We extracted information and variables on pre-hospital and hospital care factors, and regionalised system factors and compared them across countries. A total of 46 articles were identified from 13 countries, including Pakistan, India, Vietnam and Indonesia from lower middle-income countries; the Islamic Republic of Iran, Thailand, China, Malaysia from upper middle-income countries; and Saudi Arabia, the Republic of Korea, Japan, Hong Kong and Singapore from high-income countries. Trauma patients were transported via various methods. In six of the 13 countries, less than 20% of trauma patients were transported by ambulance. Pre-hospital trauma teams primarily comprised emergency medical technicians and paramedics, except in Thailand and China, where they included mainly physicians. In Iran, Pakistan and Vietnam, the proportion of patients who died before reaching hospital exceeded 50%. In only three of the 13 countries was it reported that trauma surgeons were available. In only five of the 13 countries was there a nationwide trauma registry. Trauma care systems were poorly developed and unorganised in most of the selected 13 Asian countries, with the exception of a few highly developed countries. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

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

Survey of 2582 Cases of Acute Orthopedic Trauma

PubMed Central

Soleymanha, Mehran; Mobayen, Mohammadreza; Asadi, Kamran; Adeli, Alborz; Haghparast-Ghadim-Limudahi, Zahra

2014-01-01

Background: Orthopedic injuries are among the most common causes of mortality, morbidity, hospitalization, and economic burden in societies. Objectives: In this research, we study the prevalence of different types of trauma requiring orthopedic surgery. Patients and Methods: We conducted a cross-sectional study on 2582 patients with acute orthopedic injuries admitted to the orthopedic emergency ward at the Poursina Hospital (a referral center in Guilan province (northern Iran), during December 2010 through September 2011. Patients were examined and the data collection form was filled for each patient. Data were analyzed by SPSS software version 19 and were listed in tables. Results: Of 2582 included cases, 1940 were male and 642 were female, with a mean age of 34.5 years. Most injuries were seen in the 25 to 44 year age group from rural areas. The highest frequency of trauma related to falls. On the other hand, bicycling and shooting had the lowest frequencies. There were 18 cases with limb amputation. Overall, 66.5% of patients had fractures, 5% had soft tissue lacerations, and 10% had dislocations. Conclusions: Identification of risk factors and methods of prevention is one of the most important duties of healthcare systems. Devising plans to minimize these risk factors and familiarizing people with them is prudent. PMID:25717444

Inpatients with gunshot wounds to the face.

PubMed

Sun, Gordon H; Patil, Yash J; Harmych, Brian M; Hom, David B

2012-01-01

Microvascular free tissue transfer (FTT) is an increasingly used method of reconstruction for traumatic defects of the head and neck. We describe the immediate management, FTT reconstruction techniques, and outcomes of 6 individuals who sustained maxillofacial gunshot trauma and were treated at a single tertiary-care level I trauma center. All 6 patients were white men with a mean age of 33 years. The mandible, nose, and orbital contents were the most frequently affected critical structures. All patients initially underwent primary wound debridement and tracheostomy, with concurrent maxillomandibular wire fixation and/or midface or mandible plate fixation in 5 patients. The mean time from injury to definitive FTT was 38 days. Five patients underwent fibula osteocutaneous FTT and 1 underwent radial forearm fasciocutaneous FTT. One patient also underwent concurrent local tissue rearrangement and pedicled flap surgery for nasal reconstruction. The mean hospital length of stay after FTT was 6 days. All FTT survived without necrosis. Oral incompetence and poor cosmesis from undesirable scarring patterns were the most common long-term complications. In summary, successful reconstruction of head and neck defects caused by gunshot trauma begins with airway stabilization, wound management, and bony fracture reduction and fixation. Definitive microvascular FTT is a useful method of repairing traumatic head and neck defects, although long-term functional and cosmetic complications may still occur.

A comparative approach to deep vein thrombosis risk assessment.

PubMed

Hums, Wendy; Blostein, Paul

2006-01-01

Trauma patients are at risk for developing DVT/PE. The Bronson Trauma Model incorporates a DVT scoring system into the daily routine for all injured patients admitted to the Trauma Care Unit. Dr Paul Blostein added the DVT Risk Assessment spreadsheet to his personal digital assistant and made it available to other members of the team to allow calculation of a patient's DVT risk percentage during daily multidisciplinary rounds in the Trauma Care Unit. The Trauma Program has found the incorporation of the scoring systems into the trauma registry to be a value-added component of our performance improvement process. Bronson's unique model of trauma care, where patients are admitted and discharged from the same room, combined with today's technology of wireless laptops and personal digital assistants, promotes a progressive approach to DVT/PE prophylaxis and performance improvement. Our trauma follow-up program has proven to be effective in reintegrating patients back into the trauma system to optimize their functional status and improve their outcome.

Post-Traumatic Stress Disorder (PDQ)

MedlinePlus

... with post-traumatic stress need early treatment with methods that are used to treat other trauma victims. ... symptoms of post-traumatic stress. The crisis intervention method aims to relieve distress and help the patient ...

Epidemiology of Bone Fracture in Female Trauma Patients Based on Risks of Osteoporosis Assessed using the Osteoporosis Self-Assessment Tool for Asians Score

PubMed Central

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

2017-01-01

Background: Osteoporotic fractures are defined as low-impact fractures resulting from low-level trauma. However, the exclusion of high-level trauma fractures may result in underestimation of the contribution of osteoporosis to fractures. In this study, we aimed to investigate the fracture patterns of female trauma patients with various risks of osteoporosis based on the Osteoporosis Self-Assessment Tool for Asians (OSTA) score. Methods: According to the data retrieved from the Trauma Registry System of a Level I trauma center between 1 January 2009 and 31 December 2015, a total of 6707 patients aged ≥40 years and hospitalized for the treatment of traumatic bone fracture were categorized as high-risk (OSTA < −4, n = 1585), medium-risk (−1 ≥ OSTA ≥ −4, n = 1985), and low-risk (OSTA > −1, n = 3137) patients. Two-sided Pearson’s, chi-squared, or Fisher’s exact tests were used to compare categorical data. Unpaired Student’s t-test and Mann–Whitney U-test were used to analyze normally and non-normally distributed continuous data, respectively. Propensity-score matching in a 1:1 ratio was performed with injury mechanisms as adjusted variables to evaluate the effects of OSTA-related grouping on the fracture patterns. Results: High- and medium-risk patients were significantly older, had higher incidences of comorbidity, and were more frequently injured from a fall and bicycle accident than low-risk patients did. Compared to low-risk patients, high- and medium-risk patients had a higher injury severity and mortality. In the propensity-score matched population, the incidence of fractures was only different in the extremity regions between high- and low-risk patients as well as between medium- and low-risk patients. The incidences of femoral fractures were significantly higher in high-risk (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.73–4.24; p < 0.001) and medium-risk patients (OR, 1.4; 95% CI, 1.24–1.54; p < 0.001) than in low-risk patients. In addition, high-risk patients had significantly lower odds of humeral, radial, patellar, and tibial fractures; however, such lower odds were not found in medium- risk than low-risk patients. Conclusions: The fracture patterns of female trauma patients with high- and medium-risk osteoporosis were different from that of low-risk patients exclusively in the extremity region. PMID:29137199

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.

[The Academy of Trauma Surgery (AUC). Service provider and management organization of the DGU].

PubMed

Sturm, J A; Hoffmann, R

2016-02-01

At the beginning of this century the German Trauma Society (DGU) became extensively active with an initiative on quality promotion, development of quality assurance and transparency regarding treatment of the severely injured. A white book on "Medical care of the severely injured" was published, focusing on the requirements on structural quality and especially procedural quality. The impact of the white book was immense and a trauma network with approved trauma centers, structured and graded for their individual trauma care performance, was developed. In order to monitor and document the required quality of care, a registry was needed. Furthermore, for cooperation within the trauma networks innovative methods for digital transfer of radiological images and patient documents became necessary. Finally, the auditing criteria for trauma centers had and still have to be completed with advanced medical education and training programs. In order to realize the implementation of such a broad spectrum of economically relevant and increasingly complex activities the Academy of Trauma Surgery (AUC) was established as a subsidiary of the DGU in 2004. The AUC currently has four divisions: 1) networks and health care structures, 2) registries and research management, 3) telemedicine, 4) medical education and training, all of which serve the goal of the initiative. The AUC is a full service provider and management organization in compliance with the statutes of the DGU. According to these statutes the business operations of the AUC also cover projects for numerous groups of patients, projects for the joint society the German Society for Orthopedics and Trauma (DGOU) as well as other medical institutions. This article describes the success stories of the trauma network (TraumaNetzwerk DGU®), the TraumaRegister DGU®, the telecooperation platform TKmed®, the new and fast-growing orthogeriatric center initiative (AltersTraumaZentrum DGU®) and the division of medical education and training, e.g. advanced trauma life support (ATLS®) and other training programs including the innovative interpersonal competence (IC) course.

Seven Deadly Sins in Trauma Outcomes Research: An Epidemiologic Post-Mortem for Major Causes of Bias

PubMed Central

del Junco, Deborah J.; Fox, Erin E.; Camp, Elizabeth A.; Rahbar, Mohammad H.; Holcomb, John B.

2013-01-01

Background Because randomized clinical trials (RCTs) in trauma outcomes research are expensive and complex, they have rarely been the basis for the clinical care of trauma patients. Most published findings are derived from retrospective and occasionally prospective observational studies that may be particularly susceptible to bias. The sources of bias include some common to other clinical domains, such as heterogeneous patient populations with competing and interdependent short- and long-term outcomes. Other sources of bias are unique to trauma, such as rapidly changing multi-system responses to injury that necessitate highly dynamic treatment regimes like blood product transfusion. The standard research design and analysis strategies applied in published observational studies are often inadequate to address these biases. Methods Drawing on recent experience in the design, data collection, monitoring and analysis of the 10-site observational PROMMTT study, seven common and sometimes overlapping biases are described through examples and resolution strategies. Results Sources of bias in trauma research include ignoring 1) variation in patients’ indications for treatment (indication bias), 2) the dependency of intervention delivery on patient survival (survival bias), 3) time-varying treatment, 4) time-dependent confounding, 5) non-uniform intervention effects over time, 6) non-random missing data mechanisms, and 7) imperfectly defined variables. This list is not exhaustive. Conclusion The mitigation strategies to overcome these threats to validity require epidemiologic and statistical vigilance. Minimizing the highlighted types of bias in trauma research will facilitate clinical translation of more accurate and reproducible findings and improve the evidence-base that clinicians apply in their care of injured patients. PMID:23778519

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

The experience of linking Victorian emergency medical service trauma data

PubMed Central

Boyle, Malcolm J

2008-01-01

Background The linking of a large Emergency Medical Service (EMS) dataset with the Victorian Department of Human Services (DHS) hospital datasets and Victorian State Trauma Outcome Registry and Monitoring (VSTORM) dataset to determine patient outcomes has not previously been undertaken in Victoria. The objective of this study was to identify the linkage rate of a large EMS trauma dataset with the Department of Human Services hospital datasets and VSTORM dataset. Methods The linking of an EMS trauma dataset to the hospital datasets utilised deterministic and probabilistic matching. The linking of three EMS trauma datasets to the VSTORM dataset utilised deterministic, probabilistic and manual matching. Results There were 66.7% of patients from the EMS dataset located in the VEMD. There were 96% of patients located in the VAED who were defined in the VEMD as being admitted to hospital. 3.7% of patients located in the VAED could not be found in the VEMD due to hospitals not reporting to the VEMD. For the EMS datasets, there was a 146% increase in successful links with the trauma profile dataset, a 221% increase in successful links with the mechanism of injury only dataset, and a 46% increase with sudden deterioration dataset, to VSTORM when using manual compared to deterministic matching. Conclusion This study has demonstrated that EMS data can be successfully linked to other health related datasets using deterministic and probabilistic matching with varying levels of success. The quality of EMS data needs to be improved to ensure better linkage success rates with other health related datasets. PMID:19014622

Pancreatic trauma: Universities of Melbourne HPB Group.

PubMed

Fleming, W R; Collier, N A; Banting, S W

1999-05-01

Pancreatic trauma is uncommon, but carries high morbidity and mortality rates, especially when diagnosis is delayed or inappropriate surgery is attempted. Although the retroperitoneal position of the pancreas confers it some immunity to injury, the force required to do so often results in severe associated injuries to other organs, which may be life threatening. Diagnosis may be difficult and surgery can be a considerable technical challenge. All patients with pancreatic trauma who attended one of three Melbourne teaching hospitals from 1977 to 1998 were identified. Injuries were graded and the method of diagnosis and treatment studied. The incidence and causation of postoperative morbidity and mortality was identified. Thirty-eight patients (26 men and 12 women) were studied. Blunt trauma was responsible in 30 patients, stab wounds in five, gunshot wounds in two and iatrogenic injury in one. Injuries to other organs occurred in 30 patients. Surgical procedures were undertaken in 34 patients, resulting in the death of five and complications in 25. Complications and death are related to the associated injuries, as much as to the pancreatic injury itself. In this study, we review the experience of the management of pancreatic trauma in three large teaching hospitals in Melbourne over a 21-year period, and suggest a strategy for dealing with these difficult patients. Adherence to the basic concepts of control of bleeding from associated vascular injury, minimization of contamination, accurate pancreatic assessment, judicious resection and adequate drainage can diminish the risk. By approaching the problem in a systematic way and adopting a generally conservative management plan, complications and deaths can be minimized in these complex cases.

The relationship between childhood trauma and adult psychosis in a UK Early Intervention Service: results of a retrospective case note study.

PubMed

Reeder, Francesca D; Husain, Nusrat; Rhouma, Abdul; Haddad, Peter M; Munshi, Tariq; Naeem, Farooq; Khachatryan, Davit; Chaudhry, Imran B

2017-01-01

There is evidence that childhood trauma is a risk factor for the development of psychosis and it is recommended that childhood trauma is inquired about in all patients presenting with psychosis. This study aimed to determine the prevalence of childhood trauma in patients in the UK Early Intervention Service based on a case note review. This is a retrospective case note study of 296 patients in an UK Early Intervention Service. Trauma history obtained on service entry was reviewed and trauma experienced categorized. Results were analyzed using crosstab and frequency analysis. The mean age of the sample was 24 years, 70% were male, 66% were White, and 23% Asian (ethnicity not documented in 11% of the sample). Approximately 60% of patients reported childhood trauma, 21% reported no childhood trauma, and data were not recorded for the remaining 19%. Among those reporting trauma, the prevalence of most frequently reported traumas were: severe or repeated disruption (21%), parental mental illness (19%), bullying (18%), absence of a parent (13%), and 'other' trauma (24%) - the majority of which were victimization events. Sixty-six percent of those reporting trauma had experienced multiple forms of trauma. A high prevalence of childhood trauma (particularly trauma related to the home environment or family unit) was reported. This is consistent with other studies reporting on trauma and psychosis. The main weakness of the study is a lack of a control group reporting experience of childhood trauma in those without psychosis. Guidelines recommend that all patients with psychosis are asked about childhood trauma; but in 19% of our sample there was no documentation that this had been done indicating the need for improvement in assessment.

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

The Incidence of Fever in US Critical Care Air Transport Team Combat Trauma Patients Evacuated from the Theater between March 2009 and March 2010

DTIC Science & Technology

2013-11-01

THE INCIDENCE OF FEVER IN US CRITICAL CARE AIR TRANSPORT TEAM COMBAT TRAUMA PATIENTS EVACUATED FROM THE THEATER BETWEEN MARCH 2009 AND MARCH 2010...Critical Care Air Transport Teams (CCATTs). Fever after trauma is correlated with surgical complications and infection. The purposes of this study are...248 trauma patients met the inclusion criteria, and 101 trauma patients (40%) had fever . The mean age was 28 years, and 98% of patients were men. The

Should air medical patients be transferred on helipad or trauma bay?

PubMed

Lehrfeld, David; Gemignani, Robert; Shiroff, Adam; Kuhlmann, Sarah; Ohman-Strickland, Pamela; Merlin, Mark A

2013-01-01

Helicopter emergency medical services (HEMS) are widely used in regional trauma care and present unique challenges in the patient handoff process. In particular, the practice of patient handoff on the landing zone versus the trauma bay does not exist in ground emergency medical services. We hypothesized that patients handed off on the landing zone versus the trauma bay would have different patient characteristics and outcomes. A retrospective review identified 305 HEMS trauma patients received at our level 1 trauma center over a 3-year period. Patients were sorted on the basis of the handoff location, (landing zone vs. trauma bay) and assessed for predictors of injury severity including the Revised Trauma Score, the Injury Severity Score, the Trauma and Injury Severity Score, and other outcomes, primarily mortality. Of the 305 patients, 235 (77%) were handed off in the bay, and 70 (23%) were not. Regarding the characteristics of patients who were handed off in the bay, they were more likely to have hypotension (100% vs. 73%), have a lower O(2) saturation level (97.9 vs. 99.4), and a lower Glasgow Coma Scale at the scene (10.9 vs. 13.9.). When controlling for injury severity, the odds of survival for patients who were handed off in the bay were 11.06 times the odds for patients who were not handed off in the bay. In this limited study, we found that HEMS did identify the sickest patients and brought them to the trauma bay. Despite their greater injury severity, the patients handed off in the bay fared better than those handed off on the landing zone. Copyright © 2013 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.

Implementation of Cognitive Therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample☆

PubMed Central

Ehlers, Anke; Grey, Nick; Wild, Jennifer; Stott, Richard; Liness, Sheena; Deale, Alicia; Handley, Rachel; Albert, Idit; Cullen, Deborah; Hackmann, Ann; Manley, John; McManus, Freda; Brady, Francesca; Salkovskis, Paul; Clark, David M.

2013-01-01

Objective Trauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area. Method A consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects. Results CT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience. Conclusions The results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas. PMID:24076408

Predictors of "occult" intra-abdominal injuries in blunt trauma patients.

PubMed

Parreira, José Gustavo; Malpaga, Juliano Mangini Dias; Olliari, Camilla Bilac; Perlingeiro, Jacqueline A G; Soldá, Silvia C; Assef, José Cesar

2015-01-01

to assess predictors of intra-abdominal injuries in blunt trauma patients admitted without abdominal pain or abnormalities on the abdomen physical examination. We conducted a retrospective analysis of trauma registry data, including adult blunt trauma patients admitted from 2008 to 2010 who sustained no abdominal pain or abnormalities on physical examination of the abdomen at admission and were submitted to computed tomography of the abdomen and/or exploratory laparotomy. Patients were assigned into: Group 1 (with intra-abdominal injuries) or Group 2 (without intra-abdominal injuries). Variables were compared between groups to identify those significantly associated with the presence of intra-abdominal injuries, adopting p<0.05 as significant. Subsequently, the variables with p<0.20 on bivariate analysis were selected to create a logistic regression model using the forward stepwise method. A total of 268 cases met the inclusion criteria. Patients in Group I were characterized as having significantly (p<0.05) lower mean AIS score for the head segment (1.0 ± 1.4 vs. 1.8 ± 1.9), as well as higher mean AIS thorax score (1.6 ± 1.7 vs. 0.9 ± 1.5) and ISS (25.7 ± 14.5 vs. 17,1 ± 13,1). The rate of abdominal injuries was significantly higher in run-over pedestrians (37.3%) and in motorcyclists (36.0%) (p<0.001). The resultant logistic regression model provided 73.5% accuracy for identifying abdominal injuries. The variables included were: motorcyclist accident as trauma mechanism (p<0.001 - OR 5.51; 95%CI 2.40-12.64), presence of rib fractures (p<0.003 - OR 3.00; 95%CI 1.47-6.14), run-over pedestrian as trauma mechanism (p=0.008 - OR 2.85; 95%CI 1.13-6.22) and abnormal neurological physical exam at admission (p=0.015 - OR 0.44; 95%CI 0.22-0.85). Intra-abdominal injuries were predominantly associated with trauma mechanism and presence of chest injuries.

Prevalence of sacral dysmorphia in a prospective trauma population: Implications for a "safe" surgical corridor for sacro-iliac screw placement

PubMed Central

2011-01-01

Background Percutaneous sacro-iliac (SI) screw fixation represents a widely used technique in the management of unstable posterior pelvic ring injuries and sacral fractures. The misplacement of SI-screws under fluoroscopic guidance represents a critical complication for these patients. This study was designed to determine the prevalence of sacral dysmorphia and the radiographic anatomy of surgical S1 and S2 corridors in a representative trauma population. Methods Prospective observational cohort study on a consecutive series of 344 skeletally mature trauma patients of both genders enrolled between January 1, 2007, to September 30, 2007, at a single academic level 1 trauma center. Inclusion criteria included a pelvic CT scan as part of the initial diagnostic trauma work-up. The prevalence of sacral dysmorphia was determined by plain radiographic pelvic films and CT scan analysis. The anatomy of sacral corridors was analyzed on 3 mm reconstruction sections derived from multislice CT scan, in the axial, coronal, and sagittal plane. "Safe" potential surgical corridors at S1 and S2 were calculated based on these measurements. Results Radiographic evidence of sacral dysmorphia was detected in 49 patients (14.5%). The prevalence of sacral dysmorphia was not significantly different between male and female patients (12.2% vs. 19.2%; P = 0.069). In contrast, significant gender-related differences were detected with regard to radiographic analysis of surgical corridors for SI-screw placement, with female trauma patients (n = 99) having significantly narrower corridors at S1 and S2 in all evaluated planes (axial, coronal, sagittal), compared to male counterparts (n = 245; P < 0.01). In addition, the mean S2 body height was higher in dysmorphic compared to normal sacra, albeit without statistical significance (P = 0.06), implying S2 as a safe surgical corridor of choice in patients with sacral dysmorphia. Conclusions These findings emphasize a high prevalence of sacral dysmorphia in a representative trauma population and imply a higher risk of SI-screw misplacement in female patients. Preoperative planning for percutaneous SI-screw fixation for unstable pelvic and sacral fractures must include a detailed CT scan analysis to determine the safety of surgical corridors. PMID:21569232

Dissociative symptoms are associated with reduced neuropsychological performance in patients with recurrent depression and a history of trauma exposure

PubMed Central

Frewen, Paul A.; Oremus, Carolina; Lanius, Ruth A.; McKinnon, Margaret C.

2016-01-01

Background Although preliminary work suggests that dissociative symptoms may impact neuropsychological performance in trauma-exposed populations, the relation between dissociation and cognitive performance has not been explored in patients with depression. Objective The present study examined dissociative symptoms in relation to neuropsychological performance in participants with a primary diagnosis of recurrent major depressive disorder (MDD) and a history of trauma exposure. Method Twenty-three participants with MDD and 20 healthy controls who did not differ in age, sex, education, or IQ were assessed. In addition to a standardized neuropsychological battery assessing frontotemporally mediated cognitive processes, participants completed clinical measures assessing dissociative symptoms, illness severity, and past history of trauma exposure. Results Among participants with MDD, greater severity of derealization was associated with reduced performance on measures of delayed visuospatial recall and recognition on a task of verbal memory recognition. In addition, more severe depersonalization was associated with slower processing speed and a response style lending itself toward better performance in a less active environment. Conclusions These findings point toward dissociative symptoms as a transdiagnostic factor associated with neuropsychological dysfunction in patients with depression and a history of trauma. Limitations and recommendations for future research are discussed. PMID:26927902

Epidemiology of Pelvic Ring Fractures in a Level 1 Trauma Center in the Netherlands

PubMed Central

Biert, Jan; Edwards, Michael John Richard

2017-01-01

Purpose This study was conducted to study the epidemiology, classification, treatment and outcome of a large patient group with pelvic ring injury in a level 1 trauma center in the Netherlands. Materials and Methods In the period of 2004 to 2014, we encountered 537 patients with a pelvic fracture. Many of them are due to a high energy trauma and therefore many concomitant injuries are observed. Tile A fractures were seen in 137 patients (25.5%), Tile B fractures in 211 (39.3%) and Tile C fractures in 189 patients (35.2%). Results Patients with unstable fracture types (Tile B1 and B3, Tile C) had significantly higher injury severity score, transfusion rates, need for laparotomy and definitive operative stabilization and complication rate. However, mortality did not differ significantly among Tile A, B or C fractures. Conclusion Overall outcome was good with a mortality rate of 13.6%, which is comparable with other rAelpmorotsst. half of the patients treated could directly be dismissed to their own homes. PMID:29250500

A Hybrid Web-Based and In-Person Self-Management Intervention to Prevent Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): Protocol for a Pilot Single-Blind Randomized Controlled Trial

PubMed Central

2017-01-01

Background Acute pain frequently transitions to chronic pain after major lower extremity trauma (ET). Several modifiable psychological risk and protective factors have been found to contribute to, or prevent, chronic pain development. Some empirical evidence has shown that interventions, including cognitive and behavioral strategies that promote pain self-management, could prevent chronic pain. However, the efficacy of such interventions has never been demonstrated in ET patients. We have designed a self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma). Objective This pilot randomized controlled trial (RCT) aims to evaluate the feasibility and research methods of the intervention, as well as the potential effects of iPACT-E-Trauma, on pain intensity and pain interference with daily activities. Methods A 2-arm single-blind pilot RCT will be conducted. Participants will receive the iPACT-E-Trauma intervention (experimental group) or an educational pamphlet (control group) combined with usual care. Data will be collected at baseline, during iPACT-E-Trauma delivery, as well as at 3 and 6 months post-injury. Primary outcomes are pain intensity and pain interference with daily living activities at 6 months post-injury. Secondary outcomes are pain self-efficacy, pain acceptance, pain catastrophizing, pain-related fear, anxiety and depression symptoms, health care service utilization, and return to work. Results Fifty-three patients were recruited at the time of manuscript preparation. Comprehensive data analyses will be initiated in July 2017. Study results are expected to be available in 2018. Conclusions Chronic pain is an important problem after major lower ET. However, no preventive intervention has yet been successfully proven in these patients. This study will focus on developing a feasible intervention to prevent acute to chronic pain transition in the context of ET. Findings will allow for the refinement of iPACT-E-Trauma and methodological parameters in prevision of a full-scale multi-site RCT. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6rR8G2vMs) PMID:28652226

Usage of Riot Control Agents and other methods resulting in physical and psychological injuries sustained during civil unrest in Turkey in 2013.

PubMed

Unuvar, Umit; Yilmaz, Deniz; Ozyildirim, Ilker; Dokudan, Erenc Y; Korkmaz, Canan; Doğanoğlu, Senem; Kutlu, Levent; Fincanci, Sebnem Korur

2017-01-01

Turkey has experienced a wave of demonstrations in the summer of 2013, called Gezi Park Demonstrations. Between 31 May and 30 August, 297 people who had been subjected to trauma by several methods of demonstration control and Riot Control Agents applied to the Human Rights Foundation of Turkey Rehabilitation Centers to receive treatment/rehabilitation and/or documentation. 296 patients except one 5-year-old child were included in the study. Of the 296 patients; 175 were male, 120 were female, and one was a transgender individual. The highest number of applications was received by the Istanbul center with 216 patients. The mean age of applicants was 33.85, and the age range was 15-71 years. While 268 of applicants (91%) stated that they had been exposed to Riot Control Agents, 62 patients suffered only chemical exposure who had no other traumatic injuries whereas 234 patients suffered at least one blunt trauma injury. Blunt trauma injuries are due to being shot by gas canisters in 127 patients (43%), by plastic bullets in 31 patients (10%). 59 patients (20%) were severely beaten, and 30 patients (10%) were injured by pressurized cold water ejected by water cannons. Thirteen patients (4.4%) suffered injuries that caused loss of vision or eye. Psychiatric evaluations were carried out for 117 patients while 43% of them were diagnosed with Acute Stress Disorder. Post Traumatic Stress Disorder and Major Depressive Disorder followed this diagnosis. This study includes the medical evaluation of injuries allegedly sustained during Gezi Park demonstrations in 2013 as a result of several methods of demonstration control and/or by being exposed to Riot Control Agents. The aim is to discuss different types of injuries due to those methods and health consequences of Riot Control Agents. Copyright © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

Characteristics and Management of Blunt Renal Injury in Children

PubMed Central

Ishida, Yuichi; Tyroch, Alan H.; Emami, Nader; McLean, Susan F.

2017-01-01

Background: Renal trauma in the pediatric population is predominately due to blunt mechanism of injury. Our purpose was to determine the associated injuries, features, incidence, management, and outcomes of kidney injuries resulting from blunt trauma in the pediatric population in a single level I trauma center. Methods: This was a retrospective chart and trauma registry review of all pediatric blunt renal injuries at a regional level I trauma center that provides care to injured adults and children. The inclusion dates were January 2001–June 2014. Results: Of 5790 pediatric blunt trauma admissions, 68 children sustained renal trauma (incidence: 1.2%). Only two had nephrectomies (2.9%). Five renal angiograms were performed, only one required angioembolization. Macroscopic hematuria rate was significantly higher in the high-grade injury group (47% vs. 16%; P = 0.031). Over half of the patients had other intra-abdominal injuries. The liver and spleen were the most frequently injured abdominal organs. Conclusion: Blunt renal trauma is uncommon in children and is typically of low American Association for the Surgery of Trauma injury grade. It is commonly associated with other intra-abdominal injuries, especially the liver and the spleen. The nephrectomy rate in pediatric trauma is lower compared to adult trauma. Most pediatric blunt renal injury can be managed conservatively by adult trauma surgeons. PMID:28855777

The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma

PubMed Central

Chou, Yi-Pin; Kuo, Liang-Chi; Soo, Kwan-Ming; Tarng, Yih-Wen; Chiang, Hsin-I.; Huang, Fong-Dee; Lin, Hsing-Lin

2014-01-01

OBJECTIVES Retained haemothorax and pneumothorax are the most common complications after blunt chest traumas. Lung lacerations derived from fractures of the ribs are usually found in these patients. Video-assisted thoracoscopic surgery (VATS) is usually used as a routine procedure in the treatment of retained pleural collections. The objective of this study was to find out if there is any advantage in adding the procedure for repairing lacerated lungs during VATS. METHODS Patients who were brought to our hospital with blunt chest trauma were enrolled into this prospective cohort study from January 2004 to December 2011. All enrolled patients had rib fractures with type III lung lacerations diagnosed by CT scans. They sustained retained pleural collections and surgical drainage was indicated. On one group, only evacuation procedure by VATS was performed. On the other group, not only evacuations but also repair of lung injuries were performed. Patients with penetrating injury or blunt injury with massive bleeding, that required emergency thoracotomy, were excluded from the study, in addition to those with cardiovascular or oesophageal injuries. RESULTS During the study period, 88 patients who underwent thoracoscopy were enrolled. Among them, 43 patients undergoing the simple thoracoscopic evacuation method were stratified into Group 1. The remaining 45 patients who underwent thoracoscopic evacuation combined with resection of lung lacerations were stratified into Group 2. The rates of post-traumatic infection were higher in Group 1. The durations of chest-tube drainage and ventilator usage were shorter in Group 2, as were the lengths of patient intensive care unit stay and hospital stay. CONCLUSIONS When compared with simple thoracoscopic evacuation methods, repair and resection of the injured lungs combined may result in better clinical outcomes in patients who sustained blunt chest injuries. PMID:24242850

Childhood trauma in Chronic Fatigue Syndrome: focus on personality disorders and psychopathology.

PubMed

Sáez-Francàs, Naia; Calvo, Natalia; Alegre, José; Castro-Marrero, Jesús; Ramírez, Nicolás; Hernández-Vara, Jorge; Casas, Miguel

2015-10-01

Personality Disorders (PDs) and childhood traumatic experiences have been considered risk factors for Chronic Fatigue Syndrome (CFS). However, the relationship between these factors and their associated psychopathological impact has not been explored in this population. This study was designed to evaluate the association between different childhood traumas and the presence and number of PDs and current psychopathology in a sample of CFS patients. For this purpose, 166 CFS patients were evaluated with the Personality Diagnostic Questionnaire-4+ (PDQ-4+) and the Child Trauma Questionnaire. Other instruments were used to assess the associated psychopathology and the impact of fatigue. Of the total sample, 55 (33.1%) presented childhood trauma, the most frequent of which were emotional neglect (21.7%) and emotional abuse (18.1%). Considering PD presence, 79 (47.6%) patients presented some PD. There were no differences in frequency of physical childhood trauma in patients with and without PD. However, patients with PD had more frequently experienced emotional childhood trauma (OR=2.18, p=0.034). Severity of childhood trauma was related to a higher number of PDs, more severe depressive symptoms (p=0.025) and suicide risk (p=0.001). Patients with PD and any childhood trauma presented more severe depressive and irritable symptoms and a higher suicide risk than those without any PD and non-childhood traumatic event. These patients' psychopathological symptoms were similar to those of patients with childhood trauma and without PD. These results suggest that emotional childhood trauma but not physical childhood trauma is related to higher frequency of PD presence. More severe childhood emotional and physical traumas are related to a higher number of PDs and to more severe psychopathological symptoms. Copyright © 2015 Elsevier Inc. All rights reserved.

Academic time at a level 1 trauma center: no resident, no problem?

PubMed

Matsushima, Kazuhide; Dickinson, Rebecca M; Schaefer, Eric W; Armen, Scott B; Frankel, Heidi L

2012-01-01

Globally, the compliance of resident work-hour restrictions has no impact on trauma outcome. However, the effect of protected education time (PET), during which residents are unavailable to respond to trauma patients, has not been studied. We hypothesized that PET has no impact on the outcome of trauma patients. We conducted a retrospective review of relevant patients at an academic level I trauma center. During PET, a trauma attending and advanced practice providers (APPs) responded to trauma activations. PGY1, 3, and 4 residents were also available at all other times. The outcome of new trauma patient activations during Thursday morning 3-hours resident PET was compared with same time period on other weekdays (non-PET) using a univariate and multivariate analysis. From January 2005 to April 2010, a total of 5968 trauma patients were entered in the registry. Of these, 178 patients (2.98%) were included for study (37 PET and 141 non-PET). The mean injury severity score (ISS) was 16.2. Although no significant difference were identified in mortality, complications, or length of stay (LOS), we do see that length of emergency department stay (ED-LOS) tends to be longer during PET, although not significantly (314 vs 381 minutes, p = 0.74). On the multiple logistic regression model, PET was not a significant factor of complications, LOS, or ED-LOS. Few trauma activations occur during PET. New trauma activations can be staffed safely by trauma activations and APPs. However, there could be some delays in transferring patients to appropriate disposition. Additional study is required to determine the effect of PET on existing trauma inpatients. Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Specific abbreviated injury scale values are responsible for the underestimation of mortality in penetrating trauma patients by the injury severity score.

PubMed

Rowell, Susan E; Barbosa, Ronald R; Diggs, Brian S; Schreiber, Martin A; Holcomb, J B; Wade, C E; Brasel, K J; Vercruysse, G; MacLeod, J; Dutton, R P; Hess, J R; Duchesne, J C; McSwain, N E; Muskat, P; Johannigamn, J; Cryer, H M; Tillou, A; Cohen, M J; Pittet, J F; Knudson, P; De Moya, M A; Schreiber, M A; Tieu, B; Brundage, S; Napolitano, L M; Brunsvold, M; Sihler, K C; Beilman, G; Peitzman, A B; Zenait, M S; Sperry, J; Alarcon, L; Croce, M A; Minei, J P; Kozar, R; Gonzalez, E A; Stewart, R M; Cohn, S M; Mickalek, J E; Bulger, E M; Cotton, B A; Nunez, T C; Ivatury, R; Meredith, J W; Miller, P; Pomper, J; Marin, B

2011-08-01

The Injury Severity Score (ISS) is widely used as a method for rating severity of injury. The ISS is the sum of the squares of the three worst Abbreviated Injury Scale (AIS) values from three body regions. Patients with penetrating injuries tend to have higher mortality rates for a given ISS than patients with blunt injuries. This is thought to be secondary to the increased prevalence of multiple severe injuries in the same body region in patients with penetrating injuries, which the ISS does not account for. We hypothesized that the mechanism-based difference in mortality could be attributed to certain ISS ranges and specific AIS values by body region. Outcome and injury scoring data were obtained from transfused patients admitted to 23 Level I trauma centers. ISS values were grouped into categories, and a logistic regression model was created. Mortality for each ISS category was determined and compared with the ISS 1 to 15 group. An interaction term was added to evaluate the effect of mechanism. Additional logistic regression models were created to examine each AIS category individually. There were 2,292 patients in the cohort. An overall interaction between ISS and mechanism was observed (p = 0.049). Mortality rates between blunt and penetrating patients with an ISS between 25 and 40 were significantly different (23.6 vs. 36.1%; p = 0.022). Within this range, the magnitude of the difference in mortality was far higher for penetrating patients with head injuries (75% vs. 37% for blunt) than truncal injuries (26% vs. 17% for blunt). Penetrating trauma patients with an AIS head of 4 or 5, AIS abdomen of 3, or AIS extremity of 3 all had adjusted mortality rates higher than blunt trauma patients with those values. Significant differences in mortality between blunt and penetrating trauma patients exist at certain ISS and AIS category values. The mortality difference is greatest for head injured patients.

Barriers to compliance with evidence-based care in trauma.

PubMed

Rayan, Nadine; Barnes, Sunni; Fleming, Neil; Kudyakov, Rustam; Ballard, David; Gentilello, Larry M; Shafi, Shahid

2012-03-01

We have preciously demonstrated that trauma patients receive less than two-thirds of the care recommended by evidence-based medicine. The purpose of this study was to identify patients least likely to receive optimal care. Records of a random sample of 774 patients admitted to a Level I trauma center (2006-2008) with moderate to severe injuries (Abbreviated Injury Scale score ≥3) were reviewed for compliance with 25 trauma-specific processes of care (T-POC) endorsed by Advanced Trauma Life Support, Eastern Association for the Surgery of Trauma, the Brain Trauma Foundation, Surgical Care Improvement Project, and the Glue Grant Consortium based on evidence or consensus. These encompassed all aspects of trauma care, including initial evaluation, resuscitation, operative care, critical care, rehabilitation, and injury prevention. Multivariate logistic regression was used to identify patients likely to receive recommended care. Study patients were eligible for a total of 2,603 T-POC, of which only 1,515 (58%) were provided to the patient. Compliance was highest for T-POC involving resuscitation (83%) and was lowest for neurosurgical interventions (17%). Increasing severity of head injuries was associated with lower compliance, while intensive care unit stay was associated with higher compliance. There was no relationship between compliance and patient demographics, socioeconomic status, overall injury severity, or daily volume of trauma admissions. Little over half of recommended care was delivered to trauma patients with moderate to severe injuries. Patients with increasing severity of traumatic brain injuries were least likely to receive optimal care. However, differences among patient subgroups are small in relation to the overall gap between observed and recommended care. II.

Vocal Cord Paralysis and Laryngeal Trauma in Cardiac Surgery

PubMed Central

Chen, Yung-Yuan; Chia, Yeo-Yee; Wang, Pa-Chun; Lin, Hsiu-Yen; Tsai, Chiu-Ling; Hou, Shaw-Min

2017-01-01

Background Cardiac surgery – associated iatrogenic laryngeal trauma is often overlooked. We investigated the risk factors of vocal cord paralysis in cardiac surgery. Methods Medical records were reviewed from 169 patients who underwent elective or emergency cardiac surgeries. Patients had transesophageal echocardiography (TEE) placed either under video fiberscopic image guidance (guided group) or blind placement (blind group). Routine postoperative otolaryngologist consultation with video laryngoscopic recording were performed. Results Vocal cord paralyses were found in 18 patients (10.7%; left-13, right-4, bilateral-1). The risk of vocal cord paralysis was associated with emergency operation [odds ratio, 97.5 (95% confidence interval [CI], 2.9 to 366), p = 0.01]. Use of fiberscope-guided TEE [odds ratio, 0.04 (95% CI 0.01 to 0.87), p = 0.04] can effectively reduce vocal cord injury. Conclusions Emergency cardiac surgery increased the risk of vocal cord paralysis. Fiberscope-guided TEE placement is recommended for all patients having cardiac surgery to decrease the risk of severe peri-operative laryngeal trauma. PMID:29167615

[Surgical tactics in duodenal trauma].

PubMed

Ivanov, P A; Grishin, A V

2004-01-01

Results of surgical treatment of 61 patients with injuries of the duodenum are analyzed. The causes of injuries were stab-incised wounds in 24 patients, missile wound -- in 7, closed abdominal trauma -- in 26, trauma of the duodenum during endoscopic papillosphincterotomy -- in 4. All the patients underwent surgery. Complications were seen in 32 (52.5%) patients, 21 patients died, lethality was 34.4%. Within the first 24 hours since the trauma 7 patients died due to severe combined trauma, blood loss, 54 patients survived acute period of trauma, including 28 patients after open trauma, 26 -- after closed and 4 -- after trauma of the duodenum during endoscopic papillosphincterotomy. Diagnostic and surgical policies are discussed. Results of treatment depending on kind and time of surgery are regarded. It is demonstrated that purulent complications due to retroperitoneal phlegmona, traumatic pancreatitis, pneumonia are the causes of significant number of unfavorable outcomes. Therefore, it is important to adequately incise and drainage infected parts of retroperitoneal fat tissue with two-lumen drainages. Decompression through duodenal tube is the effective procedure for prophylaxis of suture insufficiency and traumatic pancreatitis. Suppression of pancreatic and duodenal secretion with octreotid improves significantly surgical treatment results.

Deficits in reticuloendothelial humoral control mechanisms in patients after trauma.

PubMed

Scovill, W A; Saba, T M; Kaplan, J E; Bernard, H; Powers, S

1976-11-01

Plasma opsonic activity as expressed by an alpha-2-globulin which stimulates hepatic Kupffer cell phagocytosis, and thus modulates RES clearance, was determined in patients at varying intervals following whole-body trauma. Plasma opsonic activity decreased markedly following trauma in both nonsurviving (NS) and surviving (S) trauma patients as compared to an age- and sex-matched group of healthy volunteers. The initial post-traumatic hypoopsonemia (0-72 hr) was more severe (p less than 0.01) in nonsurviving patients than surviving patients. Survivors following trauma manifested restoration of opsonin levels with a definite transient rebound hyperopsonemia during the recovery phase (11-30 days); nonsurviving patients exhibited persistent systemic alpha-2-globulin opsonic deficiency. On the basis of previous animal and human studies, the presently observed humoral deficits following trauma in patients could contribute to impairment of reticuloendothelial Kupffer cell clearance of blood-borne particulate matter such as fibrin, damaged platelets, and other altered autologous tissue. The importance of post-trauma RES dysfunction to survival following severe injury warrants further investigation and clinical consideration.

Chronic consequences of acute injuries: worse survival after discharge.

PubMed

Shafi, Shahid; Renfro, Lindsay A; Barnes, Sunni; Rayan, Nadine; Gentilello, Larry M; Fleming, Neil; Ballard, David

2012-09-01

The Trauma Quality Improvement Program uses inhospital mortality to measure quality of care, which assumes patients who survive injury are not likely to suffer higher mortality after discharge. We hypothesized that survival rates in trauma patients who survive to discharge remain stable afterward. Patients treated at an urban Level I trauma center (2006-2008) were linked with the Social Security Administration Death Master File. Survival rates were measured at 30, 90, and 180 days and 1 and 2 years from injury among two groups of trauma patients who survived to discharge: major trauma (Abbreviated Injury Scale score ≥ 3 injuries, n = 2,238) and minor trauma (Abbreviated Injury Scale score ≤ 2 injuries, n = 1,171). Control groups matched to each trauma group by age and sex were simulated from the US general population using annual survival probabilities from census data. Kaplan-Meier and log-rank analyses conditional upon survival to each time point were used to determine changes in risk of mortality after discharge. Cox proportional hazards models with left truncation at the time of discharge were used to determine independent predictors of mortality after discharge. The survival rate in trauma patients with major injuries was 92% at 30 days posttrauma and declined to 84% by 3 years (p > 0.05 compared with general population). Minor trauma patients experienced a survival rate similar to the general population. Age and injury severity were the only independent predictors of long-term mortality given survival to discharge. Log-rank tests conditional on survival to each time point showed that mortality risk in patients with major injuries remained significantly higher than the general population for up to 6 months after injury. The survival rate of trauma patients with major injuries remains significantly lower than survival for minor trauma patients and the general population for several months postdischarge. Surveillance for early identification and treatment of complications may be needed for trauma patients with major injuries. Prognostic study, level III.

Backward Planning a Craniomaxillofacial Trauma Curriculum for the Surgical Workforce in Low-Resource Settings.

PubMed

Shaye, David A; Tollefson, Travis; Shah, Irfan; Krishnan, Gopal; Matic, Damir; Figari, Marcelo; Lim, Thiam Chye; Aniruth, Sunil; Schubert, Warren

2018-06-06

Trauma is a significant contributor to global disease, and low-income countries disproportionately shoulder this burden. Education and training are critical components in the effort to address the surgical workforce shortage. Educators can tailor training to a diverse background of health professionals in low-resource settings using competency-based curricula. We present a process for the development of a competency-based curriculum for low-resource settings in the context of craniomaxillofacial (CMF) trauma education. CMF trauma surgeons representing 7 low-, middle-, and high-income countries conducted a standardized educational curriculum development program. Patient problems related to facial injuries were identified and ranked from highest to lowest morbidity. Higher morbidity problems were categorized into 4 modules with agreed upon competencies. Methods of delivery (lectures, case discussions, and practical exercises) were selected to optimize learning of each competency. A facial injuries educational curriculum (1.5 days event) was tailored to health professionals with diverse training backgrounds who care for CMF trauma patients in low-resource settings. A backward planned, competency-based curriculum was organized into four modules titled: acute (emergent), eye (periorbital injuries and sight preserving measures), mouth (dental injuries and fracture care), and soft tissue injury treatments. Four courses have been completed with pre- and post-course assessments completed. Surgeons and educators from a diverse geographic background found the backward planning curriculum development method effective in creating a competency-based facial injuries (trauma) course for health professionals in low-resource settings, where contextual aspects of shortages of surgical capacity, equipment, and emergency transportation must be considered.

Blood culture gram stain, acridine orange stain and direct sensitivity-based antimicrobial therapy of bloodstream infection in patients with trauma.

PubMed

Behera, B; Mathur, P; Gupta, B

2010-01-01

The purpose of this study was to ascertain if the simple practice of Gram stain, acridine orange stain and direct sensitivity determination of positive blood culture bottles could be used to guide early and appropriate treatment in trauma patients with clinical suspicion of sepsis. The study also aimed to evaluate the error in interpreting antimicrobial sensitivity by direct method when compared to standard method and find out if specific antibiotic-organism combination had more discrepancies. Findings from consecutive episodes of blood stream infection at an Apex Trauma centre over a 12-month period are summarized. A total of 509 consecutive positive blood cultures were subjected to Gram staining. AO staining was done in BacT/ALERT-positive Gram-stain negative blood cultures. Direct sensitivity was performed from 369 blood culture broths, showing single type of growth in Gram and acridine orange staining. Results of direct sensitivity were compared to conventional sensitivity for errors. No 'very major' discrepancy was found in this study. About 5.2 and 1.8% minor error rates were noted in gram-positive and gram-negative bacteria, respectively, while comparing the two methods. Most of the discrepancies in gram-negative bacteria were noted in beta lactam - beta lactamase inhibitor combinations. Direct sensitivity testing was not reliable for reporting of methicillin and vancomycin resistance in Staphylococci. Gram stain result together with direct sensitivity testing is required for optimizing initial antimicrobial therapy in trauma patients with clinical suspicion of sepsis. Gram staining and AO staining proved particularly helpful in the early detection of candidaemia.

Effect of a brief intervention for alcohol and illicit drug use on trauma recidivism in a cohort of trauma patients.

PubMed

Cordovilla-Guardia, Sergio; Fernández-Mondéjar, Enrique; Vilar-López, Raquel; Navas, Juan F; Portillo-Santamaría, Mónica; Rico-Martín, Sergio; Lardelli-Claret, Pablo

2017-01-01

Estimate the effectiveness of brief interventions in reducing trauma recidivism in hospitalized trauma patients who screened positive for alcohol and/or illicit drug use. Dynamic cohort study based on registry data from 1818 patients included in a screening and brief intervention program for alcohol and illicit drug use for hospitalized trauma patients. Three subcohorts emerged from the data analysis: patients who screened negative, those who screened positive and were offered brief intervention, and those who screened positive and were not offered brief intervention. Follow-up lasted from 10 to 52 months. Trauma-free survival, adjusted hazard rate ratios (aHRR) and adjusted incidence rate ratios (aIRR) were calculated, and complier average causal effect (CACE) analysis was used. We found a higher cumulative risk of trauma recidivism in the subcohort who screened positive. In this subcohort, an aHRR of 0.63 (95% CI: 0.41-0.95) was obtained for the group offered brief intervention compared to the group not offered intervention. CACE analysis yielded an estimated 52% reduction in trauma recidivism associated with the brief intervention. The brief intervention offered during hospitalization in trauma patients positive for alcohol and/or illicit drug use can halve the incidence of trauma recidivism.

Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center?

PubMed

Benedict, Leo Andrew; Paulus, Jessica K; Rideout, Leslie; Chwals, Walter J

2014-01-01

To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging. A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry. A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score <14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%). The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging. © 2014.

Risk Factors for Venous Thromboembolism in Pediatric Trauma Patients and Validation of a Novel Scoring System: The Risk of Clots in Kids with Trauma (ROCKIT score)

PubMed Central

Yen, Jennifer; Van Arendonk, Kyle J.; Streiff, Michael B.; McNamara, LeAnn; Stewart, F. Dylan; Conner G, Kim G; Thompson, Richard E.; Haut, Elliott R.; Takemoto, Clifford M.

2017-01-01

OBJECTIVES Identify risk factors for venous thromboembolism (VTE) and develop a VTE risk assessment model for pediatric trauma patients. DESIGN, SETTING, AND PATIENTS We performed a retrospective review of patients 21 years and younger who were hospitalized following traumatic injuries at the John Hopkins level 1 adult and pediatric trauma center (1987-2011). The clinical characteristics of patients with and without VTE were compared, and multivariable logistic regression analysis was used to identify independent risk factors for VTE. Weighted risk assessment scoring systems were developed based on these and previously identified factors from patients in the National Trauma Data Bank (NTDB 2008-2010); the scoring systems were validated in this cohort from Johns Hopkins as well as a cohort of pediatric admissions from the NTDB (2011-2012). MAIN RESULTS Forty-nine of 17,366 pediatric trauma patients (0.28%) were diagnosed with VTE after admission to our trauma center. After adjusting for potential confounders, VTE was independently associated with older age, surgery, blood transfusion, higher Injury Severity Score (ISS), and lower Glasgow Coma Scale (GCS) score. These and additional factors were identified in 402,329 pediatric patients from the NTDB from 2008-2010; independent risk factors from the logistic regression analysis of this NTDB cohort were selected and incorporated into weighted risk assessment scoring systems. Two models were developed and were cross-validated in 2 separate pediatric trauma cohorts: 1) 282,535 patients in the NTDB from 2011 to 2012 2) 17,366 patients from Johns Hopkins. The receiver operator curve using these models in the validation cohorts had area under the curves that ranged 90% to 94%. CONCLUSIONS VTE is infrequent after trauma in pediatric patients. We developed weighted scoring systems to stratify pediatric trauma patients at risk for VTE. These systems may have potential to guide risk-appropriate VTE prophylaxis in children after trauma. PMID:26963757

Contributions of Risk and Protective Factors to Prediction of Psychological Symptoms after Traumatic Experiences

PubMed Central

Carlson, Eve B.; Palmieri, Patrick A.; Field, Nigel P.; Dalenberg, Constance J.; Macia, Kathryn S.; Spain, David A.

2016-01-01

Objective Traumatic experiences cause considerable suffering and place a burden on society due to lost productivity, increases in suicidality, violence, criminal behavior, and psychological disorder. The impact of traumatic experiences is complicated because many factors affect individuals’ responses. By employing several methodological improvements, we sought to identify risk factors that would account for a greater proportion of variance in later disorder than prior studies. Method In a sample of 129 traumatically injured hospital patients and family members of injured patients, we studied pre-trauma, time of trauma, and post-trauma psychosocial risk and protective factors hypothesized to influence responses to traumatic experiences and posttraumatic (PT) symptoms (including symptoms of PTSD, depression, negative thinking, and dissociation) two months after trauma. Results The risk factors were all significantly correlated with later PT symptoms, with post-trauma life stress, post-trauma social support, and acute stress symptoms showing the strongest relationships. A hierarchical regression, in which the risk factors were entered in 6 steps based on their occurrence in time, showed the risks accounted for 72% of the variance in later symptoms. Most of the variance in PT symptoms was shared among many risk factors, and pre-trauma and post-trauma risk factors accounted for the most variance. Conclusions Collectively, the risk factors accounted for more variance in later PT symptoms than in previous studies. These risk factors may identify individuals at risk for PT psychological disorders and targets for treatment. PMID:27423351

Colloid cyst mimicking intracranial hemorrhage after head trauma.

PubMed

Buyukkaya, Ayla; Buyukkaya, Ramazan; Özel, Mehmet Ali; Sarıtas, Ayhan

2015-02-01

Trauma patients consist vast majority of the patients who admit to emergency department, and most of them have a head trauma. A 58-year-old patient was taken to emergency department with head trauma, and a hyperdense lesion neighboring to third ventricle was detected. A diagnosis of colloid cyst was made in the patient who was being followed up for hemorrhage. In patients with head trauma, colloid cyst may easly be confused with intracranial hemorrhage due to hyperdensity. The aim of this report is to emphasize the importance of clinical thinking in the differential diagnosis of hyperdense lesion on computed tomography imaging of a patient with head injury.

[In-patient hypnotherapeutic trauma exposure for posttraumatic stress disorder: a case report].

PubMed

Elsig, Claudia; Schopper, Christian; Anthony, Marion; Gramigna, Ronald; Böker, Heinz

2002-03-01

This paper describes the treatment of a patient with the diagnoses of a borderline personality disorder and posttraumatic stress disorder (DSM-IV and ICD-10) within the setting of a psychiatric ward spezializing in depression. For purposes of controlled re-exposure to the patient's trauma, a hypnotherapeutic method was chosen. A significant reduction of symptoms, in particular the intrusions and the hyperarousal, was observed. Of great importance in the successful outcome of this case is the integration of hypnotherapy into a multi-dimensional treatment concept including group therapy, physical therapy and anxiety-reducing self-management therapy. This approach facilitated the development of trust and security in the patient required for the hypnotherapeutic intervention and minimized the splitting tendencies specific to borderline patients. Further discussion is centered on the difficulties arising in the context of an emergency ward setting with its high intensity atmosphere encompassing the danger of retraumatization of this special group of patients. Finally several aspects of the clinical implications of this method are addressed.

Benchmarking of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB).

PubMed

Haider, Adil H; Hashmi, Zain G; Gupta, Sonia; Zafar, Syed Nabeel; David, Jean-Stephane; Efron, David T; Stevens, Kent A; Zafar, Hasnain; Schneider, Eric B; Voiglio, Eric; Coimbra, Raul; Haut, Elliott R

2014-08-01

National trauma registries have helped improve patient outcomes across the world. Recently, the idea of an International Trauma Data Bank (ITDB) has been suggested to establish global comparative assessments of trauma outcomes. The objective of this study was to determine whether global trauma data could be combined to perform international outcomes benchmarking. We used observed/expected (O/E) mortality ratios to compare two trauma centers [European high-income country (HIC) and Asian lower-middle income country (LMIC)] with centers in the North American National Trauma Data Bank (NTDB). Patients (≥16 years) with blunt/penetrating injuries were included. Multivariable logistic regression, adjusting for known predictors of trauma mortality, was performed. Estimates were used to predict the expected deaths at each center and to calculate O/E mortality ratios for benchmarking. A total of 375,433 patients from 301 centers were included from the NTDB (2002-2010). The LMIC trauma center had 806 patients (2002-2010), whereas the HIC reported 1,003 patients (2002-2004). The most important known predictors of trauma mortality were adequately recorded in all datasets. Mortality benchmarking revealed that the HIC center performed similarly to the NTDB centers [O/E = 1.11 (95% confidence interval (CI) 0.92-1.35)], whereas the LMIC center showed significantly worse survival [O/E = 1.52 (1.23-1.88)]. Subset analyses of patients with blunt or penetrating injury showed similar results. Using only a few key covariates, aggregated global trauma data can be used to adequately perform international trauma center benchmarking. The creation of the ITDB is feasible and recommended as it may be a pivotal step towards improving global trauma outcomes.

[Advanced Trauma Life Support (ATLS) in the emergency room. Is it suitable as an SOP?].

PubMed

Shafizadeh, S; Tjardes, T; Steinhausen, E; Balke, M; Paffrath, T; Bouillon, B; Bäthis, H

2010-08-01

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient's physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

Does Mode of Transport Confer a Mortality Benefit in Trauma Patients? Characteristics and Outcomes at an Ontario Lead Trauma Hospital.

PubMed

Buchanan, Ian M; Coates, Angela; Sne, Niv

2016-09-01

Evidence-based guidelines regarding the optimal mode of transport for trauma patients from scene to trauma centre are lacking. The purpose of this study was to investigate the relationship between trauma patient outcomes and mode of transport at a single Ontario Level I Trauma Centre, and specifically to investigate if the mode of transport confers a mortality benefit. A historical, observational cohort study was undertaken to compare rotor-wing and ground transported patients. Captured data included demographics, injury severity, temporal and mortality variables. TRISS-L analysis was performed to examine mortality outcomes. 387 rotor-wing transport and 2,759 ground transport patients were analyzed over an 18-year period. Rotor-wing patients were younger, had a higher Injury Severity Score, and had longer prehospital transport times. Mechanism of injury was similarly distributed between groups. After controlling for heterogeneity with TRISS-L analysis, the mortality of rotor-wing patients was found to be lower than predicted mortality, whereas the converse was found with ground patients. Rotor-wing and ground transported trauma patients represent heterogeneous populations. Accounting for these differences, rotor-wing patients were found to outperform their predicted mortality, whereas ground patients underperformed predictions.

Detecting jaundice by using digital image processing

NASA Astrophysics Data System (ADS)

Castro-Ramos, J.; Toxqui-Quitl, C.; Villa Manriquez, F.; Orozco-Guillen, E.; Padilla-Vivanco, A.; Sánchez-Escobar, JJ.

2014-03-01

When strong Jaundice is presented, babies or adults should be subject to clinical exam like "serum bilirubin" which can cause traumas in patients. Often jaundice is presented in liver disease such as hepatitis or liver cancer. In order to avoid additional traumas we propose to detect jaundice (icterus) in newborns or adults by using a not pain method. By acquiring digital images in color, in palm, soles and forehead, we analyze RGB attributes and diffuse reflectance spectra as the parameter to characterize patients with either jaundice or not, and we correlate that parameters with the level of bilirubin. By applying support vector machine we distinguish between healthy and sick patients.

The influence of sex and trauma impact on the rupture site of the ulnar collateral ligament of the thumb

PubMed Central

Huf, Wolfgang; Rettl, Gregor; Dahm, Falko; Meznik, Alexander; Muschitz, Gabriela; Kitzinger, Hugo; Bukaty, Adam; Fialka, Christian; Vierhapper, Martin

2017-01-01

Purpose and hypothesis Although sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL. Methods This study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis. Results In total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9–90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site. Conclusions The results of this study demonstrate that with regression analysis both sex and trauma intensity allow to predict rupture site in UCL injuries. PMID:28738083

Missing data in trauma registries: A systematic review.

PubMed

Shivasabesan, Gowri; Mitra, Biswadev; O'Reilly, Gerard M

2018-03-30

Trauma registries play an integral role in trauma systems but their valid use hinges on data quality. The aim of this study was to determine, among contemporary publications using trauma registry data, the level of reporting of data completeness and the methods used to deal with missing data. A systematic review was conducted of all trauma registry-based manuscripts published from 01 January 2015 to current date (17 March 2017). Studies were identified by searching MEDLINE, EMBASE, and CINAHL using relevant subject headings and keywords. Included manuscripts were evaluated based on previously published recommendations regarding the reporting and discussion of missing data. Manuscripts were graded on their degree of characterization of such observations. In addition, the methods used to manage missing data were examined. There were 539 manuscripts that met inclusion criteria. Among these, 208 (38.6%) manuscripts did not mention data completeness and 88 (16.3%) mentioned missing data but did not quantify the extent. Only a handful (n = 26; 4.8%) quantified the 'missingness' of all variables. Most articles (n = 477; 88.5%) contained no details such as a comparison between patient characteristics in cohorts with and without missing data. Of the 331 articles which made at least some mention of data completeness, the method of managing missing data was unknown in 34 (10.3%). When method(s) to handle missing data were identified, 234 (78.8%) manuscripts used complete case analysis only, 18 (6.1%) used multiple imputation only and 34 (11.4%) used a combination of these. Most manuscripts using trauma registry data did not quantify the extent of missing data for any variables and contained minimal discussion regarding missingness. Out of the studies which identified a method of managing missing data, most used complete case analysis, a method that may bias results. The lack of standardization in the reporting and management of missing data questions the validity of conclusions from research based on trauma registry data. Copyright © 2018 Elsevier Ltd. All rights reserved.

Selective Angiographic Embolization of Blunt Hepatic Trauma Reduces Failure Rate of Nonoperative Therapy and Incidence of Post-Traumatic Complications.

PubMed

Xu, Han; Jie, Li; Kejian, Sun; Xiaojun, He; Chengli, Liu; Hongyi, Zhang; Yalin, Kong

2017-11-20

BACKGROUND Conflict still remains as to the benefit of angioembolization (AE) for non-operative therapy (NOT) of blunt hepatic trauma (BHT). The aim of this study was to determine whether AE could result in lower failure rates in hemodynamically stable BHT patients with high failure risk factors for NOT, and to systematically evaluate the effectiveness of AE for NOT of BHT. MATERIAL AND METHODS Medical records of all BHT patients from January 1, 1998 to December 31, 2015 at a large trauma center were collected and analyzed. Failure of NOT (FNOT) occurred if hepatic surgery was performed after attempted NOT. Logistic regression analysis was used to identify factors associated with FNOT. Hepatobiliary complications related to hepatic trauma during follow-up were reviewed. RESULTS No significant difference in FNOT for the no angiographic embolization (NO-AE) group versus angiographic embolization (AE) group was found in hepatic trauma of grades I, II, and V. However, decrease in FNOT was significant with AE performed for hepatic trauma of grades III to IV. Risk factors for FNOT included grade III to IV injuries and contrast blush on CT. Follow-up data of six months also showed that the incidence of hepatobiliary complications in the NO-AE group was higher than the AE group. CONCLUSIONS Hemodynamically stable BHT patients with grade III to IV injuries, contrast blush on initial CT, and/or decreasing hemoglobin levels can be candidates for selective AE during NOT course.

Selective Angiographic Embolization of Blunt Hepatic Trauma Reduces Failure Rate of Nonoperative Therapy and Incidence of Post-Traumatic Complications

PubMed Central

Xu, Han; Jie, Li; Kejian, Sun; Xiaojun, He; Chengli, Liu; Hongyi, Zhang; Yalin, Kong

2017-01-01

Background Conflict still remains as to the benefit of angioembolization (AE) for non-operative therapy (NOT) of blunt hepatic trauma (BHT). The aim of this study was to determine whether AE could result in lower failure rates in hemodynamically stable BHT patients with high failure risk factors for NOT, and to systematically evaluate the effectiveness of AE for NOT of BHT. Material/Methods Medical records of all BHT patients from January 1, 1998 to December 31, 2015 at a large trauma center were collected and analyzed. Failure of NOT (FNOT) occurred if hepatic surgery was performed after attempted NOT. Logistic regression analysis was used to identify factors associated with FNOT. Hepatobiliary complications related to hepatic trauma during follow-up were reviewed. Results No significant difference in FNOT for the no angiographic embolization (NO-AE) group versus angiographic embolization (AE) group was found in hepatic trauma of grades I, II, and V. However, decrease in FNOT was significant with AE performed for hepatic trauma of grades III to IV. Risk factors for FNOT included grade III to IV injuries and contrast blush on CT. Follow-up data of six months also showed that the incidence of hepatobiliary complications in the NO-AE group was higher than the AE group. Conclusions Hemodynamically stable BHT patients with grade III to IV injuries, contrast blush on initial CT, and/or decreasing hemoglobin levels can be candidates for selective AE during NOT course. PMID:29155699

Coagulation management in trauma-associated coagulopathy: allogenic blood products versus coagulation factor concentrates in trauma care.

PubMed

Klages, Matthias; Zacharowski, Kai; Weber, Christian Friedrich

2016-04-01

Coagulation management by transfusion of allogenic blood products and coagulation factors are competing concepts in current trauma care. Rapid and adequate therapy of trauma-associated coagulopathy is crucial to survival of severely injured patients. Standard coagulation tests such as prothrombin time and activated partial thromboplastin time are commonly used, but these tests are inappropriate for monitoring and guiding therapy in trauma patients. Coagulation factor-based treatment showed promising results, but randomized trials have not yet been performed. In addition, viscoelastic tests are needed to guide therapy, although there is in fact limited evidence for these in tests in trauma care. Regarding transfusion therapy with allogenic blood products, plasma transfusion has been associated with improved survival in trauma patients following massive transfusion. In contrast, patients not requiring massive transfusion seem to be at risk for suffering complications with increasing volumes of plasma transfused. The collective of trauma patients is heterogeneous. Despite the lack of evidence, there are strong arguments for individualized patient treatment with coagulation factors for some indications and to abstain from the use of fresh frozen plasma. In patients with severe trauma and major bleeding, plasma, platelets, and red blood cells should be considered to be administered at a ratio of 1 : 1 : 1.

An unusual case of foreign body pulmonary embolus: case report and review of penetrating trauma at a pediatric trauma center.

PubMed

Boomer, Laura A; Watkins, Daniel J; O'Donovan, Julie; Kenney, Brian D; Yates, Andrew R; Besner, Gail E

2015-03-01

Penetrating thoracic trauma is relatively rare in the pediatric population. Embolization of foreign bodies from penetrating trauma is very uncommon. We present a case of a 6-year-old boy with a penetrating foreign body from a projectile dislodged from a lawn mower. Imaging demonstrated a foreign body that embolized to the left pulmonary artery, which was successfully treated non-operatively. We reviewed the penetrating thoracic trauma patients in the trauma registry at our institution between 1/1/03 and 12/31/12. Data collected included demographic data, procedures performed, complications and outcome. Sixty-five patients were identified with a diagnosis of penetrating thoracic trauma. Fourteen of the patients had low velocity penetrating trauma and 51 had high velocity injuries. Patients with high velocity injuries were more likely to be older and less likely to be Caucasian. There were no statistically significant differences between patients with low vs. high velocity injuries regarding severity scores or length of stay. There were no statistically significant differences in procedures required between patients with low and high velocity injuries. Penetrating thoracic trauma is rare in children. The case presented here represents the only report of cardiac foreign body embolus we could identify in a pediatric patient.

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.

Trauma Resuscitation Evaluation Times and Correlating Human Patient Simulation Training Differences-What is the Standard?

PubMed

Bonjour, Timothy J; Charny, Grigory; Thaxton, Robert E

2016-11-01

Rapid effective trauma resuscitations (TRs) decrease patient morbidity and mortality. Few studies have evaluated TR care times. Effective time goals and superior human patient simulator (HPS) training can improve patient survivability. The purpose of this study was to compare live TR to HPS resuscitation times to determine mean incremental resuscitation times and ascertain if simulation was educationally equivalent. The study was conducted at San Antonio Military Medical Center, Department of Defense Level I trauma center. This was a prospective observational study measuring incremental step times by trauma teams during trauma and simulation patient resuscitations. Trauma and simulation patient arms had 60 patients for statistical significance. Participants included Emergency Medicine residents and Physician Assistant residents as the trauma team leader. The trauma patient arm revealed a mean evaluation time of 10:33 and simulation arm 10:23. Comparable time characteristics in the airway, intravenous access, blood sample collection, and blood pressure data subsets were seen. TR mean times were similar to the HPS arm subsets demonstrating simulation as an effective educational tool. Effective stepwise approaches, incremental time goals, and superior HPS training can improve patient survivability and improved departmental productivity using TR teams. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

Trauma indices for prediction of acute respiratory distress syndrome.

PubMed

Afshar, Majid; Smith, Gordon S; Cooper, Richard S; Murthi, Sarah; Netzer, Giora

2016-04-01

A myriad of trauma indices has been validated to predict probability of trauma survival. We aimed to compare the performance of commonly used indices for the development of the acute respiratory distress syndrome (ARDS). Historic, observational cohort study of 27,385 consecutive patients admitted to a statewide referral trauma center between July 11, 2003 and October 31, 2011. A validated algorithm was adapted to identify patients with ARDS. Each trauma index was evaluated in logistic regression using the area under the receiver operating characteristic curve. The case rate for ARDS development was 5.8% (1594). The receiver operating characteristics for injury severity score (ISS) had the best discrimination and had an area under the curve of 0.88 (95% confidence interval [CI] = 0.87-0.89). Glasgow coma score (0.71, 95% CI = 0.70-0.73), A Severity Characterization of Trauma (0.86, 95% CI = 0.85-0.87), Revised Trauma Score (0.71, 95% CI = 0.70-0.72) and thorax Abbreviated Injury Score (0.73, 95% CI = 0.72-0.74) performed worse (P < 0.001) and Trauma and Injury Severity Score (0.88, 95% CI = 0.87-0.88) performed equivocally (P = 0.51) in comparison to ISS. Using a cutoff point ISS ≥16, sensitivity and specificity were 84.9% (95% CI = 83.0%-86.6%) and 75.6% (95% CI = 75.1%-76.2%), respectively. Among commonly used trauma indices, ISS has superior or equivocal discriminative ability for development of ARDS. A cutoff point of ISS ≥16 provided good sensitivity and specificity. The use of ISS ≥16 is a simple method to evaluate ARDS in trauma epidemiology and outcomes research. Copyright © 2016 Elsevier Inc. All rights reserved.

A novel prospective approach to evaluate trauma recidivism: the concept of the past trauma history.

PubMed

McCoy, Andrew M; Como, John J; Greene, Gregory; Laskey, Sara L; Claridge, Jeffrey A

2013-07-01

The purpose of this study was to determine the incidence and burden of trauma recidivism at a regional Level 1 trauma center by incorporating the concept of the past trauma history (PTHx) into the general trauma history. All trauma patients who met prehospital trauma criteria and activated the trauma team during a 13-month period were asked about their PTHx, that is, their history of injury in the previous 5 years. A recidivist presented more than once for separate severe injuries. Recurrent recidivists presented multiple times during the study period. Of the 4,971 trauma activations during the study period, 1,246 (25.2%) were identified as recidivists. Recidivists were 75% male, 62% white, 36% unemployed, 26% uninsured, and 90% unmarried. The recidivism rate among admitted patients was 23.4% compared with 29.3% in those discharged from the emergency department. The highest recidivism rates were noted in patients who reported alcohol or illegal drug use on the day of injury and in victims of interpersonal violence (IPV), defined as those who sustained gunshot wounds, stab wounds, or assaults, Those involved in IPV were more likely to have been involved in IPV at the previous trauma than those with other trauma mechanisms. Key risk factors for recidivism among all patients were male sex and single marital status. Seventy-three patients (1.5%) were recurrent recidivists, representing 157 unique encounters. This is the highest trauma recidivism rate reported on a large population of all consecutive trauma activations at a regional Level 1 trauma center. These data illustrate the tremendous burden of recidivism in the modern era, more than previously recognized. Efforts specifically targeting those involved in IPV may reduce recidivism rates. Incorporating the concept of the PTHx into the general history of the trauma patient is feasible and provides valuable information to the provider. Prognostic study, level II.

Patient volume per surgeon does not predict survival in adult level I trauma centers.

PubMed

Margulies, D R; Cryer, H G; McArthur, D L; Lee, S S; Bongard, F S; Fleming, A W

2001-04-01

The 1999 American College of Surgeons resources for optimal care document added the requirement that Level I trauma centers admit over 240 patients with Injury Severity Score (ISS) > 15 per year or that trauma surgeons care for at least 35 patients per year. The purpose of this study was to test the hypothesis that high volume of patients with ISS > 15 per individual trauma surgeon is associated with improved outcome. Data were obtained from the trauma registry of the five American College of Surgeons-verified adult Level I trauma centers in our mature trauma system between January 1, 1998, and March 31, 1999. Data abstracted included age, sex, Glasgow Coma Scale (GCS) score, intensive care unit length of stay, hospital length of stay, probability of survival (Ps), mechanism of injury, number of patients per each trauma surgeon and institution, and mortality. Multiple logistic regression was performed to select independent variables for modeling of survival. From the five Level I centers there were 11,932 trauma patients in this time interval; of these, 1,754 patients (14.7%) with ISS > 15 were identified and used for analysis. Patients with ISS > 15 varied from 173 to 625 per institution; trauma surgeons varied from 8 to 25 per institution; per-surgeon patient volume varied from 0.8 to 96 per year. Logistic regression analysis revealed that the best independent predictors of survival were Ps, GCS score, age, mechanism of injury, and institutional volume (p < 0.01). Age and institutional volume correlated negatively with survival. Analysis of per-surgeon patient caseload added no additional predictive value (p = 0.44). The significant independent predictors of survival in severely injured trauma patients are Ps, GCS score, age, mechanism of injury, and institutional volume. We found no statistically meaningful contribution to the prediction of survival on the basis of per-surgeon patient volume. Since this volume criterion for surgeon enpanelment and trauma center designation would not be expected to improve outcome, such a requirement should be justified by other measures or abandoned.

Patient perspectives of care in a regionalised trauma system: lessons from the Victorian State Trauma System.

PubMed

Gabbe, Belinda J; Sleney, Jude S; Gosling, Cameron M; Wilson, Krystle; Hart, Melissa J; Sutherland, Ann M; Christie, Nicola

2013-02-18

To explore injured patients' experiences of trauma care to identify areas for improvement in service delivery. Qualitative study using in-depth, semi-structured interviews, conducted from 1 April 2011 to 31 January 2012, with 120 trauma patients registered by the Victorian State Trauma Registry and the Victorian Orthopaedic Trauma Outcomes Registry and managed at the major adult trauma services (MTS) in Victoria. Emergent themes from patients' experiences of acute, rehabilitation and post-discharge care in the Victorian State Trauma System (VSTS). Patients perceived their acute hospital care as high quality, although 3s with communication and surgical management delays were common. Discharge from hospital was perceived as stressful, and many felt ill prepared for discharge. A consistent emerging theme was the sense of a lack of coordination of post-discharge care, and the absence of a consistent point of contact for ongoing management. Most patients' primary point of contact after discharge was outpatient clinics at the MTS, which were widely criticised because of substantial delays in receiving an appointment, prolonged waiting times, limited time with clinicians, lack of continuity of care and inability to see senior clinicians. This study highlights perceived 3s in the patient care pathway in the VSTS, especially those relating to communication, information provision and post-discharge care. Trauma patients perceived the need for a single point of contact for coordination of post-discharge care.

The association of insurance status on the probability of transfer for pediatric trauma patients.

PubMed

Hamilton, Emma C; Miller, Charles C; Cotton, Bryan A; Cox, Charles; Kao, Lillian S; Austin, Mary T

2016-12-01

The purpose of this study was to evaluate the association of insurance status on the probability of transfer of pediatric trauma patients to level I/II centers after initial evaluation at lower level centers. A retrospective review of all pediatric trauma patients (age<16years) registered in the 2007-2012 National Trauma Data Bank was performed. Multiple regression techniques controlling for clustering at the hospital level were used to determine the impact of insurance status on the probability of transfer to level I/II trauma centers. Of 38,205 patients, 33% of patients (12,432) were transferred from lower level centers to level I/II trauma centers. Adjusting for demographics and injury characteristics, children with no insurance had a higher likelihood of transfer than children with private insurance. Children with public or unknown insurance status were no more likely to be transferred than privately insured children. There were no variable interactions with insurance status. Among pediatric trauma patients, lack of insurance is an independent predictor for transfer to a major trauma center. While burns, severely injured, and younger patients remain the most likely to be transferred, these findings suggest a triage bias influenced by insurance status. Additional policies may be needed to avoid unnecessary transfer of uninsured pediatric trauma patients. Case-control study, level III. Copyright © 2016 Elsevier Inc. All rights reserved.

Evaluation of SOCOM Wireless Monitor in Trauma Patients

DTIC Science & Technology

2015-02-01

DOD Award W81XWH-11-2-0098 page 7 Do all trauma patients benefit from tranexamic acid ? J Trauma Acute Care Surg 2014...2015 11) Valle EJ, Allen CJ, Van Haren RM, Jouria JM, Li H, Livingstone AS, Proctor KG: Tranexamic acid may have undesirable actions in some trauma...Livingstone AS, Proctor KG: Do all patients benefit from tranexamic acid ? The experience of an urban level 1 trauma center. Presented at 72nd Annual

Risk of symptomatic heterotopic ossification following plate osteosynthesis in multiple trauma patients: an analysis in a level-1 trauma centre

PubMed Central

Zeckey, Christian; Hildebrand, Frank; Mommsen, Philipp; Schumann, Julia; Frink, Michael; Pape, Hans-Christoph; Krettek, Christian; Probst, Christian

2009-01-01

Background Symptomatic heterotopic ossification (HO) in multiple trauma patients may lead to follow up surgery, furthermore the long-term outcome can be restricted. Knowledge of the effect of surgical treatment on formation of symptomatic heterotopic ossification in polytrauma is sparse. Therefore, we test the effects of surgical treatment (plate osteosynthesis or intramedullary nailing) on the formation of heterotopic ossification in the multiple trauma patient. Methods We retrospectively analysed prospectively documented data of blunt multiple trauma patients with long bone fractures which were treated at our level-1 trauma centre between 1997 and 2005. Patients were distributed to 2 groups: Patients treated by intramedullary nails (group IMN) or plate osteosynthesis (group PLATE) were compared. The expression and extension of symptomatic heterotopic ossifications on 3-6 months follow-up x-rays in antero-posterior (ap) and lateral views were classified radiologically and the maximum expansion was measured in millimeter (mm). Additionally, ventilation time, prophylactic medication like indomethacine and incidence and correlation of head injuries were analysed. Results 101 patients were included in our study, 79 men and 22 women. The fractures were treated by intramedullary nails (group IMN n = 50) or plate osteosynthesis (group PLATE n = 51). Significantly higher radiologic ossification classes were detected in group PLATE (2.9 ± 1.3) as compared to IMN (2.2 ± 1.1; p = 0.013). HO size in mm ap and lateral showed a tendency towards larger HOs in the PLATE group. Additionally PLATE group showed a higher rate of articular fractures (63% vs. 28% in IMN) while IMN demonstrated a higher rate of diaphyseal fractures (72% vs. 37% in PLATE; p = 0.003). Ventilation time, indomethacine and incidence of head injuries showed no significant difference between groups. Conclusion Fracture care with plate osteosynthesis in polytrauma patients is associated with larger formations of symptomatic heterotopic ossifications (HO) while intramedullary nailing was associated with a higher rate of remote HO. For future fracture care of multiply injured patients these facts may be considered by the responsible surgeon. PMID:19825174

Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma.

PubMed

Fu, Chen Ju; Wong, Yon Cheong; Tsang, Yuk Ming; Wang, Li Jen; Chen, Huan Wu; Ku, Yi Kang; Wu, Cheng Hsien; Chen, Huan Wen; Kang, Shih Ching

2015-01-01

Intrahepatic portal vein injuries secondary to blunt abdominal trauma are difficult to diagnose and can result in insidious bleeding. We aimed to compare computed tomography arterial portography (CTAP), reperfusion CTAP (rCTAP), and conventional computed tomography (CT) for diagnosing portal vein injuries after blunt hepatic trauma. Patients with blunt hepatic trauma, who were eligible for nonoperative management, underwent CTAP, rCTAP, and CT. The number and size of perfusion defects observed using the three methods were compared. A total of 13 patients (seven males/six females) with a mean age of 34.5±14.1 years were included in the study. A total of 36 hepatic segments had perfusion defects on rCTAP and CT, while there were 47 hepatic segments with perfusion defects on CTAP. The size of perfusion defects on CT (239 cm3; interquartile range [IQR]: 129.5, 309.5) and rCTAP (238 cm3; IQR: 129.5, 310.5) were significantly smaller compared with CTAP (291 cm3; IQR: 136, 371) (both, P = 0.002). Perfusion defects measured by CTAP were significantly greater than those determined by either rCTAP or CT in cases of blunt hepatic trauma. This finding suggests that CTAP is superior to rCTAP and CT in evaluating portal vein injuries after blunt liver trauma.

Trauma-associated lung injury differs clinically and biologically from acute lung injury due to other clinical disorders*

PubMed Central

Calfee, Carolyn S.; Eisner, Mark D.; Ware, Lorraine B.; Thompson, B. Taylor; Parsons, Polly E.; Wheeler, Arthur P.; Korpak, Anna; Matthay, Michael A.

2009-01-01

Objective Patients with trauma-associated acute lung injury have better outcomes than patients with other clinical risks for lung injury, but the mechanisms behind these improved outcomes are unclear. We sought to compare the clinical and biological features of patients with trauma-associated lung injury with those of patients with other risks for lung injury and to determine whether the improved outcomes of trauma patients reflect their baseline health status or less severe lung injury, or both. Design, Setting, and Patients Analysis of clinical and biological data from 1,451 patients enrolled in two large randomized, controlled trials of ventilator management in acute lung injury. Measurements and Main Results Compared with patients with other clinical risks for lung injury, trauma patients were younger and generally less acutely and chronically ill. Even after adjusting for these baseline differences, trauma patients had significantly lower plasma levels of intercellular adhesion molecule-1, von Willebrand factor antigen, surfactant protein-D, and soluble tumor necrosis factor receptor-1, which are biomarkers of lung epithelial and endothelial injury previously found to be prognostic in acute lung injury. In contrast, markers of acute inflammation, except for interleukin-6, and disordered coagulation were similar in trauma and nontrauma patients. Trauma-associated lung injury patients had a significantly lower odds of death at 90 days, even after adjusting for baseline clinical factors including age, gender, ethnicity, comorbidities, and severity of illness (odds ratio, 0.44; 95% confidence interval, 0.24 – 0.82; p = .01). Conclusions Patients with trauma-associated lung injury are less acutely and chronically ill than other lung injury patients; however, these baseline clinical differences do not adequately explain their improved outcomes. Instead, the better outcomes of the trauma population may be explained, in part, by less severe lung epithelial and endothelial injury. PMID:17944012

Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center.

PubMed

Wang, Hao; Coppola, Marco; Robinson, Richard D; Scribner, James T; Vithalani, Veer; de Moor, Carrie E; Gandhi, Raj R; Burton, Mandy; Delaney, Kathleen A

2013-04-01

It has been found that significantly different clinical outcomes occur in trauma patients with different mechanisms of injury. Ground level falls (GLF) are usually considered "minor trauma" with less injury occurred in general. However, it is not uncommon that geriatric trauma patients sustain cervical spine (C-spine) fractures with other associated injuries due to GLF or less. The aim of this study is to determine the injury patterns and the roles of clinical risk factors in these geriatric trauma patients. Data were reviewed from the institutional trauma registry of our local level 1 trauma center. All patients had sustained C-spine fracture(s). Basic clinical characteristics, the distribution of C-spine fracture(s), and mechanism of injury in geriatric patients (65 years or older) were compared with those less than 65 years old. Furthermore, different clinical variables including age, gender, Glasgow coma scale (GCS), blood alcohol level, and co-existing injuries were analyzed by multivariate logistic regression in geriatric trauma patients due to GLF and internally validated by random bootstrapping technique. From 2006 - 2010, a total of 12,805 trauma patients were included in trauma registry, of which 726 (5.67%) had sustained C-spine fracture(s). Among all C-spine fracture patients, 19.15% (139/726) were geriatric patients. Of these geriatric patients 27.34% (38/139) and 53.96% (75/139) had C1 and C2 fractures compared with 13.63% (80/587) and 21.98% (129/587) in young trauma patients (P < 0.001). Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139) had C6 and C7 fractures compared with 32.03% (188/587) and 41.40% (243/587) in younger ones separately (P < 0.001). Furthermore, 53.96% (75/139) geriatric patients had sustained C-spine fractures due to GLF with more upper C-spine fractures (C1 and C2). Only 3.2% of those had positive blood alcohol levels compared with 52.9% of younger patients (P < 0.001). In addition, 6.34% of geriatric patients due to GLF had intracranial pathology (ICP) which was one of the most common co-injuries with C-spine fractures. Logistic regression analysis showed the adjusted odds ratios of 1.17 (age) and 91.57 (male) in geriatric GLF patients to predict this co-injury pattern of C-spine fracture and ICP. Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. GLF or less not only can cause isolated C-spines fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients.

Pediatric trauma at an adult trauma center.

PubMed

Siram, Suryanarayana; Oyetunji, Tolulope A; Khoury, Amal L; Walker, Sonya R; Bolorunduro, Oluwaseyi B; Chang, David C; Greene, Wendy R; Cornwell, Edward E; Frederick, Wayne A I

2010-08-01

Accidental traumatic injury is the number 1 cause of morbidity and mortality in the pediatric population. In this study, we aim to prove that certain pediatric patients can be treated with good outcomes at an adult level 1 trauma center. Retrospective analysis using the Howard University Hospital trauma registry identified 71 patients treated at Howard University Hospital between the ages of 1 and 17 years old. Specific variables were identified and collected for each patient. The majority of pediatric traumas treated at Howard University Hospital between June 2004 and May 2005 had high survival rates (93%). The patients who did not survive (7%) included 3 patients who were dead on arrival and 2 who died shortly after arrival to the hospital. Certain pediatric populations who present with minor and/or isolated injuries can be treated in an adult level 1 trauma center with similar outcomes to treatment in a pediatric level 1 trauma center.

[Management of pediatric multiple trauma patients. Perspective of the pediatric intensive care unit].

PubMed

Carreras González, E; Rey Galán, C; Concha Torre, A; Cañadas Palaz, S; Serrano González, A; Cambra Lasaosa, F J

2007-08-01

To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU). A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded. Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66% of the hospitals. No training courses were available in 59% of the hospitals. No trauma register was available in 62% of the hospitals. Trauma patients represented 11% of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100% of the hospitals. A radiologist and traumatologist were always at the hospital in 91%, a neurosurgeon in 66% and a pediatric surgeon in 50%. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87% of the PICUs, jugular venous saturation monitoring in 54% and continuous electroencephalogram and transcranial Doppler ultrasound in 50%. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44% of the hospitals, and arteriography in 42%. In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required.

The first 5 years since trauma center designation in the Hong Kong Special Administrative Region, People's Republic of China.

PubMed

Leung, Gilberto Ka Kit; Chang, Annice; Cheung, F C; Ho, H F; Ho, Wendy; Hui, S M; Kam, C W; Lai, Albert; Lam, K W; Leung, M; Liu, S H; Lo, C B; Mok, Francis; Rainer, Timothy H; Shen, W Y; So, F L; Wong, Gordon; Wu, Amy; Yeung, Janice; Yuen, W K

2011-05-01

In 1994, the Hong Kong Special Administrative Region (HKSAR) introduced plans to implement a trauma system based on the recommendations outlined by Professor Donald Trunkey in his report to the local Hospital Authority. Five government-subsidized public hospitals were subsequently designated as trauma centers in 2003. This article reviews the initial experience in these five centers. Prospective trauma registries from January 2004 to December 2008 were reviewed. Primary clinical outcome measures were hospital mortality. The Trauma and Injury Severity Score methodology was used for benchmarking with the Major Trauma Outcome Study (MTOS) database. The majority (83.3%) of the 10,462 patients suffered from blunt trauma. Severe injury, defined as Injury Severity Score>15, occurred in 29.7% of patients. The leading causes of trauma were motor vehicle collisions and falls, with crude hospital mortality rates of 6.9% and 10.7%, respectively. The M-statistic was 0.95, indicating comparable case-mix with the MTOS. The worst outcome occurred in the first year. Significant improvement was seen in patients with penetrating injuries. By 2008, these patients had significantly higher survival rates than expected (Z-statistic=0.85). Although the overall mortality rates for blunt trauma were higher than expected, the difference was no longer statistically significant from the second year onward. The case-mix of trauma patients in the HKSAR is comparable with that of the MTOS. A young trauma system relatively unburdened by dissimilar reimbursement and patient access issues may achieve significant improvement and satisfactory patient outcomes. Our findings may serve as a useful benchmark for HK and other Southeast Asian cities and trauma systems to establish local coefficients for future evaluations.

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.

Evaluation of a Mature Trauma System

PubMed Central

Durham, Rodney; Pracht, Etienne; Orban, Barbara; Lottenburg, Larry; Tepas, Joseph; Flint, Lewis

2006-01-01

Introduction: An effective trauma system should offer patients triaged to a trauma center (TC) a survival advantage and cost-effective treatment. Three questions were asked: 1) Does treatment at a TC versus a nontrauma center (NTC) improve survival? 2) Is the system cost-effective? 3) Is access to the system equitable? Methods: The 2003 Florida discharge database identified patients with ICD9 codes 800 to 959. Survival risk ratios (SRR) were calculated using1999–2000 data and ICISS were produced for each code. Using 2003 data, mortality rates were calculated for matched patients at TCs and NTCs. Instrumental variables methodology was used to account for differences in mortality risks of patients triaged to TCs versus NTCs. Logistic regression analysis was used to determine differences in mortality. Charge/cost ratios were analyzed to compute the cost care and cost/life saved. Accessibility to a TC within 85 minutes of injury was assessed. Results: Treatment at a TC was associated with an 18% reduction in mortality. Mean costs of care in TCs and NTCs were $11,910 and $6019, respectively. Dividing the mean cost difference by the reduction in mortality yields a cost of $34,887/life saved. A total of 42% of patients returned to work within 24 months of injury. Using an expected median of 19 years of employment for a 33-year-old individual and proposed state funding figures for the trauma system, a life saved results in an approximate annual cost to the state of between $100 and $500. Currently, 95% of citizens of the state have access to the trauma system within 85 minutes of injury; however, only 38% of trauma patients are triaged to a TC. Addition of 3 TCs would increase these percentages to 99% and 65%. Conclusions: Triage to a Florida TC is associated with a decreased risk of death. Moreover, cost/life year saved is favorable when compared with societal expenditures for other health problems. Improved deployment of TCs is necessary to optimize access. This assessment methodology is a useful model for evaluation of mature trauma systems. PMID:16772781

Comparisons of survival predictions using survival risk ratios based on International Classification of Diseases, Ninth Revision and Abbreviated Injury Scale trauma diagnosis codes.

PubMed

Clarke, John R; Ragone, Andrew V; Greenwald, Lloyd

2005-09-01

We conducted a comparison of methods for predicting survival using survival risk ratios (SRRs), including new comparisons based on International Classification of Diseases, Ninth Revision (ICD-9) versus Abbreviated Injury Scale (AIS) six-digit codes. From the Pennsylvania trauma center's registry, all direct trauma admissions were collected through June 22, 1999. Patients with no comorbid medical diagnoses and both ICD-9 and AIS injury codes were used for comparisons based on a single set of data. SRRs for ICD-9 and then for AIS diagnostic codes were each calculated two ways: from the survival rate of patients with each diagnosis and when each diagnosis was an isolated diagnosis. Probabilities of survival for the cohort were calculated using each set of SRRs by the multiplicative ICISS method and, where appropriate, the minimum SRR method. These prediction sets were then internally validated against actual survival by the Hosmer-Lemeshow goodness-of-fit statistic. The 41,364 patients had 1,224 different ICD-9 injury diagnoses in 32,261 combinations and 1,263 corresponding AIS injury diagnoses in 31,755 combinations, ranging from 1 to 27 injuries per patient. All conventional ICD-9-based combinations of SRRs and methods had better Hosmer-Lemeshow goodness-of-fit statistic fits than their AIS-based counterparts. The minimum SRR method produced better calibration than the multiplicative methods, presumably because it did not magnify inaccuracies in the SRRs that might occur with multiplication. Predictions of survival based on anatomic injury alone can be performed using ICD-9 codes, with no advantage from extra coding of AIS diagnoses. Predictions based on the single worst SRR were closer to actual outcomes than those based on multiplying SRRs.

Estimation of plasma fibrinogen levels based on hemoglobin, base excess and Injury Severity Score upon emergency room admission

PubMed Central

2013-01-01

Introduction Fibrinogen plays a key role in hemostasis and is the first coagulation factor to reach critical levels in massively bleeding trauma patients. Consequently, rapid estimation of plasma fibrinogen (FIB) is essential upon emergency room (ER) admission, but is not part of routine coagulation monitoring in many centers. We investigated the predictive ability of the laboratory parameters hemoglobin (Hb) and base excess (BE) upon admission, as well as the Injury Severity Score (ISS), to estimate FIB in major trauma patients. Methods In this retrospective study, major trauma patients (ISS ≥16) with documented FIB analysis upon ER admission were eligible for inclusion. FIB was correlated with Hb, BE and ISS, alone and in combination, using regression analysis. Results A total of 675 patients were enrolled (median ISS 27). FIB upon admission correlated strongly with Hb, BE and ISS. Multiple regression analysis showed that Hb and BE together predicted FIB (adjusted R2 = 0.46; loge(FIB) = 3.567 + 0.223.Hb - 0.007.Hb2 + 0.044.BE), and predictive strength increased when ISS was included (adjusted R2 = 0.51; loge(FIB) = 4.188 + 0.243.Hb - 0.008.Hb2 + 0.036.BE - 0.031.ISS + 0.0003.ISS2). Of all major trauma patients admitted with Hb <12 g/dL, 74% had low (<200 mg/dL) FIB and 54% had critical (<150 mg/dL) FIB. Of patients admitted with Hb <10 g/dL, 89% had low FIB and 73% had critical FIB. These values increased to 93% and 89%, respectively, among patients with an admission Hb <8 g/dL. Sixty-six percent of patients with only a weakly negative BE (<−2 mmol/L) showed low FIB. Of patients with BE <−6 mmol/L upon admission, 81% had low FIB and 63% had critical FIB. The corresponding values for BE <−10 mmol/L were 89% and 78%, respectively. Conclusions Upon ER admission, FIB of major trauma patients shows strong correlation with rapidly obtainable, routine laboratory parameters such as Hb and BE. These two parameters might provide an insightful and rapid tool to identify major trauma patients at risk of acquired hypofibrinogenemia. Early calculation of ISS could further increase the ability to predict FIB in these patients. We propose that FIB can be estimated during the initial phase of trauma care based on bedside tests. PMID:23849249

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

Vlies, C. H. van der, E-mail: c.h.vandervlies@amc.uva.nl; Hoekstra, J.; Ponsen, K. J.

Introduction: Nonoperative management (NOM) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury. Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States. This study was designed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center. Methods: An analysis of a prospective trauma registry was performed for a 6-year period before (period 1) and after the introduction and implementation of splenic artery embolization (SAE) (period 2). Primary outcome was the failure rate of initial treatment. Results: A total ofmore » 151 patients were reviewed. An increased use of SAE and a reduction of splenic operations during the second period was observed. Compared with period 1, the failure rate after observation in period 2 decreased from 25% to 10%. The failure rate after SAE in period 2 was 18%. The splenic salvage rate (SSR) after observation increased from 79% in the first period to 100% in the second period. During the second period, all patients with failure after observation were successfully treated with SAE. The SSR after SAE in periods 1 and 2 was respectively 100% and 86%. Conclusions: SAE of patients with blunt splenic injuries is associated with a reduction in splenic operations. The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers. Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United States.« less

Family Presence during Resuscitation after Trauma

PubMed Central

Leske, Jane S.; McAndrew, Natalie S.; Brasel, Karen J.; Feetham, Suzanne

2017-01-01

Purpose The primary aim was to examine the effects of family presence during resuscitation (FPDR) in patients who survived trauma from motor vehicle crashes (MVC) and gunshot wounds (GSW) in the emergency department. Background The ongoing controversy of FPDR, dearth of comparative designs, small sample sizes, and survey methods makes it difficult to come to a definitive conclusion about any benefits of FPDR. Methods The Resiliency Model guided the selection of variables. A multivariate, comparison, prospective design was used. A convenience sample of family members participated within three days of admission to critical care. Family strengths were measured by the Family Crisis Oriented Personal Scale, Family Inventory of Resources for Management, and Family Problem Solving Communication Index. Family outcomes were measured by the State anxiety portion of the State Trait Anxiety Inventory, Acute Stress Disorder Scale, Family Member Well-being Index, and Family Satisfaction in the Intensive Care Unit Scale. Results Family members of 140 trauma patients (MVC n=110; 79%; GSW n=30, 21%) participated. Family members ranged in age from 20–84 years (M=46, SD=15, Mdn=47). The majority were female (n=112, 80%) and related to the patient as spouse (n=46, 33%). Participating in the FPDR option reduced anxiety (t= −2.43, p=.04), reduced stress (t= −2.86, p=.005), and fostered well-being (t=3.46, p=.001) but was not significant for satisfaction with critical care (t= −.28, p=.78). Discussion Results demonstrate the positive initial effects of FPDR on family members of patients surviving trauma injury. Long term effects of FPDR remain unknown. PMID:28272181

Pharmacist's impact on acute pain management during trauma resuscitation.

PubMed

Montgomery, Kayla; Hall, A Brad; Keriazes, Georgia

2015-01-01

The timely administration of analgesics is crucial to the comprehensive management of trauma patients. When an emergency department (ED) pharmacist participates in trauma resuscitation, the pharmacist acts as a medication resource for trauma team members and facilitates the timely administration of analgesics. This study measured the impact of a pharmacist on time to first analgesic dose administered during trauma resuscitation. All adult (>18 years) patients who presented to this level II trauma center via activation of the trauma response system between January 1, 2009, and May 31, 2013, were screened for eligibility. For inclusion, patients must have received intravenous fentanyl, morphine, or hydromorphone in the trauma bay. The time to medication administration was defined as the elapsed time from ED arrival to administration of first analgesic. There were 1328 trauma response system activations during the study period; of which 340 patients were included. The most common analgesic administered was fentanyl (62% in both groups). When a pharmacist was participating, the mean time to first analgesic administered was decreased (17 vs 21 minutes; P = .03). Among the 78% of patients with documented pain scores, the overall mean reduction in pain scores from ED arrival to ED discharge was similar between the 2 groups. There was a 2.4 point reduction with a pharmacist versus 2.7 without a pharmacist, using a 0 to 10 numeric pain rating scale. The participation of a clinical pharmacist during trauma resuscitation significantly decreased the time to first analgesic administration in trauma patients. The results of this study supplement the literature supporting the integration of clinical ED pharmacists on trauma teams.

A patient education tool for nonoperative management of blunt abdominal trauma.

PubMed

Budinger, Julie Marie

2007-01-01

Blunt trauma is the primary mechanism of injury seen at Charleston Area Medical Center, a rural level I trauma center. Blunt abdominal trauma occurs as a result of various mechanisms. It can be safely managed nonoperatively and is considered to be the standard of care in hemodynamically stable patients. Appropriate patient education before discharge will enable patients to identify complications early and seek appropriate medical care.

Early response to psychological trauma--what GPs can do.

PubMed

Wade, Darryl; Howard, Alexandra; Fletcher, Susan; Cooper, John; Forbes, David

2013-09-01

There is a high prevalence of psychological trauma exposure among primary care patients. General practitioners are well placed to provide appropriate support for patients coping with trauma. This article outlines an evidence-based early response to psychological trauma. Psychological first aid is the preferred approach in providing early assistance to patients who have experienced a traumatic event. General practitioners can be guided by five empirically derived principles in their early response: promoting a sense of safety, calming, self efficacy, connectedness and hope. Structured psychological interventions, including psychological debriefing, are not routinely recommended in the first few weeks following trauma exposure. General practitioner self care is an important aspect of providing post-trauma patient care.

Evacuation Priorities in Mass Casualty Terror-Related Events

PubMed Central

Einav, Sharon; Feigenberg, Zvi; Weissman, Charles; Zaichik, Daniel; Caspi, Guy; Kotler, Doron; Freund, Herbert R.

2004-01-01

Objective: To assess evacuation priorities during terror-related mass casualty incidents (MCIs) and their implications for hospital organization/contingency planning. Summary Background Data: Trauma guidelines recommend evacuation of critically injured patients to Level I trauma centers. The recent MCIs in Israel offered an opportunity to study the impositions placed on a prehospital emergency medical service (EMS) regarding evacuation priorities in these circumstances. Methods: A retrospective analysis of medical evacuations from MCIs (29.9.2000–31.9.2002) performed by the Israeli National EMS rescue teams. Results: Thirty-three MCIs yielded data on 1156 casualties. Only 57% (506) of the 1123 available and mobilized ambulances were needed to provide 612 evacuations. Rescue teams arrived on scene within <5 minutes and evacuated the last urgent casualty within 15–20 minutes. The majority of non-urgent and urgent patients were transported to medical centers close to the event. Less than half of the urgent casualties were evacuated to more distant trauma centers. Independent variables predicting evacuation to a trauma center were its being the hospital closest to the event (OR 249.2, P < 0.001), evacuation within <10 minutes of the event (OR 9.3, P = 0.003), and having an urgent patient on the ambulance (OR 5.6, P < 0.001). Conclusions: Hospitals nearby terror-induced MCIs play a major role in trauma patient care. Thus, all hospitals should be included in contingency plans for MCIs. Further research into the implications of evacuation of the most severely injured casualties to the nearest hospital while evacuating all other casualties to various hospitals in the area is needed. The challenges posed by terror-induced MCIs require consideration of a paradigm shift in trauma care. PMID:15075645

Acute costs and predictors of higher treatment costs of trauma in New South Wales, Australia.

PubMed

Curtis, Kate; Lam, Mary; Mitchell, Rebecca; Black, Deborah; Taylor, Colman; Dickson, Cara; Jan, Stephen; Palmer, Cameron S; Langcake, Mary; Myburgh, John

2014-01-01

Accurate economic data are fundamental for improving current funding models and ultimately in promoting the efficient delivery of services. The financial burden of a high trauma casemix to designated trauma centres in Australia has not been previously determined, and there is some evidence that the episode funding model used in Australia results in the underfunding of trauma. To describe the costs of acute trauma admissions in trauma centres, identify predictors of higher treatment costs and cost variance in New South Wales (NSW), Australia. Data linkage of admitted trauma patient and financial data provided by 12 Level 1 NSW trauma centres for the 08/09 financial year was performed. Demographic, injury details and injury scores were obtained from trauma registries. Individual patient general ledger costs (actual trauma patient costs), Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs (which form the basis of funding) were obtained. The actual costs incurred by the hospital were then compared with the state-wide AR-DRG average costs. Multivariable multiple linear regression was used for identifying predictors of costs. There were 17,522 patients, the average per patient cost was $10,603 and the median was $4628 (interquartile range: $2179-10,148). The actual costs incurred by trauma centres were on average $134 per bed day above AR-DRG costs-determined costs. Falls, road trauma and violence were the highest causes of total cost. Motor cyclists and pedestrians had higher median costs than motor vehicle occupants. As a result of greater numbers, patients with minor injury had comparable total costs with those generated by patients with severe injury. However the median cost of severely injured patients was nearly four times greater. The count of body regions injured, sex, length of stay, serious traumatic brain injury and admission to the Intensive Care Unit were significantly associated with increased costs (p<0.001). This multicentre trauma costing study demonstrated the feasibility of trauma registry and financial data linkage. Discrepancies between the observed costs of care in these 12 trauma centres and the NSW average AR-DRG costs suggest that trauma care is currently underfunded in NSW. Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.

Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States

PubMed Central

Delgado, M. Kit; Staudenmayer, Kristan L.; Wang, N. Ewen; Spain, David A.; Weir, Sharada; Owens, Douglas K.; Goldhaber-Fiebert, Jeremy D.

2014-01-01

Objective We determined the minimum mortality reduction that helicopter emergency medical services (HEMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of minor injury patients. Methods We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective over a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality adjusted life year (QALY) gained compared to ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma (NSCOT), National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. Results HEMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the NSCOT cohort) to cost less than $100,000 per QALY gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per QALY. HEMS becomes more cost-effective with significant reductions in minor injury patients triaged to air transport or if long-term disability outcomes are improved. Conclusions HEMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably to other interventions considered cost-effective. Given current evidence, it is not clear that HEMS achieves this mortality or disability reduction. Reducing overtriage of minor injury patients to HEMS would improve its cost-effectiveness. PMID:23582619

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis

PubMed Central

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

BACKGROUND: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. METHODS: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients’ demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. RESULTS: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. CONCLUSION: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role. PMID:29796145

The Role of Stent-Grafts in the Management of Aortic Trauma

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

Rousseau, Herve, E-mail: rousseau.h@chu-toulouse.fr; Elaassar, Omar; Marcheix, Bertrand

Stent graft has resulted in major advances in the treatment of trauma patients with blunt traumatic aortic injury (TAI) and has become the preferred method of treatment at many trauma centers. In this review, we provide an overview of the place of stent grafts for the management of this disease. As a whole, TEVAR repair of TAIs offers a survival advantage and reduction in major morbidity, including paraplegia, compared with open surgery. However, endovascular procedures in trauma require a sophisticated multidisciplinary and experienced team approach. More research and development of TAI-specific endograft devices is needed and large, multicenter studies willmore » help to clarify the role of TEVAR compared with open repair of TAI.« less

History of sexual trauma moderates psychotherapy outcome for posttraumatic stress disorder.

PubMed

Markowitz, John C; Neria, Yuval; Lovell, Karina; Van Meter, Page E; Petkova, Eva

2017-08-01

Moderators of differential psychotherapy outcome for posttraumatic stress disorder (PTSD) are rare, yet have crucial clinical importance. We tested the moderating effects of trauma type for three psychotherapies in 110 unmedicated patients with chronic DSM-IV PTSD. Patients were randomized to 14 weeks of prolonged exposure (PE, N = 38), interpersonal psychotherapy (IPT, N = 40), or relaxation therapy (RT, N = 32). The Clinician-Administered PTSD Scale (CAPS) was the primary outcome measure. Moderator candidates were trauma type: interpersonal, sexual, physical. We fit a regression model for week 14 CAPS as a function of treatment (a three-level factor), an indicator of trauma type presence/absence, and their interactions, controlling for baseline CAPS, and evaluated potential confounds. Thirty-nine (35%) patients reported sexual, 68 (62%) physical, and 102 (93%) interpersonal trauma. Baseline CAPS scores did not differ by presence/absence of trauma types. Sexual trauma as PTSD criterion A significantly moderated treatment effect: whereas all therapies had similar efficacy among nonsexually-traumatized patients, IPT had greater efficacy among sexually traumatized patients (efficacy difference with and without sexual trauma: IPT vs. PE and IPT vs. RT P's < .05), specifically in PTSD symptom clusters B and D (P's < .05). Few studies have assessed effects of varying trauma types on effects of differing psychotherapies. In this exploratory study, sexual trauma moderated PTSD outcomes of three therapies: IPT showed greater benefit for sexually traumatized patients than PE or RT. The IPT focuses on affect to help patients determine trust in their current environments may particularly benefit patients who have suffered sexual assault. © 2017 Wiley Periodicals, Inc.

Advanced Ultrasonic Diagnosis of Extremity Trauma: The Faster Exam

NASA Technical Reports Server (NTRS)

Dulchavsky, S. A.; Henry, S. E.; Moed, B. R.; Diebel, L. N.; Marshburn, T.; Hamilton, D. R.; Logan, J.; Kirkpatrick, A. W.; Williams, D. R.

2002-01-01

Ultrasound is of prO)len accuracy in abdominal and thoracic trauma and may be useful to diagnose extremity injury in situations where radiography is not available such as military and space applications. We prospectively evaluated the utility of extremity , ultrasound performed by trained, non-physician personnel in patients with extremity trauma, to simulate remote aerospace or military applications . Methods: Patients with extremity trauma were identified by history, physical examination, and radiographic studies. Ultrasound examination was performed bilaterally by nonphysician personnel with a portable ultrasound device using a 10-5 MHz linear probe, Images were video-recorded for later analysis against radiography by Fisher's exact test. The average time of examination was 4 minutes. Ultrasound accurately diagnosed extremity, injury in 94% of patients with no false positive exams; accuracy was greater in mid-shaft locations and least in the metacarpa/metatarsals. Soft tissue/tendon injury was readily visualized . Extremity ultrasound can be performed quickly and accurately by nonphysician personnel with excellent accuracy. Blinded verification of the utility of ultrasound in patients with extremity injury should be done to determine if Extremity and Respiratory evaluation should be added to the FAST examination (the FASTER exam) and verify the technique in remote locations such as military and aerospace applications.

Management of haemothoraces in blunt thoracic trauma: study protocol for a randomised controlled trial

PubMed Central

Carver, David A; Bressan, Alexsander K; Schieman, Colin; Grondin, Sean C; Kirkpatrick, Andrew W; Lall, Rohan; McBeth, Paul B; Dunham, Michael B; Ball, Chad G

2018-01-01

Introduction Haemothorax following blunt thoracic trauma is a common source of morbidity and mortality. The optimal management of moderate to large haemothoraces has yet to be defined. Observational data have suggested that expectant management may be an appropriate strategy in stable patients. This study aims to compare the outcomes of patients with haemothoraces following blunt thoracic trauma treated with either chest drainage or expectant management. Methods and analysis This is a single-centre, dual-arm randomised controlled trial. Patients presenting with a moderate to large sized haemothorax following blunt thoracic trauma will be assessed for eligibility. Eligible patients will then undergo an informed consent process followed by randomisation to either (1) chest drainage (tube thoracostomy) or (2) expectant management. These groups will be compared for the rate of additional thoracic interventions, major thoracic complications, length of stay and mortality. Ethics and dissemination This study has been approved by the institution’s research ethics board and registered with ClinicalTrials.gov. All eligible participants will provide informed consent prior to randomisation. The results of this study may provide guidance in an area where there remains significant variation between clinicians. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. Trial registration number NCT03050502. PMID:29502092

Computed tomography in the evaluation of penetrating neck trauma: a preliminary study.

PubMed

Gracias, V H; Reilly, P M; Philpott, J; Klein, W P; Lee, S Y; Singer, M; Schwab, C W

2001-11-01

Penetrating neck trauma has traditionally been evaluated by surgical exploration and/or invasive diagnostic studies. We hypothesized that computed tomography (CT), used as an early diagnostic tool to accurately determine trajectory, would direct or eliminate further studies or procedures in stable patients with penetrating neck trauma. Retrospective case series. Academic, urban, level I trauma center. Hemodynamically stable patients without hard signs of vascular injury or aerodigestive violation who had sustained penetrating trauma to the neck. Patients underwent a spiral CT as an initial diagnostic study after initial evaluation in the trauma bay. Further invasive studies were directed by CT findings. Number of invasive studies performed. Twenty-three patients were identified during the 30-month period. Nineteen patients sustained gunshot wounds; 3, shotgun wounds; and 1, a stab wound. One patient died of a cranial gunshot wound. Three isolated zone I, 1 isolated zone II, 9 isolated zone III, and 10 multiple neck zone trajectories were evaluated. Thirteen patients were identified by CT to have trajectories remote from vital structures and required no further evaluation. Ten patients underwent angiography. Only 2 underwent bronchoscopy and esophagoscopy. Four patients were discharged from the emergency department; 7 other patients were discharged within 24 hours. No adverse patient events occurred before, during, or after CT scan. Computed tomography in stable selected patients with penetrating neck trauma appears safe. Invasive studies can often be eliminated from the diagnostic algorithm when CT demonstrates trajectories remote from vital structures. As a result, efficient evaluation and early discharge from the trauma bay or emergency department can be realized. Further prospective study of CT scan after penetrating neck trauma is needed.

Cumulative effective dose associated with computed tomography examinations in adolescent trauma patients.

PubMed

Choi, Seung Joon; Kim, Eun Young; Kim, Hyung Sik; Choi, Hye-Young; Cho, Jinseong; Yang, Hyuk Jun; Chung, Yong Eun

2014-07-01

The aims of this study were to analyze cumulative effective dose (cED) and to assess lifetime attributable risk (LAR) of cancer due to radiation exposure during computed tomography (CT) examinations in adolescent trauma patients. Between January 2010 and May 2011, the adolescent patients with trauma were enrolled in this study. Numbers of CT examinations and body regions examined were collated, and cEDs were calculated using dose-length product values and conversion factors. Lifetime attributable risk for cancer incidence and cancer-associated mortality were quantified based on the studies of survivors of the atomic bombs on Japan. Data were stratified according to severity of trauma: minor trauma, injury severity score of less than 16; and major trauma, injury severity score of 16 or greater. A total of 698 CT scans were obtained on the following regions of 484 adolescent patients: head CT, n = 647; rest of the body, n = 41; and thorax, n = 10. Mean cED per patient was 3.4 mSv, and mean LARs for cancer incidence and mortality were 0.05% and 0.02%, respectively. The majority of patients (98.4%) experienced minor trauma, and their mean cED and LARs for cancer incidence and mortality (3.0 mSv and 0.04% and 0.02%, respectively) were significantly lower than those of patients with major trauma (24.3 mSv and 0.31% and 0.15%, respectively, all P values < 0.001). The overall radiation-induced cancer risk due to CT examinations performed for the initial assessment of minor trauma was found to be relatively low in adolescent patients. However, adolescent patients with major trauma were exposed to a substantial amount of radiation during multiple CT examinations.

Epidemiological evaluation of hepatic trauma victims undergoing surgery.

PubMed

Kalil, Mitre; Amaral, Isaac Massaud Amim

2016-02-01

to evaluate the epidemiological variables and diagnostic and therapeutic modalities related to hepatic trauma patients undergoing laparotomy in a public referral hospital in the metropolitan region of Vitória-ES. we conducted a retrospective study, reviewing charts of trauma patients with liver injuries, whether isolated or in association with other organs, who underwent exploratory laparotomy, from January 2011 to December 2013. We studied 392 patients, 107 of these with liver injury. The male: female ratio was 6.6 : 1 and the mean age was 30.12 years. Penetrating liver trauma occurred in 78.5% of patients, mostly with firearms. Associated injuries occurred in 86% of cases and intra-abdominal injuries were more common in penetrating trauma (p <0.01). The most commonly used operative technique was hepatorrhaphy and damage control surgery was applied in 6.5% of patients. The average amounts of blood products used were 6.07 units of packed red blood cells and 3.01 units of fresh frozen plasma. The incidence of postoperative complications was 29.9%, the most frequent being infectious, including pneumonia, peritonitis and intra-abdominal abscess. The survival rate of patients suffering from blunt trauma was 60%, and penetrating trauma, 87.5% (p <0.05). despite technological advances in diagnosis and treatment, mortality rates in liver trauma remain high, especially in patients suffering from blunt trauma in relation to penetrating one.

The need for pediatric-specific triage criteria: results from the Florida Trauma Triage Study.

PubMed

Phillips, S; Rond, P C; Kelly, S M; Swartz, P D

1996-12-01

The objective of the Florida Trauma Triage Study was to assess the performance of state-adopted field triage criteria. The study addressed three specific age groups: pediatric (age < 15 years), adult (age 15-54 years), and geriatric (age 55+ years). Since 1990, Florida has used a uniform set of eight triage criteria, known as the trauma scorecard, for triaging adult trauma patients to state-approved trauma centers. However, only five of the criteria are recommended for use with pediatric patients. This article presents the findings regarding the performance of the scorecard when applied to a pediatric population. We used state trauma registry data linked to state hospital discharge data in a retrospective analysis of trauma patients transported by prehospital providers to any acute care hospital within nine selected Florida counties between July 1, 1991, and December 31, 1991. We used cross-table and logistic regression analysis to determine the ability of triage criteria to correctly identify patients who were retrospectively defined as major trauma. We applied the field criteria to physiologic and anatomy/mechanism of injury data contained in the trauma registry to "score" the patient as major or minor trauma. To make our retrospective determination of major or minor trauma we used the protocols developed by an expert medical panel as described by E. J. MacKenzie et al. (1990). We calculated sensitivity, specificity, and the corresponding over- and undertriage rates by comparing patient classifications (major or minor trauma) produced by the triage criteria and the retrospective algorithm. We used logistic regression to identify which triage criteria were statistically significant in predicting major trauma. Pediatric cases accounted for 9.2% of the total study population, 6.0% of all hospitalized cases, and 6.8% of all trauma deaths. Of the 1505 pediatric cases available for analysis, the triage criteria classified 269 cases as expected major trauma and 1236 cases as expected minor trauma. The retrospective algorithm classified 78 cases as expected major trauma and 1427 cases as expected minor trauma. The resulting specificity is 84.8% (15.2% overtriage), and the sensitivity is 66.7% (33.3% undertriage). Logistic regression indicated that, of the eight state-adopted field triage criteria, only the Glasgow coma score, ejection from vehicle, and penetrating injuries have a statistically significant impact on predicting major trauma in pediatric patients. Although the state-adopted trauma scorecard, applied to a pediatric population, produced acceptable overtriage, it did not produce acceptable undertriage. However, our undertriage rate is comparable to the results of other published studies on pediatric trauma. As a result of the Florida Trauma Triage Study, a new pediatric triage instrument was developed. It is currently being field-tested.

Radiation dose from initial trauma assessment and resuscitation: review of the literature.

PubMed

Hui, Catherine M; MacGregor, John H; Tien, Homer C; Kortbeek, John B

2009-04-01

Trauma care benefits from the use of imaging technologies. Trauma patients and trauma team members are exposed to radiation during the continuum of care. Knowledge of exposure amounts and effects are important for trauma team members. We performed a review of the published literature; keywords included "trauma," "patients," "trauma team members," "wounds," "injuries," "radiation," "exposure," "dose" and "computed tomography" (CT). We also reviewed the Board on Radiation Effects Research (BEIR VII) report, published in 2005 and 2006. We found no randomized controlled trials or studies. Relevant studies demonstrated that CT accounts for the single largest radiation exposure in trauma patients. Exposure to 100 mSv could result in a solid organ cancer or leukemia in 1 of 100 people. Trauma team members do not exceed the acceptable occupation radiation exposure determined by the National Council of Radiation Protection and Management. Modern imaging technologies such as 16- and 64-slice CT scanners may decrease radiation exposure. Multiple injured trauma patients receive a substantial dose of radiation. Radiation exposure is cumulative. The low individual risk of cancer becomes a greater public health issue when multiplied by a large number of examinations. Though CT scans are an invaluable resource and are becoming more easily accessible, they should not replace careful clinical examination and should be used only in appropriate patients.

Trauma associated sleep disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors.

PubMed

Mysliwiec, Vincent; O'Reilly, Brian; Polchinski, Jason; Kwon, Herbert P; Germain, Anne; Roth, Bernard J

2014-10-15

To characterize the clinical, polysomnographic and treatment responses of patients with disruptive nocturnal behaviors (DNB) and nightmares following traumatic experiences. A case series of four young male, active duty U.S. Army Soldiers who presented with DNB and trauma related nightmares. Patients underwent a clinical evaluation in a sleep medicine clinic, attended overnight polysomnogram (PSG) and received treatment. We report pertinent clinical and PSG findings from our patients and review prior literature on sleep disturbances in trauma survivors. DNB ranged from vocalizations, somnambulism to combative behaviors that injured bed partners. Nightmares were replays of the patient's traumatic experiences. All patients had REM without atonia during polysomnography; one patient had DNB and a nightmare captured during REM sleep. Prazosin improved DNB and nightmares in all patients. We propose Trauma associated Sleep Disorder (TSD) as a unique sleep disorder encompassing the clinical features, PSG findings, and treatment responses of patients with DNB, nightmares, and REM without atonia after trauma.

Obesity in trauma patients: correlations of body mass index with outcomes, injury patterns, and complications.

PubMed

Evans, David C; Stawicki, Stanislaw P A; Davido, H Tracy; Eiferman, Daniel

2011-08-01

Current understanding of the effects of obesity on trauma patients is incomplete. We hypothesized that among older trauma patients, obese patients differ from nonobese patients in injury patterns, complications, and mortality. Patients older than 45 years old presenting to a Level I trauma center were included in this retrospective database analysis (n = 461). Body mass index (BMI) groups were defined as underweight less than 18.5 kg/m(2), normal 18.5 to 24.9 kg/m(2), overweight 25.0 to 29.9 kg/m(2), or obese greater than 30 kg/m(2). Injury patterns, complications, and outcomes were analyzed using univariate analyses, multivariate logistic regression, and Kaplan-Meier survival analysis. Higher BMI is associated with a higher incidence of torso injury and proximal upper extremity injuries in blunt trauma (n = 410). All other injury patterns and complications (except anemia) were similar between BMI groups. The underweight (BMI less than 18.5 kg/m(2)) group had significantly lower 90-day survival than other groups (P < 0.05). BMI is not a predictor of morbidity or mortality in multivariate analysis. Among older blunt trauma patients, increasing BMI is associated with higher rates of torso and proximal upper extremity injuries. Our study suggests that obesity is not an independent risk factor for complications or mortality after trauma in older patients. Conversely, underweight trauma patients had a lower 90-day survival.

Maxillofacial injuries among trauma patients undergoing head computerized tomography; A Ugandan experience

PubMed Central

Krishnan, Ullas Chandrika; Byanyima, Rosemary Kusaba; Faith, Ameda; Kamulegeya, Adriane

2017-01-01

Aim: The aim of this study was to investigate epidemiological features of maxillofacial fractures within trauma patients who had head and neck computed tomography (CT) scan at the Mulago National referral hospital. Methods: CT scan records of trauma patients who had head scans at the Department of Radiology over 1-year period were accessed. Data collected included sociodemographic factors, type and etiology of injury, and concomitant maxillofacial injuries. Results: A total of 1330 trauma patients underwent head and neck CT scan in the 1-year study period. Out of these, 130 were excluded due to incomplete or unclear records and no evidence of injury. Of the remaining 1200, 32% (387) had maxillofacial fractures. The median age of the patients with maxillofacial fractures was 28 (range = 18–80) years and 18–27 age group was most common at 47.5%. Road traffic accidents constituted 49.1% of fractures. The single most affected isolated bone was the frontal bone (23%). The number of maxillofacial bones fractured was predicted by age group (df = 3 F = 5.358, P = 0.001), association with other fractures (df = 1 F = 5.317, P = 0.03). Conclusions: Good matched case–control prospective studies are needed to enable us tease out the finer difference in the circumstances and pattern of injury if we are to design appropriate preventive measures. PMID:29291177

Fever in trauma patients: evaluation of risk factors, including traumatic brain injury.

PubMed

Bengualid, Victoria; Talari, Goutham; Rubin, David; Albaeni, Aiham; Ciubotaru, Ronald L; Berger, Judith

2015-03-01

The role of fever in trauma patients remains unclear. Fever occurs as a response to release of cytokines and prostaglandins by white blood cells. Many factors, including trauma, can trigger release of these factors. To determine whether (1) fever in the first 48 hours is related to a favorable outcome in trauma patients and (2) fever is more common in patients with head trauma. Retrospective study of trauma patients admitted to the intensive care unit for at least 2 days. Data were analyzed by using multivariate analysis. Of 162 patients studied, 40% had fever during the first 48 hours. Febrile patients had higher mortality rates than did afebrile patients. When adjusted for severity of injuries, fever did not correlate with mortality. Neither the incidence of fever in the first 48 hours after admission to the intensive care unit nor the number of days febrile in the unit differed between patients with and patients without head trauma (traumatic brain injury). About 70% of febrile patients did not have a source found for their fever. Febrile patients without an identified source of infection had lower peak white blood cell counts, lower maximum body temperature, and higher minimum platelet counts than did febrile patients who had an infectious source identified. The most common infection was pneumonia. No relationship was found between the presence of fever during the first 48 hours and mortality. Patients with traumatic brain injury did not have a higher incidence of fever than did patients without traumatic brain injury. About 30% of febrile patients had an identifiable source of infection. Further studies are needed to understand the origin and role of fever in trauma patients. ©2015 American Association of Critical-Care Nurses.

Association of child maltreatment and psychiatric diagnosis in Brazilian children and adolescents

PubMed Central

Scomparini, Luciana Burim; dos Santos, Bernardo; Rosenheck, Robert Alan; Scivoletto, Sandra

2013-01-01

OBJECTIVES: The objective of this study was to evaluate the association between different types of child maltreatment and the presence of psychiatric disorders in highly vulnerable children and adolescents served by a multidisciplinary program. METHODS: In total, 351 patients with a mean age of 12.47, of whom 68.7% were male and 82.1% lived in shelters, underwent psychiatric evaluations based on the Kiddie-Sads-Present and Lifetime Version. Two different methods were used to evaluate maltreatment: medical records were reviewed to identify previous diagnoses related to socioeconomic and psychosocial circumstances, and the Childhood Trauma Questionnaire was used to obtain a structured history of trauma. Bivariate associations were evaluated between psychiatric disorders and evidence of each type and the frequency of abuse. RESULTS: The most frequent psychiatric diagnoses were substance use disorders, affective disorders and specific disorders of early childhood, whereas 13.67% of the sample had no psychiatric diagnosis. All patients suffered neglect, and 58.4% experienced physical or sexual abuse. The presence of a history of multiple traumas was only associated with a diagnosis of substance use disorder. Mental retardation showed a strong positive association with reported physical abuse and emotional neglect. However, a negative correlation was found when we analyzed the presence of a history of multiple traumas and mental retardation. CONCLUSION: All children living in adverse conditions deserve careful assistance, but we found that physical abuse and emotional neglect were most strongly associated with mental retardation and multiple traumas with substance abuse. PMID:24037004

Pediatric blunt cerebrovascular injury: the McGovern screening score.

PubMed

Herbert, Joseph P; Venkataraman, Sidish S; Turkmani, Ali H; Zhu, Liang; Kerr, Marcia L; Patel, Rajan P; Ugalde, Irma T; Fletcher, Stephen A; Sandberg, David I; Cox, Charles S; Kitagawa, Ryan S; Day, Arthur L; Shah, Manish N

2018-03-16

OBJECTIVE The objective of this study was to assess the incidence, diagnosis, and treatment of pediatric blunt cerebrovascular injury (BCVI) at a busy Level 1 trauma center and to develop a tool for accurately predicting pediatric BCVI and the need for diagnostic testing. METHODS This is a retrospective cohort study of a prospectively collected database of pediatric patients who had sustained blunt trauma (patient age range 0-15 years) and were treated at a Level 1 trauma center between 2005 and 2015. Digital subtraction angiography, MR angiography, or CT angiography was used to confirm BCVI. Recently, the Utah score has emerged as a screening tool specifically targeted toward evaluating BCVI risk in the pediatric population. Using logistical regression and adding mechanism of injury as a logit, the McGovern score was able to use the Utah score as a starting point to create a more sensitive screening tool to identify which pediatric trauma patients should receive angiographic imaging due to a high risk for BCVI. RESULTS A total of 12,614 patients (mean age 6.6 years) were admitted with blunt trauma and prospectively registered in the trauma database. Of these, 460 (3.6%) patients underwent angiography after blunt trauma: 295 (64.1%), 107 (23.3%), 6 (1.3%), and 52 (11.3%) patients underwent CT angiography, MR angiography, digital subtraction angiography, and a combination of imaging modalities, respectively. The BCVI incidence (n = 21; 0.17%) was lower than that in a comparable adult group (p < 0.05). The mean patient was age 10.4 years with a mean follow-up of 7.5 months. Eleven patients (52.4%) were involved in a motor vehicle collision, with a mean Glasgow Coma Scale score of 8.6. There were 8 patients (38.1%) with carotid canal fracture, 6 patients (28.6%) with petrous bone fracture, and 2 patients (9.5%) with infarction on initial presentation. Eight patients (38.1%) were managed with observation alone. The Denver, modified Memphis, Eastern Association for the Surgery of Trauma (EAST), and Utah scores, which are the currently used screening tools for BCVI, misclassified 6 (28.6%), 6 (28.6%), 7 (33.3%), and 10 (47.6%) patients with BCVI, respectively, as "low risk" and not in need of subsequent angiographic imaging. By incorporating the mechanism of injury into the score, the McGovern score only misclassified 4 (19.0%) children, all of whom were managed conservatively with no treatment or aspirin. CONCLUSIONS With a low incidence of pediatric BCVI and a nonsurgical treatment paradigm, a more conservative approach than the Biffl scale should be adopted. The Denver, modified Memphis, EAST, and Utah scores did not accurately predict BCVI in our equally large cohort. The McGovern score is the first BCVI screening tool to incorporate the mechanism of injury into its screening criteria, thereby potentially allowing physicians to minimize unnecessary radiation and determine which high-risk patients are truly in need of angiographic imaging.

The efficacy of initial hydrocortisone administration at preventing posttraumatic distress in adult trauma patients: a randomized trial

PubMed Central

Delahanty, Douglas L.; Gabert-Quillen, Crystal; Ostrowski, Sarah A.; Nugent, Nicole R.; Fischer, Beth; Morris, Adam; Pitman, Roger K.; Bon, John; Fallon, William

2013-01-01

Objective/Introduction Secondary pharmacological interventions have shown promise at reducing the development of posttraumatic stress disorder symptoms (PTSS) in preclinical studies. The present study examined the preliminary efficacy of a 10-day low-dose (20 mg bid) course of hydrocortisone at preventing PTSS in traumatic injury victims. Methods Sixty-four traumatic injury patients (34% female) were randomly assigned in a double-blind protocol to receive either a 10-day course of hydrocortisone or placebo initiated within 12 hours of the trauma. One-month and 3-months posttrauma participants completed an interview to assess PTSS and self-report measures of depression and health-related quality of life. Results Hydrocortisone recipients reported fewer PTSD and depression symptoms, and had greater improvements in health-related quality of life during the first 3 months posttrauma than did placebo recipients. Hydrocortisone recipients who had never received prior mental health treatment had the lowest PTSD scores. Conclusion Low-dose hydrocortisone may be a promising approach to the prevention of PTSD in acutely injured trauma patients, and may be particularly efficacious in acutely injured trauma victims without a history of significant psychopathology. PMID:23557627

Rhabdomyolysis in Critically Ill Surgical Patients.

PubMed

Kuzmanovska, Biljana; Cvetkovska, Emilija; Kuzmanovski, Igor; Jankulovski, Nikola; Shosholcheva, Mirjana; Kartalov, Andrijan; Spirovska, Tatjana

2016-07-27

Rhabdomyolysis is a syndrome of injury of skeletal muscles associated with myoglobinuria, muscle weakness, electrolyte imbalance and often, acute kidney injury as severe complication. of this study is to detect the incidence of rhabdomyolysis in critically ill patients in the surgical intensive care unit (ICU), and to raise awareness of this medical condition and its treatment among the clinicians. A retrospective review of all surgical and trauma patients admitted to surgical ICU of the University Surgical Clinic "Mother Teresa" in Skopje, Macedonia, from January 1 st till December 31 st 2015 was performed. Patients medical records were screened for available serum creatine kinase (CK) with levels > 200 U/l, presence of myoglobin in the serum in levels > 80 ng/ml, or if they had a clinical diagnosis of rhabdomyolysis by an attending doctor. Descriptive statistical methods were used to analyze the collected data. Out of totally 1084 patients hospitalized in the ICU, 93 were diagnosed with rhabdomyolysis during the course of one year. 82(88%) patients were trauma patients, while 11(12%) were surgical non trauma patients. 7(7.5%) patients diagnosed with rhabdomyolysis developed acute kidney injury (AKI) that required dialysis. Average values of serum myoglobin levels were 230 ng/ml, with highest values of > 5000 ng/ml. Patients who developed AKI had serum myoglobin levels above 2000 ng/ml. Average values of serum CK levels were 400 U/l, with highest value of 21600 U/l. Patients who developed AKI had serum CK levels above 3000 U/l. Regular monitoring and early detection of elevated serum CK and myoglobin levels in critically ill surgical and trauma patients is recommended in order to recognize and treat rhabdomyolysis in timely manner and thus prevent development of AKI.

Comparative study of earthquake-related and non-earthquake-related head traumas using multidetector computed tomography

PubMed Central

Chu, Zhi-gang; Yang, Zhi-gang; Dong, Zhi-hui; Chen, Tian-wu; Zhu, Zhi-yu; Shao, Heng

2011-01-01

OBJECTIVE: The features of earthquake-related head injuries may be different from those of injuries obtained in daily life because of differences in circumstances. We aim to compare the features of head traumas caused by the Sichuan earthquake with those of other common head traumas using multidetector computed tomography. METHODS: In total, 221 patients with earthquake-related head traumas (the earthquake group) and 221 patients with other common head traumas (the non-earthquake group) were enrolled in our study, and their computed tomographic findings were compared. We focused the differences between fractures and intracranial injuries and the relationships between extracranial and intracranial injuries. RESULTS: More earthquake-related cases had only extracranial soft tissue injuries (50.7% vs. 26.2%, RR = 1.9), and fewer cases had intracranial injuries (17.2% vs. 50.7%, RR = 0.3) compared with the non-earthquake group. For patients with fractures and intracranial injuries, there were fewer cases with craniocerebral injuries in the earthquake group (60.6% vs. 77.9%, RR = 0.8), and the earthquake-injured patients had fewer fractures and intracranial injuries overall (1.5±0.9 vs. 2.5±1.8; 1.3±0.5 vs. 2.1±1.1). Compared with the non-earthquake group, the incidences of soft tissue injuries and cranial fractures combined with intracranial injuries in the earthquake group were significantly lower (9.8% vs. 43.7%, RR = 0.2; 35.1% vs. 82.2%, RR = 0.4). CONCLUSION: As depicted with computed tomography, the severity of earthquake-related head traumas in survivors was milder, and isolated extracranial injuries were more common in earthquake-related head traumas than in non-earthquake-related injuries, which may have been the result of different injury causes, mechanisms and settings. PMID:22012045

The Trauma Time-Out: Evaluating the Effectiveness of Protocol-Based Information Dissemination in the Traumatically Injured Patient.

PubMed

Nolan, Heather R; Fitzgerald, Michael; Howard, Brett; Jarrard, Joey; Vaughn, Danny

Procedural time-outs are widely accepted safety standards that are protocolized in nearly all hospital systems. The trauma time-out, however, has been largely unstudied in the existing literature and does not have a standard protocol outlined by any of the major trauma surgery organizations. The goal of this study was to evaluate our institution's use of the trauma time-out and assess how trauma team members viewed its effectiveness. A multiple-answer survey was sent to trauma team members at a Level I trauma center. Questions included items directed at background, experience, opinions, and write-in responses. Most responders were experienced trauma team members who regularly participated in trauma codes. All respondents noted the total time required to complete the time-out was less than 5 min, with the majority saying it took less than 1 min. Seventy-five percent agreed that trauma time-outs should continue, with 92% noting that it improved understanding of patient presentation and prehospital evaluation. Seventy-seven percent said it improved understanding of other team member's roles, and 75% stated it improved patient care. Subgroups of physicians and nurses were statistically similar; yet, physicians did note that it improved their understanding of the team member's function more frequently than nurses. The trauma time-out can be an excellent tool to improve patient care and team understanding of the incoming trauma patient. Although used widely at multiple levels of trauma institutions, development of a documented protocol can be the next step in creating a unified safety standard.

Maxillofacial Fractures: Twenty Years of Study in the Department of Maxillofacial Surgery in Kosovo

PubMed Central

Loxha, Mergime Prekazi; Sejfija, Osman; Salihu, Sami; Gjinolli, Fellanza; Agani, Zana; Hamiti, Vjosa; Rexhepi, Aida Namani; Gecaj-Gashi, Agreta

2013-01-01

The aim: The aim of this study was to analyze maxillofacial region fractures during the past 20 years in the Department of Maxillofacial Surgery in Prishtina. Methods: We have analyzed the histories of all patients with trauma who were hospitalized in the Department of Maxillofacial Surgery in Prishtina since the opening of the clinic in 1983 through 2005. Narrowing the subject of our research, we concentrated on fractures of the maxillofacial region treated at the Clinic of Maxillofacial Surgery for the period 2001–2005. We have analyzed those fractures and compared them with the period from 1983 to 2005 only when it was reasonable. Results: During this period, 1,945 patients were treated for trauma in the maxillofacial region by the Department of Maxillofacial Surgery. This group included 19.8% females and 80.2% males. The largest age group were those between 20 and 20 years of age. Causes of trauma for both periods were predominantly traffic accidents; however, during the period 2001-2005, interpersonal conflicts were increasingly the cause of fractures. Conclusion: Interpersonal conflict as a cause of maxillofacial trauma has risen in recent years. With this increase the methods of treating fractures in this region are also changing. PMID:24167433

Assessment of injury severity in patients with major trauma.

PubMed

Stanford, Penelope; Booth, Nicola; Suckley, Janet; Twelvetree, Timothy; Thomas, Debbie

2016-08-03

Major trauma centres provide specialised care for patients who have experienced serious traumatic injury. This article provides information about major trauma centres and outlines the assessment tools used in this setting. Since patients in major trauma centres will be transferred to other settings, including inpatient wards and primary care, this article is relevant for both nurses working in major trauma centres and in these areas. Traumatic injuries require rapid assessment to ensure the patient receives prompt, adequate and appropriate treatment. A range of assessment tools are available to assist nurses in major trauma centres and emergency care to assess the severity of a patient's injury. The most commonly used tools are triage, Catastrophic Haemorrhage Airway to Exposure assessment, pain assessment and the Glasgow Coma Scale. This article summarises the use of these assessment tools in these settings, and discusses the use of the Injury Severity Score (ISS) to determine the severity of patient injuries.

Comparison of the predictive performance of the BIG, TRISS, and PS09 score in an adult trauma population derived from multiple international trauma registries

PubMed Central

2013-01-01

Background The BIG score (Admission base deficit (B), International normalized ratio (I), and Glasgow Coma Scale (G)) has been shown to predict mortality on admission in pediatric trauma patients. The objective of this study was to assess its performance in predicting mortality in an adult trauma population, and to compare it with the existing Trauma and Injury Severity Score (TRISS) and probability of survival (PS09) score. Materials and methods A retrospective analysis using data collected between 2005 and 2010 from seven trauma centers and registries in Europe and the United States of America was performed. We compared the BIG score with TRISS and PS09 scores in a population of blunt and penetrating trauma patients. We then assessed the discrimination ability of all scores via receiver operating characteristic (ROC) curves and compared the expected mortality rate (precision) of all scores with the observed mortality rate. Results In total, 12,206 datasets were retrieved to validate the BIG score. The mean ISS was 15 ± 11, and the mean 30-day mortality rate was 4.8%. With an AUROC of 0.892 (95% confidence interval (CI): 0.879 to 0.906), the BIG score performed well in an adult population. TRISS had an area under ROC (AUROC) of 0.922 (0.913 to 0.932) and the PS09 score of 0.825 (0.915 to 0.934). On a penetrating-trauma population, the BIG score had an AUROC result of 0.920 (0.898 to 0.942) compared with the PS09 score (AUROC of 0.921; 0.902 to 0.939) and TRISS (0.929; 0.912 to 0.947). Conclusions The BIG score is a good predictor of mortality in the adult trauma population. It performed well compared with TRISS and the PS09 score, although it has significantly less discriminative ability. In a penetrating-trauma population, the BIG score performed better than in a population with blunt trauma. The BIG score has the advantage of being available shortly after admission and may be used to predict clinical prognosis or as a research tool to risk stratify trauma patients into clinical trials. PMID:23844754

A protocol for a scoping and qualitative study to identify and evaluate indications for damage control surgery and damage control interventions in civilian trauma patients

PubMed Central

Roberts, Derek J; Zygun, David A; Kirkpatrick, Andrew W; Ball, Chad G; Faris, Peter D; Bobrovitz, Niklas; Robertson, Helen Lee; Stelfox, H Thomas

2014-01-01

Introduction Initial abbreviated surgery with planned reoperation (damage control surgery) is frequently used for major trauma patients to rapidly control haemorrhage while limiting surgical stress. Although damage control surgery may decrease mortality risk among the severely injured, it may also be associated with several complications when inappropriately applied. We seek to scope the literature on trauma damage control surgery, identify its proposed indications, map and clarify their definitions, and examine the content and evidence on which they are based. We also seek to generate a comprehensive list of unique indications to inform an appropriateness rating process. Methods and analysis We will search 11 electronic bibliographic databases, included article bibliographies and grey literature sources for citations involving civilian trauma patients that proposed one or more indications for damage control surgery or a damage control intervention. Indications will be classified into a predefined conceptual framework and categorised and described using qualitative content analysis. Constant comparative methodology will be used to create, modify and test codes describing principal findings or injuries (eg, bilobar liver injury) and associated decision variables (eg, coagulopathy) that comprise the reported indications. After a unique list of codes have been developed, we will use the organisational system recommended by the RAND/University of California, Los Angeles (RAND-UCLA) Appropriateness Rating Method to group principal findings or injuries into chapters (subdivided by associated decision variables) according to broader clinical findings encountered during surgical practice (eg, major liver injury). Ethics and dissemination This study will constitute the first step in a multistep research programme aimed at developing appropriate, evidence-informed indications for damage control in civilian trauma patients. With use of an integrated knowledge translation intervention that includes collaboration with surgical practice leaders, this research may allow for development of indications that are more likely to be relevant to and used by surgeons. Ethics approval is not required for this study. PMID:25001397

Outcomes following trauma laparotomy for hypotensive trauma patients: a UK military and civilian perspective.

PubMed

Marsden, Max; Carden, Rich; Navaratne, Lalin; Smith, Iain M; Penn-Barwell, Jowan G; Kraven, Luke M; Brohi, Karim; Tai, Nigel R M; Bowley, Douglas M

2018-05-25

The management of trauma patients has changed radically in the last decade and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts. We undertook a review of two prospectively maintained trauma databases; the UK Joint Theatre Trauma Registry (JTTR) for the military cohort (4th February 2003 to 21st September 2014), and the trauma registry of the Royal London Hospital MTC (1st January 2012 to 1st January 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the Emergency Department (ED) were included. Hypotension was present on arrival at the ED in 155/761 (20.4%) military patients. Mortality was higher in hypotensive casualties 25.8% vs 9.7% normotensive casualties (p<0.001). Hypotension was present on arrival at the ED in 63/176 (35.7%) civilian patients. Mortality was higher in hypotensive patients 47.6% vs 12.4% normotensive patients (p<0.001). In both cohorts of hypotensive patients neither the average injury severity, the prehospital time, the ED arrival SBP, nor mortality rate changed significantly during the study period. Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the Emergency Department with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients. IV; Observational Cohort Study.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review

PubMed Central

2013-01-01

Introduction The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay. Methods For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST. Results We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison. Conclusions NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups. PMID:24004931

Characteristics of ACS-verified Level I and Level II trauma centers: A study linking trauma center verification review data and the National Trauma Data Bank of the American College of Surgeons Committee on Trauma.

PubMed

Shafi, Shahid; Barnes, Sunni; Ahn, Chul; Hemilla, Mark R; Cryer, H Gill; Nathens, Avery; Neal, Melanie; Fildes, John

2016-10-01

The Trauma Quality Improvement Project of the American College of Surgeons (ACS) has demonstrated variations in trauma center outcomes despite similar verification status. The purpose of this study was to identify structural characteristics of trauma centers that affect patient outcomes. Trauma registry data on 361,187 patients treated at 222 ACS-verified Level I and Level II trauma centers were obtained from the National Trauma Data Bank of ACS. These data were used to estimate each center's observed-to-expected (O-E) mortality ratio with 95% confidence intervals using multivariate logistic regression analysis. De-identified data on structural characteristics of these trauma centers were obtained from the ACS Verification Review Committee. Centers in the lowest quartile of mortality based on O-E ratio (n = 56) were compared to the rest (n = 166) using Classification and Regression Tree (CART) analysis to identify institutional characteristics independently associated with high-performing centers. Of the 72 structural characteristics explored, only 3 were independently associated with high-performing centers: annual patient visits to the emergency department of fewer than 61,000; proportion of patients on Medicare greater than 20%; and continuing medical education for emergency department physician liaison to the trauma program ranging from 55 and 113 hours annually. Each 5% increase in O-E mortality ratio was associated with an increase in total length of stay of one day (r = 0.25; p < 0.001). Very few structural characteristics of ACS-verified trauma centers are associated with risk-adjusted mortality. Thus, variations in patient outcomes across trauma centers are likely related to variations in clinical practices. Therapeutic study, level III.

Dementia as a predictor of mortality in adult trauma patients.

PubMed

Jordan, Benjamin C; Brungardt, Joseph; Reyes, Jared; Helmer, Stephen D; Haan, James M

2018-01-01

The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls. A 5-year retrospective review was conducted of adult trauma patients with a diagnosis of dementia at an American College of Surgeons-verified level I trauma center. Patients with dementia were matched with non-dementia patients and compared on mortality, ICU length of stay, and hospital length of stay. A total of 195 patients with dementia were matched to non-dementia controls. Comorbidities and complications (11.8% vs 12.4%) were comparable between both groups. Dementia patients spent fewer days on the ventilator (1 vs 4.5, P = 0.031). The length of ICU stay (2 days), hospital length of stay (3 days), and mortality (5.1%) were the same for both groups (P > 0.05). Dementia does not appear to increase the risk of mortality in trauma patients. Further studies should examine post-discharge outcomes in dementia patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Determining venous thromboembolic risk assessment for patients with trauma: the Trauma Embolic Scoring System.

PubMed

Rogers, Frederick B; Shackford, Steven R; Horst, Michael A; Miller, Jo Ann; Wu, Daniel; Bradburn, Eric; Rogers, Amelia; Krasne, Margaret

2012-08-01

This study aimed to determine the relative "weight" of risk factors known to be associated with venous thromboembolism (VTE) for patients with trauma based on injuries and comorbidities. A retrospective review of 16,608 consecutive admissions to a trauma center was performed. Patients were separated into those who developed VTE (n = 141) versus those who did not (16,467). Univariate analysis was performed for each risk factor reported in the trauma literature. Risk factors that were shown to be significant (p < 0.05) by univariate analysis underwent multivariate analysis to develop odds ratios for VTE. The Trauma Embolic Scoring System (TESS) was derived from the multivariate coefficients. The resulting TESS was compared with a data set from the National Trauma Data Bank (2002-2006) to determine its ability to predict VTE. The multivariate analysis demonstrated that age, Injury Severity Score, obesity, ventilator use for more than 3 days, and lower-extremity trauma were significant predictors of VTE in our patient population. The TESS was from 0 to 14, with the best prediction for those patients with a score of more than 6 (sensitivity, 81.6%; specificity, 84%). Overall, the model had excellent discrimination in predicting VTE with a receiver operating characteristic curve of 0.89. The VTE rates for TESS in the National Trauma Data Bank data set were similar for all integers except for 3 and 4, in which the VTE rates were significantly higher (3, 0.2% vs. 0.6%; 4, 0.4% vs. 1.0%). The TESS provides an objective measure of classifying VTE risk for patients with trauma. The TESS could allow informed decision making regarding prophylaxis strategies in patients with trauma.

An injury mortality prediction based on the anatomic injury scale

PubMed Central

Wang, Muding; Wu, Dan; Qiu, Wusi; Wang, Weimi; Zeng, Yunji; Shen, Yi

2017-01-01

Abstract To determine whether the injury mortality prediction (IMP) statistically outperforms the trauma mortality prediction model (TMPM) as a predictor of mortality. The TMPM is currently the best trauma score method, which is based on the anatomic injury. Its ability of mortality prediction is superior to the injury severity score (ISS) and to the new injury severity score (NISS). However, despite its statistical significance, the predictive power of TMPM needs to be further improved. Retrospective cohort study is based on the data of 1,148,359 injured patients in the National Trauma Data Bank hospitalized from 2010 to 2011. Sixty percent of the data was used to derive an empiric measure of severity of different Abbreviated Injury Scale predot codes by taking the weighted average death probabilities of trauma patients. Twenty percent of the data was used to create computing method of the IMP model. The remaining 20% of the data was used to evaluate the statistical performance of IMP and then be compared with the TMPM and the single worst injury by examining area under the receiver operating characteristic curve (ROC), the Hosmer–Lemeshow (HL) statistic, and the Akaike information criterion. IMP exhibits significantly both better discrimination (ROC-IMP, 0.903 [0.899–0.907] and ROC-TMPM, 0.890 [0.886–0.895]) and calibration (HL-IMP, 9.9 [4.4–14.7] and HL-TMPM, 197 [143–248]) compared with TMPM. All models show slight changes after the extension of age, gender, and mechanism of injury, but the extended IMP still dominated TMPM in every performance. The IMP has slight improvement in discrimination and calibration compared with the TMPM and can accurately predict mortality. Therefore, we consider it as a new feasible scoring method in trauma research. PMID:28858124

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.

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

PubMed

Hay-David, A G C; Clint, S A; Brown, R R

2014-12-01

April 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS≥16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service. Retrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed. Incidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p>0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS≥16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries. We found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS<16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries. Copyright © 2014 Elsevier Ltd. All rights reserved.

[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.

Implementation and Evaluation of a Wiki Involving Multiple Stakeholders Including Patients in the Promotion of Best Practices in Trauma Care: The WikiTrauma Interrupted Time Series Protocol

PubMed Central

Turgeon, Alexis F; Witteman, Holly O; Lauzier, François; Moore, Lynne; Lamontagne, François; Horsley, Tanya; Gagnon, Marie-Pierre; Droit, Arnaud; Weiss, Matthew; Tremblay, Sébastien; Lachaine, Jean; Le Sage, Natalie; Émond, Marcel; Berthelot, Simon; Plaisance, Ariane; Lapointe, Jean; Razek, Tarek; van de Belt, Tom H; Brand, Kevin; Bérubé, Mélanie; Clément, Julien; Grajales III, Francisco Jose; Eysenbach, Gunther; Kuziemsky, Craig; Friedman, Debbie; Lang, Eddy; Muscedere, John; Rizoli, Sandro; Roberts, Derek J; Scales, Damon C; Sinuff, Tasnim; Stelfox, Henry T; Gagnon, Isabelle; Chabot, Christian; Grenier, Richard; Légaré, France

2015-01-01

Background Trauma is the most common cause of mortality among people between the ages of 1 and 45 years, costing Canadians 19.8 billion dollars a year (2004 data), yet half of all patients with major traumatic injuries do not receive evidence-based care, and significant regional variation in the quality of care across Canada exists. Accordingly, our goal is to lead a research project in which stakeholders themselves will adapt evidence-based trauma care knowledge tools to their own varied institutional contexts and cultures. We will do this by developing and assessing the combined impact of WikiTrauma, a free collaborative database of clinical decision support tools, and Wiki101, a training course teaching participants how to use WikiTrauma. WikiTrauma has the potential to ensure that all stakeholders (eg, patients, clinicians, and decision makers) can all contribute to, and benefit from, evidence-based clinical knowledge about trauma care that is tailored to their own needs and clinical setting. Objective Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec. Methods First, we will pilot-test the wiki with potential users to create a version ready to test in practice. A rapid, iterative prototyping process with 15 health professionals from nonparticipating centers will allow us to identify and resolve usability issues prior to finalizing the definitive version for the interrupted time series. Second, we will conduct an interrupted time series to measure the impact of our combined intervention on the quality of care in four trauma centers that will be selected—one level I, one level II, and two level III centers. Participants will be health care professionals working in the selected trauma centers. Also, five patient representatives will be recruited to participate in the creation of knowledge tools destined for their use (eg, handouts). All participants will be invited to complete the Wiki101 training and then use, and contribute to, WikiTrauma for 12 months. The primary outcome will be the change over time of a validated, composite, performance indicator score based on 15 process performance indicators found in the Quebec Trauma Registry. Results This project was funded in November 2014 by the Canadian Medical Protective Association. We expect to start this trial in early 2015 and preliminary results should be available in June 2016. Two trauma centers have already agreed to participate and two more will be recruited in the next months. Conclusions We expect that this study will add important and unique evidence about the effectiveness, safety, and cost savings of using collaborative platforms to adapt knowledge implementation tools across jurisdictions. PMID:25699546

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

Trauma: a major cause of death among surgical inpatients of a Nigerian tertiary hospital

PubMed Central

Ekeke, Onyeanunam Ngozi; Okonta, Kelechi Emmanuel

2017-01-01

Introduction Trauma presents a significant global health burden. Death resulting from trauma remains high in low income countries despite a steady decrease in developed countries. Analysis of the pattern of death will enable intervention to reduce these deaths from trauma in developing countries. This study aims to present the pattern of trauma-related deaths in the surgical wards of University of Port Harcourt Teaching Hospital (UPTH). Methods This was a retrospective study of all patients who died from trauma during admission into the surgical wards of UPTH from 2007 to 2012. Data on demography and traumatic events leading to death were collected from surgical wards, the emergency unit, and theatre records and analyzed using SPSS version 16.0. Results Trauma accounted for 219 (42.4%) of the 527 mortalities recorded. Most of the deaths (62.6 %) occurred between 20 and 59 years. There were 148 males (67.6 %). The yearly mortality rates were as follows: 2007(12.3 %); 2008 (16.9%); 2009 (9.1%), 2010 (12.8 %), 2011 (23.3%) and 2012 (25.6%). Most of the patients (91.3%) died within 1 month of admission. The major events leading to deaths were burns 105(47.9%), traumatic brain injuries were 63(28.8%), and spinal cord injuries 21(9.6%). The secondary causes of death were mainly septic shock 112(51.1%); Respiratory failure 60(27.4%); and Multiple organ dysfunction 44(20.1%). Conclusion Trauma is a leading cause of mortality in the surgical wards of our hospital. Trauma -related deaths continues to increase over the years. Safe keeping of petroleum products and adherence to traffic rules will reduce these avoidable deaths. PMID:29138652

[Progress on neuropsychology and event-related potentials in patients with brain trauma].

PubMed

Dong, Ri-xia; Cai, Wei-xiong; Tang, Tao; Huang, Fu-yin

2010-02-01

With the development of information technology, as one of the research frontiers in neurophysiology, event-related potentials (ERP) is concerned increasingly by international scholars, which provides a feasible and objective method for exploring cognitive function. There are many advances in neuropsychology due to new assessment tool for the last years. The basic theories in the field of ERP and neuropsychology were reviewed in this article. The research and development in evaluating cognitive function of patients with syndrome after brain trauma were focused in this review, and the perspectives for the future research of ERP was also explored.

Blood transfusion and coagulopathy in geriatric trauma patients.

PubMed

Mador, Brett; Nascimento, Bartolomeu; Hollands, Simon; Rizoli, Sandro

2017-03-29

Trauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. However, it is unclear how this strategy is applied or how effective it is in the elderly population. The study aim is to identify differences in transfusion practices and the coagulopathy of trauma in the elderly. Data was prospectively collected on all consecutive patients that met trauma activation criteria at a Level I trauma centre. Data fields included patient demographics, co-morbidities, injury and resuscitation data, laboratory values, thromboelastography (TEG) results, and outcome measures. Elderly patients were defined as those 55 and older. Propensity-score matched analysis was completed for patients receiving blood product transfusion. Patients were matched by gender, mechanism, injury severity score (ISS), head injury, and time from injury. Total of 628 patients were included, of which 142 (23%) were elderly. Elderly patients were more likely to be female (41% vs. 24%), suffer blunt mechanism of trauma (96% vs. 80%), have higher ISS scores (mean 25.4 vs. 21.6) and mortality (19% vs. 8%). Elderly patients were significantly more likely to receive a blood transfusion (42% vs. 30%), specifically for red cells and plasma. Propensity-matched analysis resulted in no difference in red cell transfusion or mortality. Despite the broad similarities between the matched cohorts, trauma coagulopathy as measured by TEG was less commonly observed in the elderly. Our results suggest that elderly trauma patients are more likely to receive blood products when admitted to a trauma centre, though this may be attributed to under-triage. The results also suggest an altered coagulopathic response to traumatic injury which is partially influenced by increased anticoagulant and antiplatelet medication use in the geriatric population. It is not clear whether the acute coagulopathy of trauma is equivalent in geriatric patients, and further study is therefore warranted.

LIVER TRANSPLANTATION AFTER SEVERE HEPATIC TRAUMA: CURRENT INDICATIONS AND RESULTS

PubMed Central

RIBEIRO-JR, Marcelo Augusto Fontenelle; MEDRADO, Melina Botelho; ROSA, Otto Mauro; SILVA, Ana Júlia de Deus; FONTANA, Mariana Prado; CRUVINEL-NETO, José; FONSECA, Alexandre Zanchenko

2015-01-01

Background : The liver is the most injured organ in abdominal trauma. Currently, the treatment in most cases is non-operative, but surgery may be necessary in severe abdominal trauma with blunt liver damage, especially those that cause uncontrollable bleeding. Despite the damage control approaches in order to achieve hemodynamic stability, many patients develop hypovolemic shock, acute liver failure, multiple organ failure and death. In this context, liver transplantation appears as the lifesaving last resource Aim : Analyze the use of liver transplantation as a treatment option for severe liver trauma. Methods : Were reviewed 14 articles in the PubMed, Medline and Lilacs databases, selected between 2008-2014 and 10 for this study. Results : Were identified 46 cases undergoing liver transplant after liver trauma; the main trauma mechanism was closed/blunt abdominal trauma in 83%, and severe trauma (>grade IV) in 81 %. The transplant can be done, in this context, performing one-stage procedure (damaged organ removed with immediate transplantation), used in 72% of cases. When the two-stage approach is performed, end-to-side temporary portacaval shunt is provided, until new organ becomes available to be transplanted. If two different periods are considered - from 1980 to 2000 and from 2000 to 2014 - the survival rate increased significantly, from 48% to 76%, while the mortality decreased from 52% to 24%. Conclusion : Despite with quite restricted indications, liver transplantation in hepatic injury is a therapeutic modality viable and feasible today, and can be used in cases when other therapeutic modalities in short and long term, do not provide the patient survival chances. PMID:26734803

Clinicians' perceptions of decision making regarding discharge from public hospitals to in-patient rehabilitation following trauma.

PubMed

Kimmel, Lara A; Holland, Anne E; Lannin, Natasha; Edwards, Elton R; Page, Richard S; Bucknill, Andrew; Hau, Raphael; Gabbe, Belinda J

2017-05-01

Objective The aim of the present study was to investigate the perceptions of consultant surgeons, allied health clinicians and rehabilitation consultants regarding discharge destination decision making from the acute hospital following trauma. Methods A qualitative study was performed using individual in-depth interviews of clinicians in Victoria (Australia) between April 2013 and September 2014. Thematic analysis was used to derive important themes. Case studies provided quantitative information to enhance the information gained via interviews. Results Thirteen rehabilitation consultants, eight consultant surgeons and 13 allied health clinicians were interviewed. Key themes that emerged included the importance of financial considerations as drivers of decision making and the perceived lack of involvement of medical staff in decisions regarding discharge destination following trauma. Other themes included the lack of consistency of factors thought to be important drivers of discharge and the difficulty in acting on trauma patients' requests in terms of discharge destination. Importantly, as the complexity of the patient increases in terms of acquired brain injury, the options for rehabilitation become scarcer. Conclusions The information gained in the present study highlights the large variation in discharge practises between and within clinical groups. Further consultation with stakeholders involved in the care of trauma patients, as well as government bodies involved in hospital funding, is needed to derive a more consistent approach to discharge destination decision making. What is known about the topic? Little is known about the drivers for referral to, or acceptance at, in-patient rehabilitation following acute hospital care for traumatic injury in Victoria, Australia, including who makes these decisions of behalf of patients and how these decisions are made. What does this paper add? This paper provides information regarding the perceptions of acute hospital consultant surgeons and allied health, as well as rehabilitation clinicians, in terms of discharge destination decision making from the acute hospital following trauma. The use of case studies further highlights differences between, and within, these specialities with regard to this decision making. This research also highlights the importance of financial considerations as drivers of decision making, and the lack of consistency of the factors thought to be important drivers of discharge between these different clinical groupings. What are the implications for practitioners? This research shows that financial factors are significant drivers of discharge destination decision making for trauma patients. The present study highlights opportunities to engage with stakeholders (acute care, rehabilitation, administration, government and patients) to develop more consistent discharge processes that optimise the use of rehabilitation resources for those patients who could benefit from in-patient rehabilitation.

Intergenerational perceptions of mass trauma's impact on physical health and well-being.

PubMed

Bezo, Brent; Maggi, Stefania

2018-01-01

This study investigated the perceived intergenerational impact of the 1932-1933 forced starvation-genocide of Ukrainians and reports the perceived impact of the mass trauma on physical health and well-being across three generations. Interviews were conducted with survivors of the 1930s mass trauma and their adult children and grandchildren. In total, 45 interviews were conducted in Ukraine and a qualitative thematic method was used to analyze the interview texts. Two main themes emerged from the qualitative analysis. First, survivors noted adverse physical health outcomes stemming from their experiences with the 1930s mass trauma. Second, mainly descendants of survivors reported that the mass trauma set into motion biological, psychological and social processes, which in turn, have negatively affected physical health across generations. Participants viewed the mass trauma of the 1930s to have affected the physical health of not only survivors, but also their adult children and grandchildren born decades after the traumatic event. Recommendations are made for cultural awareness training for clinicians who treat patients with family histories of ancestral trauma. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Initial evaluation of the "Trauma surgery course"

PubMed Central

Tugnoli, Gregorio; Ribaldi, Sergio; Casali, Marco; Calderale, Stefano M; Coletti, Massimo; Alifano, Marco; Parri, Sergio N Forti; Villani, Silvia; Biscardi, Andrea; Giordano, M Chiara; Baldoni, Franco

2006-01-01

Background The consequence of the low rate of penetrating injuries in Europe and the increase in non-operative management of blunt trauma is a decrease in surgeons' confidence in managing traumatic injuries has led to the need for new didactic tools. The aim of this retrospective study was to present the Corso di Chirurgia del Politrauma (Trauma Surgery Course), developed as a model for teaching operative trauma techniques, and assess its efficacy. Method the two-day course consisted of theoretical lectures and practical experience on large-sized swine. Data of the first 126 participants were collected and analyzed. Results All of the 126 general surgeons who had participated in the course judged it to be an efficient model to improve knowledge about the surgical treatment of trauma. Conclusion A two-day course, focusing on trauma surgery, with lectures and life-like operation situations, represents a model for simulated training and can be useful to improve surgeons' confidence in managing trauma patients. Cooperation between organizers of similar initiatives would be beneficial and could lead to standardizing and improving such courses. PMID:16759403

Nonoperative management for patients with grade IV blunt hepatic trauma

PubMed Central

2012-01-01

Introduction The treatment of complex liver injuries remains a challenge. Nonoperative treatment for such injuries is increasingly being adopted as the initial management strategy. We reviewed our experience, at a University teaching hospital, in the nonoperative management of grade IV liver injuries with the intent to evaluate failure rates; need for angioembolization and blood transfusions; and in-hospital mortality and complications. Methods This is a retrospective analysis conducted at a single large trauma centre in Brazil. All consecutive, hemodynamically stable, blunt trauma patients with grade IV hepatic injury, between 1996 and 2011, were analyzed. Demographics and baseline characteristics were recorded. Failure of nonoperative management was defined by the need for surgical intervention. Need for angioembolization and transfusions, in-hospital death, and complications were also assessed Results Eighteen patients with grade IV hepatic injury treated nonoperatively during the study period were included. The nonoperative treatment failed in only one patient (5.5%) who had refractory abdominal pain. However, no missed injuries and/or worsening of bleeding were observed during the operation. None of the patients died nor need angioembolization. No complications directly related to the liver were observed. Unrelated complications to the liver occurred in three patients (16.7%); one patient developed a tracheal stenosis (secondary to tracheal intubation); one had pleural effusion; and one developed an abscess in the pleural cavity. The hospital length of stay was on average 11.56 days. Conclusions In our experience, nonoperative management of grade IV liver injury for stable blunt trauma patients is associated with high success rates without significant complications. PMID:23531162

How accurate are resting energy expenditure prediction equations in obese trauma and burn patients?

PubMed

Stucky, Chee-Chee H; Moncure, Michael; Hise, Mary; Gossage, Clint M; Northrop, David

2008-01-01

While the prevalence of obesity continues to increase in our society, outdated resting energy expenditure (REE) prediction equations may overpredict energy requirements in obese patients. Accurate feeding is essential since overfeeding has been demonstrated to adversely affect outcomes. The first objective was to compare REE calculated by prediction equations to the measured REE in obese trauma and burn patients. Our hypothesis was that an equation using fat-free mass would give a more accurate prediction. The second objective was to consider the effect of a commonly used injury factor on the predicted REE. A retrospective chart review was performed on 28 patients. REE was measured using indirect calorimetry and compared with the Harris-Benedict and Cunningham equations, and an equation using type II diabetes as a factor. Statistical analyses used were paired t test, +/-95% confidence interval, and the Bland-Altman method. Measured average REE in trauma and burn patients was 21.37 +/- 5.26 and 21.81 +/- 3.35 kcal/kg/d, respectively. Harris-Benedict underpredicted REE in trauma and burn patients to the least extent, while the Cunningham equation underpredicted REE in both populations to the greatest extent. Using an injury factor of 1.2, Cunningham continued to underestimate REE in both populations, while the Harris-Benedict and Diabetic equations overpredicted REE in both populations. The measured average REE is significantly less than current guidelines. This finding suggests that a hypocaloric regimen is worth considering for ICU patients. Also, if an injury factor of 1.2 is incorporated in certain equations, patients may be given too many calories.

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.

Canceled to Be Called Back: A Retrospective Cohort Study of Canceled Helicopter Emergency Medical Service Scene Calls That Are Later Transferred to a Trauma Center.

PubMed

Nolan, Brodie; Ackery, Alun; Nathens, Avery; Sawadsky, Bruce; Tien, Homer

In our trauma system, helicopter emergency medical services (HEMS) can be requested to attend a scene call for an injured patient before arrival by land paramedics. Land paramedics can cancel this response if they deem it unnecessary. The purpose of this study is to describe the frequency of canceled HEMS scene calls that were subsequently transferred to 2 trauma centers and to assess for any impact on morbidity and mortality. Probabilistic matching was used to identify canceled HEMS scene call patients who were later transported to 2 trauma centers over a 48-month period. Registry data were used to compare canceled scene call patients with direct from scene patients. There were 290 requests for HEMS scene calls, of which 35.2% were canceled. Of those canceled, 24.5% were later transported to our trauma centers. Canceled scene call patients were more likely to be older and to be discharged home from the trauma center without being admitted. There is a significant amount of undertriage of patients for whom an HEMS response was canceled and later transported to a trauma center. These patients face similar morbidity and mortality as patients who are brought directly from scene to a trauma center. Copyright © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.

Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew – case identification rates and effect on the Sydney paediatric trauma system

PubMed Central

2012-01-01

Background Severe paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC. Methods Paediatric trauma patients over a two year period from the Sydney region with an Injury Severity Score (ISS) > 15 were retrospectively identified from a state wide trauma registry. Overall paediatric trauma system performance was assessed by comparisons of the availability of the physician staffed HEMS for patient characteristics, transport mode (direct versus indirect) and the times required for the patient to arrive at the paediatric trauma centre. The proportion of patients transported directly to a PTC was compared between the times that the HEMS service was available versus the time that it was unavailable to determine if the HEMS system altered the rate of direct transport to a PTC. Analysis of variance was used to compare the identifying systems for various patient characteristics when the HEMS was available. Results Ninety nine cases met the inclusion criteria, 44 when the HEMS system was operational. Patients identified for physician response by the HEMS system were significantly different to those that were not identified with higher median ISS (25 vs 18, p = 0.011), and shorter times to PTC (67 vs 261mins, p = 0.015) and length of intensive care unit stays (2 vs 0 days, p = 0.045). Of the 44 cases, 21 were not identified, 3 were identified by the paramedic system and 20 were identified by the HEMS system, (P < 0.001). Direct transport to a PTC was more likely to occur when the HEMS dispatch system was available (RR 1.81, 95% CI 1.20-2.73). The median time (minutes) to arrival at the PTC was shorter when HEMS available (HEMS available 92, IQR 50-261 versus HEMS unavailable 296, IQR 84-583, P < 0.01). Conclusions Physician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival. PMID:23244708

Inferior vena cava filters in trauma patients: efficacy, morbidity, and retrievability.

PubMed

Smoot, Rory L; Koch, Cody A; Heller, Stephanie F; Sabater, Enrique A; Cullinane, Daniel C; Bannon, Michael P; Thomsen, Kristine M; Harmsen, William S; Baerga-Varela, Yvonne; Schiller, Henry J

2010-04-01

Thromboembolic events are potentially devastating sources of morbidity in trauma patients. With increasing experience and the introduction of retrievable devices, there has been a renewed interest in inferior vena cava (IVC) filters in trauma patients. The records for consecutive trauma patients undergoing IVC filter placement during the years 2001 to 2005 were reviewed, and clinical, demographic, and procedural data were evaluated for associations with thromboembolic events and device complications. During the study years, 226 trauma patients had IVC filters inserted, and 140 of these patients (62%) had retrievable IVC filters placed. Six patients (3%) had a pulmonary embolism with the filter in place, and two patients (1%) had a pulmonary embolism after filter removal. The most common complication was thrombosis in 27 patients (12%), with clinically significant thrombus occurring in 15 patients (7%). There was no association between the type of filter (permanent or retrievable) or the brand of retrievable filter and thrombosis. Specific risk factors for thrombosis could not be identified. Retrievable filters were successfully removed in 61% of patients with retrievable filters. Technical success rate was 97% in those patients who underwent attempted removal. Removal was completed at a median of 21 days (range, 2-292 days). Retrievable IVC filters in trauma patients are safe, but complications do occur with thrombosis being the most common. Retrieval has a high technical success rate when attempted. However, a significant number of trauma patients are lost to follow-up and this may impact the utilization of retrievable filters in this patient population.

Hypersomnia Following Traumatic Brain Injury

PubMed Central

Watson, Nathaniel F; Dikmen, Sureyya; Machamer, Joan; Doherty, Michael; Temkin, Nancy

2007-01-01

Study Objectives: To evaluate the prevalence and natural history of sleepiness following traumatic brain injury. Methods: This prospective cohort study used the Sickness Impact Profile to evaluate sleepiness in 514 consecutive subjects with traumatic brain injury (TBI), 132 non-cranial trauma controls, and 102 trauma-free controls 1 month and 1 year after injury. Results: Fifty-five percent of TBI subjects, 41% of non-cranial trauma controls, and 3% of trauma-free controls endorsed 1 or more sleepiness items 1 month following injury (p < .001). One year following injury, 27% of TBI subjects, 23% of non-cranial trauma controls, and 1% of trauma-free controls endorsed 1 or more sleepiness items (p < .001). Patients with TBI were sleepier than non-cranial trauma controls at 1 month (p < .02) but not 1 year after injury. Brain-injured subjects were divided into injury-severity groups based on time to follow commands (TFC). At 1 month, the non-cranial trauma controls were less sleepy than the 1- to 6-day (p < .05), 7- to 13-day (p < .01), and 14-day or longer (p < .01) TFC groups. In addition, the ≤ 24-hour group was less sleepy then the 7- to 13-day and 14-day or longer groups (each p < .05). At 1 year, the non-cranial trauma control group (p < .05) and the ≤ 24-hour TFC group (p < .01) were less sleepy than the 14-day or longer TFC group. Sleepiness improved in 84% to 100% of subjects in the TBI TFC groups, as compared with 78% of the non-cranial trauma control group (p < .01). Conclusions: Sleepiness is common following traumatic injury, particularly TBI, with more severe injuries resulting in greater sleepiness. Sleepiness improves in many patients, particularly those with TBI. However, about a quarter of TBI subjects and non-cranial trauma control subjects remained sleepy 1 year after injury. Citation: Watson NF; Dikmen S; Machamer J et al. Hypersomnia following traumatic brain injury. J Clin Sleep Med 2007;3(4):363-368. PMID:17694724

Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma.

PubMed

Borgman, Matthew A; Maegele, Marc; Wade, Charles E; Blackbourne, Lorne H; Spinella, Philip C

2011-04-01

To develop a validated mortality prediction score for children with traumatic injuries. We identified all children (<18 years of age) in the US military established Joint Theater Trauma Registry from 2002 to 2009 who were admitted to combat-support hospitals with traumatic injuries in Iraq and Afghanistan. We identified factors associated with mortality using univariate and then multivariate regression modeling. The developed mortality prediction score was then validated on a data set of pediatric patients (≤ 18 years of age) from the German Trauma Registry, 2002-2007. Admission base deficit, international normalized ratio, and Glasgow Coma Scale were independently associated with mortality in 707 patients from the derivation set and 1101 patients in the validation set. These variables were combined into the pediatric "BIG" score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Scale), which were each calculated to have an area under the curve of 0.89 (95% confidence interval: 0.83-0.95) and 0.89 (95% confidence interval: 0.87-0.92) on the derivation and validation sets, respectively. The pediatric trauma BIG score is a simple method that can be performed rapidly on admission to evaluate severity of illness and predict mortality in children with traumatic injuries. The score has been shown to be accurate in both penetrating-injury and blunt-injury populations and may have significant utility in comparing severity of injury in future pediatric trauma research and quality-assurance studies. In addition, this score may be used to determine inclusion criteria on admission for prospective studies when accurately estimating the mortality for sample size calculation is required.

High plasma levels of high mobility group box 1 is associated with the risk of sepsis in severe blunt chest trauma patients: a prospective cohort study.

PubMed

Wang, Xiao-Wen; Karki, Avash; Zhao, Xing-Ji; Xiang, Xiao-Yong; Lu, Zhi-Qian

2014-08-02

High mobility group box 1 (HMGB1) is a late mediator of systemic inflammation. Extracellular HMGB1 play a central pathogenic role in critical illness. The purpose of the study was to investigate the association between plasma HMGB1 concentrations and the risk of poor outcomes in patients with severe blunt chest trauma. The plasma concentrations of HMGB1 in patients with severe blunt chest trauma (AIS ≥ 3) were measured by a quantitative enzyme-linked immunosorbent assay at four time points during seven days after admission, and the dynamic release patterns were monitored. The biomarker levels were compared between patients with sepsis and non-sepsis, and between patients with multiple organ dysfunction syndrome (MODS) and non-MODS. The related factors of prognosis were analyzed by using multivariate logistic regression analysis. The short-form 36 was used to evaluate the quality of life of patients at 12 months after injury. Plasma HMGB1 levels were significantly higher both in sepsis and MODS group on post-trauma day 3, 5, and 7 compared with the non-sepsis and non-MODS groups, respectively. Multivariate analysis showed that HMGB1 levels and ISS were independent risk factors for sepsis and MODS in patients with severe blunt chest trauma. Plasma HMGB1 levels were significantly elevated in patients with severe blunt chest trauma. HMGB1 levels were associated with the risk of poor outcome in patients with severe blunt chest trauma. Daily HMGB1 levels measurements is a potential useful tool in the early identification of post-trauma complications. Further studies are needed to determine whether HMGB1 intervention could prevent the development of sepsis and MODS in patients with severe blunt chest trauma.

Beta-blocker use is associated with improved outcomes in adult trauma patients.

PubMed

Arbabi, Saman; Campion, Eric M; Hemmila, Mark R; Barker, Melissa; Dimo, Mary; Ahrns, Karla S; Niederbichler, Andreas D; Ipaktchi, Kyros; Wahl, Wendy L

2007-01-01

Beta-adrenoreceptor blocker (beta-blocker) therapy may improve outcomes in surgical patients by decreasing cardiac oxygen consumption and hypermetabolism. Because beta-blockers can lower the systemic blood pressure and cerebral perfusion pressure, there is concern regarding their use in patients with head injury. However, beta-blockers may protect beta-receptor rich brain cells by attenuating cerebral oxygen consumption and metabolism. We hypothesized that beta-blockers are safe in trauma patients, even if they have suffered a significant head injury. Using pharmacy and trauma registry data of a Level I trauma center, we identified a cohort of trauma patients who received beta-blockers during their hospital stay (beta-cohort). Trauma admissions who did not receive beta-blockers were in the control cohort. beta-blocker status, in combination with other variables associated with mortality, were placed in a stepwise multivariate logistic regression to identify independent predictors of fatal outcome. In all, 303 (7%) of 4,117 trauma patients received beta-blockers. In the beta-cohort, 45% of patients were on beta-blockers preinjury. The most common reason to initiate beta-blocker therapy was blood pressure (60%) and heart rate (20%) control. The overall mortality rate was 5.6% and head injury was considered to be the major cause of death. After adjusting for age, Injury Severity Scale score, blood pressure, Glasgow Coma Scale score, respiratory status, and mechanism of injury, the odds ratio for fatal outcome was 0.3 (p < 0.001) for beta-cohort as compared with control. Decreased risk of fatal outcome was more pronounced in patients with a significant head injury. beta-blocker therapy is safe and may be beneficial in selected trauma patients with or without head injury. Further studies looking at beta-blocker therapy in trauma patients and their effect on cerebral metabolism are warranted.

[Experience in management of trauma-related acute abdomen at the "General Ignacio Zaragoza" Regional Hospital in Mexico City].

PubMed

Senado-Lara, Isaac; Castro-Mendoza, Antonio; Palacio-Vélez, Fernando; Vargas-Avila, Arcenio Luis

2004-01-01

To know the current state of surgical management of patients with abdominal trauma. We carried out a retrospective, observational, transversal study involving patients with abdominal trauma with clinical files wtih trauma who required surgery during the period of April 1, 1998 through March 30, 2003. There were 72 cases including nine male and 33 female patients. Mechanism of lesion was divided into closed and penetrating trauma, the latter group of patients divided into individuals with blunt wounds or with gunshot wounds. Most frequent early postoperative complication was hemorrhage, while most frequent late postoperative complication was acute renal failure. Causes of death were hypovolemic shock in four patients followed by two cases each with the following pathologies: acute respiratory insufficiency syndrome; myocardial infarct, and septic shock. Abdominal trauma is a frequent pathology in our environment, males the most affected patients, with penetrating trauma main lesion cause. Prolonged surgical time required hemotransfusions, and infectious processes together with processes related with tissular hypoxia are the most common cause of complications and death.

[Epidemiological aspects of spinal traumas: about 139 cases].

PubMed

Bemora, Joseph Synèse; Rakotondraibe, Willy Francis; Ramarokoto, Mijoro; Ratovondrainy, Willy; Andriamamonjy, Clément

2017-01-01

Spinal trauma is one of the most common types of injuries among victims of traffic accidents, sports accidents, domestic accidents and workplace accidents. We conducted a 3-year retrospective study of 139 cases of spinal trauma hospitalized and treated in the Neurosurgery department of the CHUJRA, Madagascar. This study shows that 25.17% of injured patients were between 21 and 30 years of age, with a clear male predominance (69.78%; sex ratio 2.3). Falls were the dominating traumatic injury mechanism (33.09%) with risk factors including alcohol use (8.63%). Spinal injuries occurred in patients with polytrauma, of whom 34.63% had cranial trauma. Patients were admitted to the department within 1-5 hours after the trauma in 31.65% of cases, using private car as their means of transport 36.69% of cases. During the hospitalization 20 patients signed the discharge form and 6.34% of patients died. Spinal trauma is a public health problem requiring high intensity management, especially for patients with life-long disabilities. Any spine trauma requires a diligent search for cranial lesion.

Increased mortality in trauma patients who develop postintubation hypotension.

PubMed

Green, Robert S; Butler, Michael B; Erdogan, Mete

2017-10-01

Postintubation hypotension (PIH) is common and associated with poor outcomes in critically ill patient populations requiring emergency endotracheal intubation (ETI). The importance of PIH in the trauma population remains unclear. The objective of this study was to determine the prevalence of PIH in trauma patients and assess the association of PIH with patient outcomes. Retrospective case series of adult (≥16 years) patients who were intubated on arrival at a tertiary trauma center in Halifax, Nova Scotia, Canada, between 2000 and 2015. Data were collected from the Nova Scotia Trauma Registry and patient chart, and included demographics, comorbidities, trauma characteristics, intubation time, as well as all fluids, medications, adverse events, interventions, and vital signs during the 15 minutes before/after ETI. We evaluated the prevalence of PIH and created a logistic regression model to determine likelihood of mortality in the PIH and non-PIH groups after controlling for patient and provider characteristics. Overall, 477 patients required ETI on assessment by the trauma service, of which 444 patients met eligibility criteria and were included in the analysis. The prevalence of PIH was 36.3% (161 of 444) in our study population. In-hospital mortality occurred in 29.8% (48 of 161) of patients in the PIH group, compared with 15.9% (45 of 283) of patients in the non-PIH group (p = 0.001). Development of PIH was associated with increased mortality in the emergency department (adjusted odds ratio, 3.45; 95% confidence interval, 1.42-8.36) and in-hospital (adjusted odds ratio, 1.83; 95% confidence interval, 1.01-3.31). In our study of trauma patients requiring ETI, development of PIH was common (36.3%) and associated with increased mortality. Intubation practices in critically ill trauma patients is an important patient safety issue that requires further investigation. Prognostic and epidemiological, level III; Level IV, Therapeutic.

Medication reconciliation in a rural trauma population.

PubMed

Miller, S Lee; Miller, Stephanie; Balon, Jennifer; Helling, Thomas S

2008-11-01

Medication errors during hospitalization can lead to adverse drug events. Because of preoccupation by health care providers with life-threatening injuries, trauma patients may be particularly prone to medication errors. Medication reconciliation on admission can result in decreased medication errors and adverse drug events in this patient population. The purpose of this study is to determine the accuracy of medication histories obtained on trauma patients by initial health care providers compared to a medication reconciliation process by a designated clinical pharmacist after the patient's admission and secondarily to determine whether trauma-associated factors affected medication accuracy. This was a prospective enrollment study during 13 months in which trauma patients admitted to a Level I trauma center were enrolled in a stepwise medication reconciliation process by the clinical pharmacist. The setting was a rural Level I trauma center. Patients admitted to the trauma service were studied. The intervention was medication reconciliation by a clinical pharmacist. The main outcome measure was accuracy of medication history by initial trauma health care providers compared to a medication reconciliation process by a clinical pharmacist who compared all sources, including telephone calls to pharmacies. Patients taking no medications (whether correctly identified as such or not) were not analyzed in these results. Variables examined included admission medication list accuracy, age, trauma team activation mode, Injury Severity Score, and Glasgow Coma Scale (GCS) score. Two hundred thirty-four patients were enrolled. Eighty-four of 234 patients (36%) had an Injury Severity Score greater than 15. Medications were reconciled within an average of 3 days of admission (range 1 to 8) by the clinical pharmacist. Overall, medications as reconciled by the clinical pharmacist were recorded correctly for 15% of patients. Admission trauma team medication lists were inaccurate in 224 of 234 cases (96%). Admitting nurses' lists were more accurate than the trauma team's (11% versus 4%; 95% confidence interval 2.5% to 11.2%). Errors were found by the clinical pharmacist in medication name, strength, route, and frequency. No patients (0/20) with admission GCS less than 13 had accurate medication lists. Seventy of 84 patients (83%) with an Injury Severity Score greater than 15 had inaccurate medication lists. Ten of 234 patients (4%) were ordered wrong medications, and 1 adverse drug event (hypoglycemia) occurred. The median duration of the reconciliation process was 2 days. Only 12% of cases were completed in 1 day, and almost 25% required 3 or more (maximum 8) days. This study showed that medication history recorded on admission was inaccurate. This patient population overall was susceptible to medication inaccuracies from multiple sources, even with duplication of medication histories by initial health care providers. Medication reconciliation for trauma patients by a clinical pharmacist may improve safety and prevent adverse drug events but did not occur quickly in this setting.

Clot formation is associated with fibrinogen and platelet forces in a cohort of severely-injured Emergency Department trauma patients

PubMed Central

White, Nathan J.; Newton, Jason C.; Martin, Erika J.; Mohammed, Bassem M.; Contaifer, Daniel; Bostic, Jessica L.; Brophy, Gretchen M.; Spiess, Bruce D.; Pusateri, Anthony E.; Ward, Kevin R.; Brophy, Donald F.

2015-01-01

Introduction Anticoagulation, fibrinogen consumption, fibrinolytic activation, and platelet dysfunction all interact to produce different clot formation responses after trauma. However, the relative contributions of these coagulation components to overall clot formation remains poorly defined. We examined for sources of heterogeneity in clot formation responses after trauma. Methods Blood was sampled in the Emergency Department from patients meeting trauma team activation criteria at an urban trauma center. Plasma prothrombin time (PT) ≥ 18 sec was used to define traumatic coagulopathy. Mean kaolin-activated thrombelastography (TEG) parameters were calculated and tested for heterogeneity using Analysis of Means (ANOM). Discriminant analysis and forward stepwise variable selection with linear regression were used to determine if PT, fibrinogen, platelet contractile force (PCF), and D-Dimer concentration, representing key mechanistic components of coagulopathy, each contribute to heterogeneous TEG responses after trauma. Results Of 95 subjects, 16% met criteria for coagulopathy. Coagulopathic subjects were more severely injured with greater shock, and received more blood products in the first 8 hours compared to non-coagulopathic subjects. Mean (SD) TEG maximal amplitude (MA) was significantly decreased in the coagulopathic group=57.5 (4.7) mm, vs. 62.7 (4.7), T test p<0.001. The MA also exceeded the ANOM predicted upper decision limit for the non-coagulopathic group and the lower decision limit for the coagulopathic group at alpha=0.05, suggesting significant heterogeneity from the overall cohort mean. Fibrinogen and PCF best discriminated TEG MA using discriminant analysis. Fibrinogen, PCF, and D-Dimer were primary covariates for TEG MA using regression analysis. Conclusion Heterogeneity in TEG-based clot formation in Emergency Department trauma patients was linked to changes in MA. Individual parameters representing fibrin polymerization, platelet contractile forces, and fibrinolysis were primarily associated with TEG MA after trauma and should be the focus of early hemostatic therapies. PMID:25643013

Vitreoretinal surgery of the posterior segment for explosive trauma in terrorist warfare.

PubMed

Bajaire, Boris; Oudovitchenko, Elena; Morales, Edgar

2006-08-01

To describe surgical management and establish anatomic and visual results of patients with explosive ocular trauma in terrorist attacks treated with extreme vitreoretinal surgery. Retrospective study of clinical records (6-month follow-up) of patients with visual acuity (VA) of light perception or better with posterior segment injuries [vitreous hemorrhage, retinal detachment (RD), intra-ocular foreign bodies (IOFB), perforating trauma (PT)] from explosive weapons who underwent vitreoretinal surgery. We reviewed the demographic characteristics, type of weapon, time between injury and surgery, VA at arrival and 6 months after surgery, and type of trauma according to the International Trauma Classification. Fifty-seven out of 236 patients with ocular injuries from explosive weapons were included in the study; all of them were military men, average age 22 years (range 16-53 years). The average time between the blast and primary closing was 1 day, and 10 days between primary closing and vitreoretinal surgery. Open traumas by laceration accounted for 96% of cases and 4% were closed traumas; 76% of the eyes had IOFB, of which 18% involved PT; 5% had endophthalmitis. Contusion was the diagnosis for 100% of the closed traumas. Of the open traumas, 40% were localized at zone I, 44% at zone II, and 16% at zone III. Upon arrival, 98% of patients had VA 20/800-LP and 2% had >20/40. The patients with closed trauma had the injuries at zone III and presented VA 20/800-LP. All patients underwent posterior vitrectomy, scleral buckling, endotaponade and when required, lensectomy (82%), IOFB removal (72%), and/or retinectomy (25%). Postoperative VA improved in 43% of the patients, stabilized in 41% and evolved to NLP in 15% of the cases. Initial expressions of ocular trauma such as RD, PT and endophthalmitis suggest bad prognosis. We presented a series of patients with severe ocular trauma of the posterior segment from explosive weapons. These patients were treated according to our surgical protocol with extreme vitreoretinal surgery within the first 2 weeks after the blast; with our procedure we obtained stabilization or improvement of the VA for 84% of the cases.

A Comparison of Functional Outcome in Patients Sustaining Major Trauma: A Multicentre, Prospective, International Study

PubMed Central

Rainer, Timothy H.; Yeung, Hiu Hung; Gabbe, Belinda J.; Yuen, Kai Y.; Ho, Hiu F.; Kam, Chak W.; Chang, Annice; Poon, Wai S.; Cameron, Peter A.; Graham, Colin A.

2014-01-01

Objectives To compare 6 month and 12 month health status and functional outcomes between regional major trauma registries in Hong Kong and Victoria, Australia. Summary Background Data Multicentres from trauma registries in Hong Kong and the Victorian State Trauma Registry (VSTR). Methods Multicentre, prospective cohort study. Major trauma patients and aged ≥18 years were included. The main outcome measures were Extended Glasgow Outcome Scale (GOSE) functional outcome and risk-adjusted Short-Form 12 (SF-12) health status at 6 and 12 months after injury. Results 261 cases from Hong Kong and 1955 cases from VSTR were included. Adjusting for age, sex, ISS, comorbid status, injury mechanism and GCS group, the odds of a better functional outcome for Hong Kong patients relative to Victorian patients at six months was 0.88 (95% CI: 0.66, 1.17), and at 12 months was 0.83 (95% CI: 0.60, 1.12). Adjusting for age, gender, ISS, GCS, injury mechanism and comorbid status, Hong Kong patients demonstrated comparable mean PCS-12 scores at 6-months (adjusted mean difference: 1.2, 95% CI: −1.2, 3.6) and 12-months (adjusted mean difference: −0.4, 95% CI: −3.2, 2.4) compared to Victorian patients. Keeping age, gender, ISS, GCS, injury mechanism and comorbid status, there was no difference in the MCS-12 scores of Hong Kong patients compared to Victorian patients at 6-months (adjusted mean difference: 0.4, 95% CI: −2.1, 2.8) or 12-months (adjusted mean difference: 1.8, 95% CI: −0.8, 4.5). Conclusion The unadjusted analyses showed better outcomes for Victorian cases compared to Hong Kong but after adjusting for key confounders, there was no difference in 6-month or 12-month functional outcomes between the jurisdictions. PMID:25157522

The importance of surgeon involvement in the evaluation of non-accidental trauma patients.

PubMed

Larimer, Emily L; Fallon, Sara C; Westfall, Jaimee; Frost, Mary; Wesson, David E; Naik-Mathuria, Bindi J

2013-06-01

Non-Accidental Trauma (NAT) is a significant cause of childhood morbidity and mortality, causing 50% of trauma-related deaths at our institution. Our purpose was to evaluate the necessity of primary surgical evaluation and admission to the trauma service for children presenting with NAT. We reviewed all NAT patients from 2007-2011. Injury types, demographic data, and hospitalization information were collected. Comparisons to accidental trauma (AT) patients were made using Wilcoxon rank sum and Student's t tests. We identified 267 NAT patients presenting with 473 acute injuries. Injuries in NAT patients were more severe than in AT patients, and Injury Severity Scores, ICU admission rates, and mortality were all significantly (p<0.001) higher. The majority suffered from polytrauma. Multiple areas of injury were seen in patients with closed head injuries (72%), extremity fractures (51%), rib fractures (82%), and abdominal/thoracic trauma (80%). Despite these complex injury patterns, only 56% received surgical consults, resulting in potential delays in diagnosis, as 24% of abdominal CT scans were obtained >12 hours after hospitalization. Given the high incidence of polytrauma in NAT patients, prompt surgical evaluation is necessary to determine the scope of injury. Admission to the trauma service and a thorough tertiary survey should be considered for all patients. Copyright © 2013 Elsevier Inc. All rights reserved.

Clinical findings provide criteria to evaluate priorities of ophthalmologic intervention in conscious multiple trauma patients.

PubMed

Shams-Vahdati, Samad; Gholipour, Changiz; Jalilzadeh-Binazar, Mehran; Moharamzadeh, Payman; Sorkhabi, Rana; Jalilian, Respina

2015-07-01

Multiple trauma patients frequently suffer eye injuries, especially those patients with head traumas. We evaluated the accuracy of physical findings to determine the priorities of emergency ophthalmologic intervention in these patients. This study included all multiple trauma patients with ophthalmic trauma who had a GCS of 15 when they arrived at the emergency department during the period of March, 2008-March, 2009. First, we evaluated the patients according to the criteria of the study. Then, an ophthalmologist evaluated them. From March 2008-March 2009, 306 multiple trauma patients with ocular trauma came to our ED. The sensitivity and accuracy of emergency physicians in diagnosing the priority of ophthalmologic treatment were comparable to an ophthalmologist (measure of agreement in kappa=0.967). The ability of an emergency physician or general surgeon to determine the actual need of early ophthalmologist intervention can improve decision making and saving both time and money. Our study suggests that it is possible to determine according to clinical findings the need of the patient to have ophthalmologic intervention without referring the patient to ophthalmologist examination. Defining specific criteria of ophthalmologic examinations can clarify the necessity of emergency ophthalmologic examination and intervention. Copyright © 2014 Elsevier Ltd. All rights reserved.

SU-F-I-36: In-Utero Dose Measurements Within Postmortem Subjects for Estimating Fetal Doses in Pregnant Patients Examined with Pulmonary Embolism, Trauma, and Appendicitis CT

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

Lipnharski, I; Quails, N; Carranza, C

Purpose: The imaging of pregnant patients is medically necessary in certain clinical situations. The purpose of this work was to directly measure uterine doses in a cadaver scanned with CT protocols commonly performed on pregnant patients in order to estimate fetal dose and assess potential risk. Method: One postmortem subject was scanned on a 320-slice CT scanner with standard pulmonary embolism, trauma, and appendicitis protocols. All protocols were performed with the scan parameters and ranges currently used in clinical practice. Exams were performed both with and without iterative reconstruction to highlight the dose savings potential. Optically stimulated luminescent dosimeters (OSLDs)more » were inserted into the uterus in order to approximate fetal doses. Results: In the pulmonary embolism CT protocol, the uterus is outside of the primary beam, and the dose to the uterus was under 1 mGy. In the trauma and appendicitis protocols, the uterus is in the primary beam, the fetal dose estimates were 30.5 mGy for the trauma protocol, and 20.6 mGy for the appendicitis protocol. Iterative reconstruction reduced fetal doses by 30%, with uterine doses at 21.3 for the trauma and 14.3 mGy for the appendicitis protocol. Conclusion: Fetal doses were under 1 mGy when exposed to scatter radiation, and under 50 mGy when exposed to primary radiation with the trauma and appendicitis protocols. Consistent with the National Council on Radiation Protection & Measurements (NCRP) and the International Commission on Radiological Protection (ICRP), these doses exhibit a negligible risk to the fetus, with only a small increased risk of cancer. Still, CT scans are not recommended during pregnancy unless the benefits of the exam clearly outweigh the potential risk. Furthermore, when possible, pregnant patients should be examined on CT scanners equipped with iterative reconstruction in order to keep patient doses as low as reasonable achievable.« less

Physical Trauma and Infection as Precipitating Factors in Patients with Fibromyalgia.

PubMed

Jiao, Juan; Vincent, Ann; Cha, Stephen S; Luedtke, Connie A; Kim, Chul H; Oh, Terry H

2015-12-01

The objective of this study was to evaluate both precipitating factors in patients with fibromyalgia and any differences in clinical presentation, symptom severity, and quality-of-life between those with and without precipitating physical trauma or infection. In a retrospective cross-sectional study, the authors compared patient characteristics and fibromyalgia symptom severity and quality-of-life with the Fibromyalgia Impact Questionnaire and the Short Form-36 Health Survey in patients seen in a fibromyalgia treatment program. Of 939 patients, 27% reported precipitating factors (trauma, n = 203; infection, n = 53), with the rest having idiopathic fibromyalgia (n = 683). Patients with precipitating trauma were more likely to have worse Fibromyalgia Impact Questionnaire physical function than patients with idiopathic onset (P = 0.03). Compared with patients with idiopathic onset and precipitating trauma, patients with precipitating infection were more likely to have worse Short Form-36 Health Survey physical component summary (P = 0.01 and P = 0.003) but better role emotional (P = 0.04 and P = 0.005), mental health index (P = 0.02 and P = 0.007), and mental component summary (P = 0.03 and P = 0.004), respectively. One-fourth of this study's patients with fibromyalgia had precipitating physical trauma or infection. Patients with precipitating infection had different sociodemographic characteristics, clinical presentation, and quality-of-life from the idiopathic and trauma groups. Further studies are needed to look into the relationships between precipitating events and fibromyalgia.

Risk factors for injury acute renal in patients with severe trauma and its effect on mortality.

PubMed

Baitello, André Luciano; Marcatto, Gustavo; Yagi, Roberto Kaoru

2013-01-01

The studies which associated acute kidney injury (AKI) and trauma emerged during the Second World War, and since then we have seen a progressive evolution of healthcare aiming at AKI prevention. However, establishing the risk factors for post-trauma AKI development remains crucial and may help reduce this complication. This study aims at identifying risk factors vis-à-vis the development of AKI in patients with severe trauma and its impact on mortality. This is a retrospective study of 75 patients with severe trauma. Six were taken off because they arrived at the hospital past the point of resuscitation. The variables considered were age, gender, trauma severity according to the Injury Severity Score (ISS) and the Glasgow Coma Scale (GCS), trauma mechanism, mean blood pressure upon admission, fluid replacement in the first 24 hours, serum creatinine levels, use of nephrotoxic antibiotics, length of hospital stay, need for ICU admission and mortality. The prevalence of AKI in severe trauma patients was 17.3%, and the factors associated with ARF in this sample were Head Injury and GCS < 10. Mortality, length of hospital stay and the need for ICU were significantly higher in patients who developed AKI. The identification of these risk factors is of paramount importance for the development of care strategies for patients suffering from severe trauma, for the prevention of acute kidney injury and the associated high mortality.

Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa.

PubMed

Boschini, Laura P; Lu-Myers, Yemeng; Msiska, Nelson; Cairns, Bruce; Charles, Anthony G

2016-05-01

Traumatic injuries account for the greatest portion of global surgical burden particularly in low- and middle-income countries (LMICs). To assess effectiveness of a developing trauma system, we hypothesize that there are survival differences between direct and indirect transfer of trauma patients to a tertiary hospital in sub Saharan Africa. Retrospective analysis of 51,361 trauma patients within the Kamuzu Central Hospital (KCH) trauma registry from 2008 to 2012 was performed. Analysis of patient characteristics and logistic regression modelling for in-hospital mortality was performed. The primary study outcome is in hospital mortality in the direct and indirect transfer groups. There were 50,059 trauma patients were included in this study. 6578 patients transferred from referring facilities and 43,481 patients transported from the scene. The indirect and direct transfer cohorts were similar in age and sex. The mechanism of injury for transferred patients was 78.1% blunt, 14.5% penetrating, and 7.4% other, whereas for the scene group it was 70.7% blunt, 24.0% penetrating, and 5.2% other. Median times to presentation were 13 (4-30) and 3 (1-14)h for transferred and scene patients, respectively. Mortality rate was 4.2% and 1.6% for indirect and direct transfer cohorts, respectively. A total of 8816 patients were admitted of which 3636 and 5963 were in the transfer and scene cohort, respectively. After logistic regression analysis, the adjusted in-hospital mortality odds ratio was 2.09 (1.24-3.54); P=0.006 for indirect transfer versus direct transfer cohort, after controlling for significant covariates. Direct transfer of trauma patients from the scene to the tertiary care centre is associated with a survival benefit. Our findings suggest that trauma education and efforts directed at regionalization of trauma care, strengthening pre-hospital care and timely transfer from district hospitals could mitigate trauma-related mortality in a resource-poor setting. Copyright © 2016 Elsevier Ltd. All rights reserved.

Plastic surgical operative workload in major trauma patients following establishment of the major trauma network in England: A retrospective cohort study.

PubMed

Hendrickson, S A; Khan, M A; Verjee, L S; Rahman, K M A; Simmons, J; Hettiaratchy, S P

2016-07-01

The introduction of major trauma centres (MTCs) in England has led to 63% reduction in trauma mortality.(1) The role of plastic surgeons supporting these centres has not been quantified previously. This study aimed to quantify plastic surgical workload at an urban MTC to determine the contribution of plastic surgeons to major trauma care. All Trauma Audit and Research Network (TARN)-recorded major trauma patients who presented to an urban MTC in 2013 and underwent an operation were identified retrospectively. Patients who underwent plastic surgery were identified and the type and date of procedure(s) were recorded. The trauma operative workload data of another tertiary surgical specialty and local historical plastics workload data from pre-MTC go-live were collected for comparison. Of the 416 major trauma patients who required surgical intervention, 29% (n = 122) underwent plastic surgery. Of these patients, 43% had open lower limb fractures, necessitating plastic surgical involvement according to British Orthopaedic Association Standards for Trauma (BOAST) 4 guidance. The overall plastic surgery operative workload increased sevenfold post-MTC go-live. A similar proportion of the same cohort required neurosurgery (n = 115; p = 0.589). This study quantifies plastic surgery involvement in major trauma and demonstrates that plastic surgical operative workload is at least on par with other tertiary surgical specialties. It also reports one centre's experience of a significant change in plastic surgery activity following designation of MTC status. The quantity of plastic surgical operative workload in major trauma must be considered when planning major trauma service design and workforce provision, and for plastic surgical postgraduate training. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Traumatic injury may be a predisposing factor for cerebrovascular accident.

PubMed

Wojcik, Jodi B; Benns, Matthew V; Franklin, Glen A; Harbrecht, Brian G; Broughton-Miller, Kimberly D; Frisbie, Michelle C; Smith, Jason W; Pentecost, Karina M; Bozeman, Matthew C

2013-01-01

The purpose of the study was to assess whether trauma may be an independent risk factor for stroke. Evidence has shown that trauma patients experience a hypercoagulable state postinjury, increasing the risk of thrombotic events. A case-controlled, retrospective analysis was performed on admitted trauma patients over a 2-year period. Results revealed that trauma patients are 1.6 times more likely to have a cerebrovascular accident (CVA) during their hospital admission, when compared with nontrauma patients with similar CVA risk factors. Several statistically significant differences between the groups were identified. On the basis of these results, trauma appears to be an independent, nonmodifiable risk factor for CVA.

Quality of Documentation as a Surrogate Marker for Awareness and Training Effectiveness of PHTLS-Courses. Part of the Prospective Longitudinal Mixed-Methods EPPTC-Trial.

PubMed

Häske, David; Beckers, Stefan K; Hofmann, Marzellus; Lefering, Rolf; Gliwitzky, Bernhard; Wölfl, Christoph C; Grützner, Paul; Stöckle, Ulrich; Dieroff, Marc; Münzberg, Matthias

2017-01-01

Care for severely injured patients requires multidisciplinary teamwork. A decrease in the number of accident victims ultimately affects the routine and skills. PHTLS ("Pre-Hospital Trauma Life Support") courses are established two-day courses for medical and non-medical rescue service personnel, aimed at improving the pre-hospital care of trauma patients worldwide. The study aims the examination of the quality of documentation before and after PHTLS courses as a surrogate endpoint of training effectiveness and awareness. This was a prospective pre-post intervention trial and was part of the mixed-method longitudinal EPPTC (Effect of Paramedic Training on Pre-Hospital Trauma Care) study, evaluating subjective and objective changes among participants and real patient care, as a result of PHTLS courses. The courses provide an overview of the SAMPLE approach for interrogation of anamnestic information, which is believed to be responsible for patient safety as relevant, among others, "Allergies," "Medication," and "Patient History" (AMP). The focus of the course is not the documentation. In total, 320 protocols were analyzed before and after the training. The PHTLS course led to a significant increase (p < 0.001) in the "AMP" information in the documentation. The subgroups analysis of "allergies" (+47.2%), "drugs" (+38.1%), and "medical history" (+27.8%) before and after the PHTLS course showed a significant increase in the information content. In summary, we showed that PHTLS training improves documentation quality, which we used as a surrogate endpoint for learning effectiveness and awareness. In this regard, we demonstrated that participants use certain parts of training in real life, thereby suggesting that the learning methods of PHTLS training are effective. These results, however, do not indicate whether patient care has changed.

Quality assurance for patients with head injuries admitted to a regional trauma unit.

PubMed

Schwartz, M L; Sharkey, P W; Andersen, J A

1991-07-01

The efficacy of trauma systems in reducing preventable deaths has been established but the methods of auditing care are still evolving. Various "audit filters" to identify which patients' charts should be reviewed have been proposed. An analysis of all patients admitted to the Regional Trauma Unit (RTU) over a 19-month period was conducted. Of 729 patients, 135 were identified as having suffered a traumatic intracranial hemorrhage (TICH). On review, neither delay in transfer from the emergency room to the operating room nor increasing time from the incident to the operating room correlated with increasing mortality. In contrast to delay, the Glasgow Coma Scale (GCS) score on admission correlated well with outcome. The charts of patients with anomalous outcomes based on admission GCS score were reviewed, and two possibly preventable deaths were identified. There were 48 patients with TICH who had no operations but there were no deaths attributable to a missed operation. There were 76 patients for whom the GCS score at the referring hospital and the GCS score on admission to the RTU were available. Seven of 19 patients who worsened on transfer declined because of significant pulmonary injuries. Anomalous outcomes based on admission GCS score and declining GCS scores are recommended as quality assurance filters.

The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review.

PubMed

Tyroch, Alan H; McGuire, Emmett L; McLean, Susan F; Kozar, Rosemary A; Gates, Keith A; Kaups, Krista L; Cook, Charles; Cowgill, Sarah M; Griswold, John A; Sue, Larry A; Craun, Michael L; Price, Jan

2005-05-01

The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.

Angiographic Findings and Embolotherapy in Renal Arterial Trauma

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

Sofocleous, Constantinos T., E-mail: constant@pol.net; Hinrichs, Clay; Hubbi, Basil

Purpose To evaluate the angiographic findings and embolotherapy in the management of traumatic renal arterial injury Methods This is a retrospective review of 22 patients with renal trauma who underwent arteriography and percutaneous embolization from December 1995 to January 2002. Medical records, imaging studies and procedural reports were reviewed to assess the type of injury, arteriographic findings and immediate embolization results. Long-term clinical outcome was obtained by communication with the trauma physicians and by clinical chart review.Results Arteriography was performed in 125 patients admitted to a State Trauma Center with suspected internal bleeding. Renal arterial injury was documented in 22more » and was the result of a motor-vehicle accident (10), auto-pedestrian accident (1), gunshot (4) or stab wounds (6) and a fall (1). Percutaneous renal arterial embolization was undertaken in 22 of 125 (18%) patients to treat extravasation (11), arterial pedicle rupture (5), abnormal arteriovenous (3) or arteriocalyceal (2) communication and pseudoaneurysm (3). One of the pseudoaneurysms and one of the arteriovenous fistulae were found in addition to extravasation. All 22 patients (16 men, 6 women) were hemodynamically stable, or controlled during arteriography and embolotherapy. Selective and/or superselective embolization of the abnormal vessels was performed using coils in 9 patients, microcoils in 9 patients and Gelfoam pledgets in 3 patients. In one patient Gelfoam pledgets mixed with polyvinyl alcohol (PVA) particles were used for embolization. Immediate angiographic evidence of hemostasis was demonstrated in all cases. Two initial technical failures were treated with repeat arteriography and embolization. There was no procedure-related death. There was no non-target embolization. One episode of renal abscess after embolization was treated by nephrectomy and 3 patients underwent elective post-embolization nephrectomy to prevent infection. Follow-up ranged from 1 month to 7 years (mean 31 months). No procedure-related or delayed onset of renal insufficiency occurred.Conclusion In hemodynamically stable and controlled patients selective and superselective embolization is a safe and effective method for the management of renal vascular injury.« less

Failure to Clear Elevated Lactate Predicts 24-Hour Mortality in Trauma Patients

PubMed Central

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

2015-01-01

Background Lactate clearance is a standard resuscitation goal in patients in non-traumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes. Methods A retrospective chart review identified patients who were admitted directly from the scene of injury to an urban trauma center between 2010 and 2013 and who had at least one lactate concentration measurement within 24 hours. Transfers, patients without lactate measurement, and those who were dead on arrival were excluded. Of the 26,545 screened patients, 18,304 constituted the initial lactate measurement population and 3,887 were the lactate clearance cohorts. Results Initial lactate had an area-under-the-receiver operating curve of 0.86 and 0.73 for mortality at 24 hours and in-hospital, respectively. An initial concentration ≥3 mmol/L had sensitivity of 0.86 and specificity of 0.73 for mortality at 24 hours. The mortality rate among patients with elevated lactate concentrations (n=2381, 5.6±2.8 mmol/L) that did not decline to <2.0 mmol/L in response to resuscitative efforts (mean second measurement, 3.7±1.9 mmol/L) was nearly seven times higher (4.1% vs 0.6% [p<0.001]) than among those with an elevated concentration (n=1506, 5.3±2.7 mmol/L) that normalized (1.4±0.4 mmol/L). Logistic regression analysis showed that failure to clear lactate was associated with death more than any other feature (OR=7.4; CI, 1.5–35.5), except having an Injury Severity Score >25 (OR=8.2; CI, 2.7–25.2). Conclusions Failure to clear lactate is a strong negative prognostic marker after injury. An initial lactate measurement combined with a second measurement for high-risk individuals might constitute a useful method of risk-stratifying injured patients. PMID:26402531

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa

PubMed Central

Oosthuizen, GV; Sartorius, B; Keene, C; Clarke, DL

2014-01-01

Introduction Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. Methods This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. Results A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20–29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the ‘triangle of safety’ but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation. PMID:25350185

Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center

PubMed Central

Lockwood, Megan M.; Smith, Gabriel A.; Tanenbaum, Joseph; Lubelski, Daniel; Seicean, Andreea; Pace, Jonathan; Benzel, Edward C.; Mroz, Thomas E.; Steinmetz, Michael P.

2017-01-01

OBJECT Screening for vertebral artery injury (VAI) following cervical spine fractures is routinely performed across trauma centers in North America. From 2002 to 2007, the total number of neck CT angiography (CTA) studies performed in the Medicare population after trauma increased from 9796 to 115,021. In the era of cost-effective medical care, the authors aimed to evaluate the utility of CTA screening in detecting VAI and reduce chances of posterior circulation strokes after traumatic cervical spine fractures. METHODS A retrospective review of all patients presenting with cervical spine fractures to Northeast Ohio’s Level I trauma institution from 2002 to 2012 was performed. RESULTS There was a total of 1717 cervical spine fractures in patients presenting to Northeast Ohio’s Level I trauma institution between 2002 and 2012. CTA screening was performed in 732 patients, and 51 patients (0.7%) were found to have a VAI. Fracture patterns with increased odds of VAI were C-1 and C-2 combined fractures, transverse foramen fractures, and subluxation of adjacent vertebral levels. Ten posterior circulation strokes were identified in this patient population (0.6%) and found in only 4 of 51 cases of VAI (7.8%). High-risk fractures defined by Denver Criteria, VAI, and antiplatelet treatment of VAI were not independent predictors of stroke. CONCLUSIONS Cost-effective screening must be reevaluated in the setting of blunt cervical spine fractures on a case-by-case basis. Further prospective studies must be performed to elucidate the utility of screening for VAI and posterior circulation stroke prevention, if identified. PMID:26613284

Endovascular treatment of penetrating arterial trauma with stent grafts.

PubMed

Biagioni, Rodrigo Bruno; Burihan, Marcelo Calil; Nasser, Felipe; Biagioni, Luisa Ciucci; Ingrund, José Carlos

2018-02-01

The endovascular management of arterial injuries has resulted in reduced operating time, blood loss, hospital mortality, lower incidence of sepsis, and decrease in mortality rates. For penetrating trauma, however, the benefits of endovascular therapy are questionable. Data were obtained by retrospective analysis of electronic medical records. All patients with vascular trauma seeking care at our institution from January 2010 to December 2015 were reviewed. A total of 223 vascular trauma patients were enrolled. Of these, 18 patients (8 %) were treated with endovascular techniques. The data related to clinical presentation, patient characteristics, technical aspects of the treatment, and follow-up were analysed. The mean patient age was 35.4 ± 17.8 years, 94 % were male. The mean injury severity score was 10.4 ± 2.5. The most commonly observed trauma mechanism was a gunshot in 10 cases (55 %), followed by lesions provoked by arterial catheter misplacement in five cases (27 %), and stab wounds in three cases (16.6 %). The main injury site was the subclavian artery, accounting for eight cases (44 %), followed by the superficial femoral artery and the tibiofibular trunk in two cases, respectively (18 %). The anterior tibial, fibular artery, axillary, common carotid, superior mesenteric, and profunda femoris were each affected once. Arteriovenous fistula was detected in nine cases (50 %), pseudoaneurysms in nine cases (50 %), and short occlusion in two cases (11 %). The mean follow-up duration was 753 days. The primary patency rate was 92.3 and 61.5 % after one and two years, respectively. The survival rate was 94.4 % after one and two years. Infection of the stents or limb amputations were not identified at follow-up. The endovascular treatment of penetrating arterial injuries with covered stents is feasible. However, the criteria used to choose the best method must be individualized.

Predictors of Death in Trauma Patients who are Alive on Arrival at Hospital.

PubMed

Lichtveld, Rob A; Panhuizen, Ivo F; Smit, Ronald B J; Holtslag, Hermann R; van der Werken, Christian

2007-02-01

To determine which factors predict death occurring in trauma patients who are alive on arrival at hospital Design Prospective cohort study Method Data were collected from 507 trauma patients with multiple injuries, with a Hospital Trauma Index-Injury Severity Score of 16 or more, who were initially delivered by the Emergency Medical Services to the Emergency Department of the University Medical Centre Utrecht (UMCU) during the period 1999-2000. Univariate analysis showed that every year of age increase resulted in a 2% greater risk of death. If the patient had been intubated at the scene of the accident, this risk was increased 4.3-fold. Every point of increase in the Triage Revised Trauma Score (T-RTS) reduced the risk of death by 30%. A similar (but inverse) tendency was found for the HTI-ISS score, with every point of increase resulting in a 5% greater risk of death. There was a clear relationship between the base excess (BE) and hemoglobin (Hb) levels and the risk of death, the latter being increased by 8% for each mmol/l drop in BE, and reduced by 22% for each mmol/l increase in Hb. The risk of death occurring was 2.6 times higher in cases with isolated neurotrauma. These associations hardly changed in the multivariate analysis; only the relation with having been intubated at the scene disappeared. The risk of severely injured accident patients dying after arriving in hospital is mainly determined by the T-RTS, age, presence of isolated neurological damage, BE and Hb level. Skull/brain damage and hemorrhage appear to be the most important causes of death in the first 24 h after the accident. The time interval between the accident and arrival at the hospital does not appear to affect the risk of death.

Utilization of tracheostomy in craniomaxillofacial trauma at a level-1 trauma center.

PubMed

Holmgren, Eric P; Bagheri, Shahrokh; Bell, R Bryan; Bobek, Sam; Dierks, Eric J

2007-10-01

The decision to perform a tracheostomy on patients with maxillofacial trauma is complex. There is little data exploring the role of tracheostomy in facial fracture management. We sought to profile the utilization of tracheostomy in the context of maxillofacial trauma at our institution by comparing patients who required tracheostomy with and without facial fractures versus those with facial fractures not requiring tracheostomy. All patients admitted to the Trauma Service at Legacy Emanuel Hospital and Health Center (LEHHC), Portland, OR, from 1993 to 2003 that sustained facial fractures or underwent tracheostomy were identified and data were retrospectively reviewed using patient charts and the trauma registry. Variables such as age, gender, death, injury severity score (ISS), facial injury severity score (FISS), Glasgow coma score (GCS), intensive care days (ICU), hospital length of stay (LOS), facial fracture profile, and oral and maxillofacial surgery (OMFS) operative intervention were tabulated and analyzed. Data were divided into 3 groups for comparison: group 1 (ffxT) consisted of patients who underwent a tracheostomy procedure and repair of their facial fracture during the SAME operation by the OMFS department (N = 125); group 2 (ffxNT) were those patients who had repair of their facial fractures by OMFS and did not require a tracheostomy (N = 224); and group 3 (NffxT) were patients who did not have facial fractures but received a tracheostomy during their hospitalization (N = 259). Ten-year data were used to analyze the ffxT and 5-year data were used to analyze the ffxNT and NffxT. Analysis of variance and chi2 testing was used for statistical analysis. A total of 18,187 patients were admitted to the trauma LEHHC Trauma Service during the study period, of which 1,079 (5.9%) patients sustained facial fractures and 788 (4.3%) required a tracheostomy. One hundred twenty-five patients (0.69% of total; 11.6% of facial fracture) received a tracheostomy at the same time as the facial fracture repair. All patients had their facial fractures successfully managed, regardless of the type of method used to stabilize the airway. There were no known cases of tracheal stenosis, severe bleeding requiring a return to the operating room, airway obstruction, or loss of secured airway. Males were the predominate gender in all 3 groups. The NffxT group (mean, 44.9 years) was much older compared with the ffxT (mean, 36.2 years) and ffxNT (mean, 30.9 years) groups. The incidence of death was higher in the tracheostomy groups compared with 0% with the non-tracheostomy group. The ffxNT group had a statistically significant higher GCS with an average of 12.4 when compared with the tracheostomy groups (ffxT = 6.8; NffxT = 6.7). ISS was nearly the same in the tracheostomy group (ffxT = 28.45; NffxT = 30.04), but higher when compared with the ffxNT (ISS = 17.33). All 3 groups were much different in terms of LOS and ICU days, in which the NffxT group had an average hospital LOS and ICU days of 34.4 and 16.56, respectively. This was higher when compared with the ffxT (LOS = 19.71 days; ICU = 7.21 days) and ffxNT (LOS = 6.82 days; ICU = 1.33 days) groups. The FISS averaged 6.22 in the ffxT group and was higher compared with an FISS of 3.16 in the ffxNT group. Overall, the fracture profile was different between the tracheostomy and non-tracheostomy groups. There was a higher prevalence of mandibular fractures, multiple mandibular fractures, and Le Fort III fractures in the ffxT group compared with the ffxNT group. Tracheostomy is commonly performed in the context of multisystem trauma and is a safe method for airway stabilization in patients with craniomaxillofacial trauma. Multi-institutional collaboration and a prospective, randomized trial measuring outcome, resource utilization, and length of ICU stay is necessary to determine if tracheostomy is indeed of measurable benefit to patients with complex injuries.

Trauma operating room in conjunction with an air ambulance system: indications, interventions, and outcomes.

PubMed

Law, D K; Law, J K; Brennan, R; Cleveland, H C

1982-09-01

We report a retrospective study of 198 trauma patients brought directly to a trauma operating room by an air ambulance system. Despite rapid transport, expert prehospital resuscitation, and the capability of early surgical intervention, the overall mortality was high (57%). There was no significant salvage of patients arriving without pulse, blood pressure or cardiac activity. Optimal trauma care failed to show encouraging results in this preselected group of patients with predominantly blunt and multisystem injury. The justification and cost effectiveness of this system of trauma care is discussed.

Endovascular Treatment of Acute Arterial Hemorrhage in Trauma Patients Using Ethylene Vinyl Alcohol Copolymer (Onyx)

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

Mueller-Wille, R., E-mail: rene.mueller-wille@klinik.uni-regensburg.de; Heiss, P., E-mail: peter.heiss@klinik.uni-regensburg.de; Herold, T., E-mail: thomas.herold@helios-kliniken.de

Purpose: This study was designed to determine the feasibility and efficacy of endovascular embolization with liquid embolic agent ethylene vinyl alcohol copolymer (Onyx) in patients with acute traumatic arterial bleeding. Methods: This is a retrospective review of 13 patients (9 men and 4 women; mean age 45 years) with severe trauma who underwent embolotherapy using Onyx from November 2003 to February 2009. Bleeding was located in the pelvis (5 patients), kidney (3 patients), mesenteric region (2 patients), retroperitoneal space (2 patients), neck (1 patient), and thigh (1 patient). In three cases (23.1%), Onyx was used in conjunction with coils. Wemore » evaluate the technical and clinical success, procedural and embolization time, occurrence of rebleeding, and embolotherapy-related complications, such as necrosis or migration of Onyx into nontarget vessels. Results: In all patients, embolotherapy was technically and clinically successful on the first attempt. Control of bleeding could be reached with a mean time of 19 (range, 4-63) min after correct placement of the microcatheter in the feeding artery. No recurrent bleeding was detected. No unintended necrosis or migration of Onyx into a nontarget region was observed. During the follow-up period, three patients (23.1%) died due to severe intracranial hemorrhage, cardiac arrest, and sepsis. Conclusions: Transcatheter embolization with new liquid embolic agent Onyx is technically feasible and effective in trauma patients with acute arterial hemorrhage.« less

Multi-Drug–Resistant Gram-Negative Infections in Deployment-Related Trauma Patients

PubMed Central

Li, Ping; Whitman, Timothy J.; Blyth, Dana M.; Schnaubelt, Elizabeth R.; Mende, Katrin; Tribble, David R.

2017-01-01

Abstract Background: The contribution of multi-drug–resistant gram-negative bacilli infections (MDRGN-I) in patients with trauma is not well described. We present characteristics of MDRGN-Is among military personnel with deployment-related trauma (2009–2014). Patients and Methods: Data from the Trauma Infectious Disease Outcomes Study were assessed for infectious outcomes and microbial recovery. Infections were classified using standardized definitions. Gram-negative bacilli were defined as multi-drug–resistant if they showed resistance to ≥3 antibiotic classes or were producers of extended-spectrum β-lactamase or carbapenemases. Results: Among 2,699 patients admitted to participating U.S. hospitals, 913 (33.8%) experienced ≥1 infection event, of which 245 (26.8%) had a MDRGN-I. There were 543 MDRGN-I events (24.6% of unique 2,210 infections) with Escherichia coli (48.3%), Acinetobacter spp. (38.6%), and Klebsiella pneumoniae (8.4%) as the most common MDRGN isolates. Incidence of MDRGN-I was 9.1% (95% confidence interval [CI]: 8.0–10.2). Median time to MDRGN-I event was seven days with 75% occurring within 13 days post-trauma. Patients with MDRGN-Is had a greater proportion of blast injuries (84.1% vs. 62.5%; p < 0.0001), traumatic amputations (57.5% vs. 16.3%; p < 0.0001), and higher injury severity (82.0% had injury severity score ≥25 vs. 33.7%; p < 0.0001) compared with patients with either no infections or non-MDRGN-Is. Furthermore, MDRGN-I patients were more frequently admitted to the intensive care unit (90.5% vs. 48.5%; p < 0.0001), colonized with a MDRGN before infection (58.0% vs. 14.7%; p < 0.0001), and required mechanical ventilation (78.0% vs. 28.8% p < 0.0001). Antibiotic exposure before the MDRGN-I event was significantly higher across antibiotic classes except first generation cephalosporins and tetracyclines, which were very commonly used with all patients. Regarding outcomes, patients with MDRGN-Is had a longer length of hospitalization than the comparator group (53 vs. 18 days; p < 0.0001). Conclusions: We found a high rate of MDRGN-I in our population characterized by longer hospitalization and greater injury severity. These findings inform treatment and infection control decisions in the trauma patient population. PMID:29173084

Culture-sensitive psychotraumatology

PubMed Central

Schnyder, Ulrich; Bryant, Richard A.; Ehlers, Anke; Foa, Edna B.; Hasan, Aram; Mwiti, Gladys; Kristensen, Christian H.; Neuner, Frank; Oe, Misari; Yule, William

2016-01-01

Background Although there is some evidence of the posttraumatic stress disorder (PTSD) construct's cross cultural validity, trauma-related disorders may vary across cultures, and the same may be true for treatments that address such conditions. Experienced therapists tailor psychotherapy to each patient's particular situation, to the nature of the patient's psychopathology, to the stage of therapy, and so on. In addition, culture-sensitive psychotherapists try to understand how culture enhances the meaning of their patient's life history, the cultural components of their illness and help-seeking behaviors, as well as their expectations with regard to treatment. We cannot take for granted that all treatment-seeking trauma survivors speak our language or share our cultural values. Therefore, we need to increase our cultural competencies. Methods The authors of this article are clinicians and/or researchers from across the globe, working with trauma survivors in various settings. Each author focused on one or more specific cultural aspects of working with trauma survivors and highlighted the following aspects. Results As a result of culture-specific individual and collective meanings linked to trauma and trauma-related disorders survivors may be exposed to (self-)stigma in the aftermath of trauma. Patients who are reluctant to talk about their traumatic experiences may instead be willing to write or use other ways of accessing the painful memories such as drawing. In other cultures, community and family cohesion are crucial elements of recovery. While awareness of culture-specific aspects is important, we also need to beware of premature cultural stereotyping. When disseminating empirically supported psychotherapies for PTSD across cultures, a number of additional challenges need to be taken into account: many low and middle income countries have very limited resources available and suffer from a poor health infrastructure. Conclusions In summary, culture-sensitive psychotraumatology means assuming an empathic and non-judgmental attitude, trying to understand each individual's cultural background. Highlights of the article Cultural sensitivity is required to successfully treat trauma survivors. Empirically supported treatments may need to be modified depending on the patient’s cultural background. In addition to talking, patients may write or use other ways of accessing the traumatic memories such as painting, dancing, or singing. In low and middle income countries, dissemination of evidence-based treatments is frequently impeded by limited resources and poor health infrastructure. Beware of cultural stereotyping! PMID:27473520

Bayesian averaging over Decision Tree models for trauma severity scoring.

PubMed

Schetinin, V; Jakaite, L; Krzanowski, W

2018-01-01

Health care practitioners analyse possible risks of misleading decisions and need to estimate and quantify uncertainty in predictions. We have examined the "gold" standard of screening a patient's conditions for predicting survival probability, based on logistic regression modelling, which is used in trauma care for clinical purposes and quality audit. This methodology is based on theoretical assumptions about data and uncertainties. Models induced within such an approach have exposed a number of problems, providing unexplained fluctuation of predicted survival and low accuracy of estimating uncertainty intervals within which predictions are made. Bayesian method, which in theory is capable of providing accurate predictions and uncertainty estimates, has been adopted in our study using Decision Tree models. Our approach has been tested on a large set of patients registered in the US National Trauma Data Bank and has outperformed the standard method in terms of prediction accuracy, thereby providing practitioners with accurate estimates of the predictive posterior densities of interest that are required for making risk-aware decisions. Copyright © 2017 Elsevier B.V. All rights reserved.

DAMP-Mediated Innate Immune Failure and Pneumonia after Trauma

DTIC Science & Technology

2017-10-01

Correlation Between Chemotaxis and Ca2+ release AUC ND6 ND3 ND4 ND5 COX1 6 similarity of amino acid sequences based upon their component residues. We used... correlation to chemotaxis studies. These findings give us confidence that our mechanistic studies in mice can be able be used translationally to...evaluated time-dependent changes in peripheral blood in trauma patients to identify changes correlated with infection. Methods: Total leukocytes were

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.

Postpartum Perineal Pain in a Low Episiotomy Setting: Association with Severity of Genital Trauma, Labor Care and Birth Variables

PubMed Central

Leeman, Lawrence; Fullilove, Anne M.; Borders, Noelle; Manocchio, Regina; Albers, Leah L.; Rogers, Rebecca G.

2013-01-01

Background Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative delivery. Methods A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the Present Pain Intensity (PPI) and Visual Analog Scale (VAS) components of the validated short form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. Results At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 +/− 1.61 vs 1.48 +/− 1.40; P< 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, P= 0.002) than women with mild or no trauma. By 3 months average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non-Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model only trauma group and length of active pushing predicted pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on level of pain at discharge beyond its effect on the incidence of major trauma. Conclusions Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain. PMID:20002420

Exploring the Effect of Trauma Care Simulation on Undergraduate Critical Care Nursing Students' Attitude at a College of Nursing, in Jeddah--An Intervention Study

ERIC Educational Resources Information Center

El-Gamal, Seham; de Beer, Jennifer; Sunari, Dalia

2017-01-01

Background: Patient safety has become a priority and prerequisite for the provision for effective quality care. Simulation is seen as one method to ensure patient safety as this method allows for the attainment of skills and promotes the transference of these skills into safe clinical practice. Method: A pretest-posttest research design was used.…

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma: A retrospective cohort study.

PubMed

Hong, Zhi-Jie; Chen, Cheng-Jueng; Yu, Jyh-Cherng; Chan, De-Chuan; Chou, Yu-Ching; Liang, Chia-Ming; Hsu, Sheng-Der

2016-09-01

We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT.Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome.Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients' time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06-0.75, P = 0.016).Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma.

Implementation of recommended trauma system criteria in south-eastern Norway: a cross-sectional hospital survey.

PubMed

Kristiansen, Thomas; Ringdal, Kjetil G; Skotheimsvik, Tarjei; Salthammer, Halvor K; Gaarder, Christine; Naess, Pål A; Lossius, Hans M

2012-01-26

Formalized trauma systems have shown beneficial effects on patient survival and have harvested great recognition among health care professionals. In spite of this, the implementation of trauma systems is challenging and often met with resistance.Recommendations for a national trauma system in Norway were published in 2007. We wanted to assess the level of implementation of these recommendations. A survey of all acute care hospitals that receive severely injured patients in the south-eastern health region of Norway was conducted. A structured questionnaire based on the 2007 national recommendations was used in a telephone interview of hospital trauma personnel between January 17 and 21, 2011. Seventeen trauma system criteria were identified from the recommendations. Nineteen hospitals were included in the study and these received more than 2000 trauma patients annually via their trauma teams. Out of the 17 criteria that had been identified, the hospitals fulfilled a median of 12 criteria. Neither the size of the hospitals nor the distance between the hospitals and the regional trauma centre affected the level of trauma resources available. The hospitals scored lowest on the criteria for transfer of patients to higher level of care and on the training requirements for members of the trauma teams. Our study identifies a major shortcoming in the efforts of regionalizing trauma in our region. The findings indicate that training of personnel and protocols for inter-hospital transfer are the major deficiencies from the national trauma system recommendations. Resources for training of personnel partaking in trauma teams and development of inter-hospital transfer agreements should receive immediate attention.

The care of a child with multiple trauma and severe anemia who was a Jehovah's Witness.

PubMed

Digieri, Luciana Andrea; Pistelli, Ivan Pollastrini; de Carvalho, Cid Eduardo

2006-06-01

Jehovah's Witness followers do not accept blood derived transfusions and available methods for avoiding transfusion have been used with degrees of success, demonstrating that the probability of death after trauma in these patients may not be significantly different from religious groups. In this report, we describe the case of a child victim of a multiple trauma with severe anemia due to blood loss, whose family would not authorize blood transfusion because of their Jehovah's Witness faith. We discuss the current indications for restricting transfusion, as well as highlighting new tools that contribute to the success of minimizing blood loss, thus avoiding transfusion.

Trauma-induced pemphigus: a case series of 36 patients.

PubMed

Daneshpazhooh, Maryam; Fatehnejad, Mina; Rahbar, Ziba; Balighi, Kamran; Ghandi, Narges; Ghiasi, Maryam; Abedini, Robabeh; Lajevardi, Vahideh; Chams-Davatchi, Cheyda

2016-02-01

Pemphigus is a group of autoimmune diseases characterized by intraepidermal acantholytic blisters. Isomorphic responses, or Koebner phenomenon (KP), defined as the appearance of typical lesions of a disease following trauma are rarely reported in pemphigus. Our aim was to present patients who developed new pemphigus lesions as a result of skin trauma. The medical files of pemphigus patients from the Autoimmune Bullous Diseases Research Center, who had a history of trauma before the onset or flare of their disease, between 1999 and 2013 were reviewed. Thirty-six pemphigus vulgaris (PV) patients had a history of trauma. Thirteen patients developed new-onset PV and the other 23 had previously been diagnosed with PV. Pemphigus lesions developed most often following major surgeries including abdominal, orthopedic, and chest surgeries as well as dental procedures, blunt physical trauma, and skin surgeries. Moreover, post-cataract laser surgery, burns, radiation therapy, and physiotherapy were also shown to induce pemphigus. Mean time between trauma and lesions was 4.7 weeks for recurrent PV and 15.0 weeks for new-onset PV. Unnecessary surgery and blunt trauma should be avoided in pemphigus patients. Furthermore, posttraumatic pemphigus should be suspected in poorly healing surgical wounds and confirmatory biopsies are mandatory. © 2016 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.

Prevalence of childhood trauma and correlations between childhood trauma, suicidal ideation, and social support in patients with depression, bipolar disorder, and schizophrenia in southern China.

PubMed

Xie, Peng; Wu, Kai; Zheng, Yingjun; Guo, Yangbo; Yang, Yuling; He, Jianfei; Ding, Yi; Peng, Hongjun

2018-03-01

Childhood trauma has long-term adverse effects on physical and psychological health. Previous studies demonstrated that suicide and mental disorders were related to childhood trauma. In China, there is insufficient research available on childhood trauma in patients with mental disorders. Outpatients were recruited from a psychiatric hospital in southern China, and controls were recruited from local communities. The demographic questionnaire, the Childhood Trauma Questionnaire-Short Form (CTQ-SF), and the Social Support Rating Scale (SSRS) were completed by all participants, and the Self-rating Idea of Suicide Scale (SIOSS) were completed only by patients. Prevalence rates of childhood trauma were calculated. Kruskal-Wallis test and Dunnett test were used to compare CTQ-SF and SSRS scores between groups. Logistic regression was used to control demographic characteristics and examine relationships between diagnosis and CTQ-SF and SSRS scores. Spearman's rank correlation test was conducted to analyze relationships between suicidal ideation and childhood trauma and suicidal ideation and social support. The final sample comprised 229 patients with depression, 102 patients with bipolar, 216 patient with schizophrenia, and 132 healthy controls. In our sample, 55.5% of the patients with depression, 61.8% of the patients with bipolar disorder, 47.2% of the patients with schizophrenia, and 20.5% of the healthy people reported at least one type of trauma. In patient groups, physical neglect (PN) and emotional neglect (EN) were most reported, and sexual abuse (SA) and physical abuse (PA) were least reported. CTQ-SF and SSRS total scores, and most of their subscale scores in patient groups were significantly different from the control group. After controlling demographic characteristics, mental disorders were associated with higher CTQ-SF scores and lower SSRS scores. CTQ-SF scores and number of trauma types were positively correlated with the SIOSS score. Negative correlations existed between SSRS scores and the SIOSS score. Our sample may not be sufficiently representative. Some results might have been interfered by demographic characteristics. The SIOSS was not completed by controls. Data from self-report scales were not sufficiently objective. In southern China, childhood trauma is more severe and more prevalent in patients with mental disorders (depression, bipolar disorder and schizophrenia) than healthy people. Among patients with mental disorders in southern China, suicidal ideation is associated with childhood trauma and poor social support. Copyright © 2017 Elsevier B.V. All rights reserved.

Role of ERCP in pediatric blunt abdominal trauma: a case series at a level one pediatric trauma center.

PubMed

Garvey, Erin M; Haakinson, Danielle J; McOmber, Mark; Notrica, David M

2015-02-01

There is no consensus regarding the appropriate use of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric trauma. We report our experience with ERCP for management of pediatric pancreatic and biliary injury following blunt abdominal trauma. A retrospective chart review was performed for pediatric patients with blunt abdominal trauma from July 2008 through December 2012 at our pediatric trauma center. For patients who underwent ERCP, demographics, injury characteristics, diagnostic details, procedures performed, length of stay, total parenteral nutrition use, and complications were reviewed. There were 532 patients identified: 115 hepatic injuries, 25 pancreatic injuries and one gall bladder injury. Nine patients (mean age 7.8 years) underwent ERCP. Seven (78%) had pancreatic injuries, while two (22%) had bilateral hepatic duct injuries. The median time to diagnosis was one day (range, 0-12). Diagnostic ERCP only was performed in three patients, two of which proceeded to distal pancreatectomy. Five patients had stents placed (two biliary and three pancreatic) and four sphincterotomies were performed. Despite pancreatic stenting, one patient required distal pancreatectomy for persistent leak. Median length of stay was 11 days. Pediatric pancreatic and biliary ductal injuries following blunt abdominal trauma are uncommon. ERCP can safely provide definitive treatment for some patients. Copyright © 2015 Elsevier Inc. All rights reserved.

Trauma center finances and length of stay: identifying a profitability inflection point.

PubMed

Fakhry, Samir M; Couillard, Debbie; Liddy, Casey T; Adams, David; Norcross, E Douglass

2010-05-01

Trauma centers frequently report unfavorable financial results for the care of injured patients. Many variables contribute to these results. The objective of this study was to determine the relationship of adult trauma patient hospital length of stay (LOS) to trauma center profitability. The trauma registry of a Level I trauma center was queried for patients older than 18 years for the period July 1, 2003 to June 30, 2008. Hospital financial records were matched to patient trauma registry data. There were 7,990 patients who met selection criteria: 71% were men, mean age was 40 years, mean Injury Severity Score was 12 +/-10, 84.2% of injuries were blunt, and mean LOS was 6.23 days. In the 5 years of the study, total charges were $329,315,191, total costs were $137,680,039, and overall profit was $7,644,894. Total costs rose each year and percent collections fell. The bulk of the profit was realized from patients with LOS < 11 days, with progressively escalating cost per case, lower collections, and resultant lower profitability as LOS increased. A notable "inflection point" at 11 days defined the cohort of profitable patients. Trauma patient LOS correlates closely with profitability. In this center, the vast majority of profit was realized from patients with LOS < 11 days and was eroded by most patient cohorts with longer LOS. Identification of an institution's "inflection point" may help direct efforts at increasing profitability and reflects the current reimbursement environment, which rewards shorter LOS over severity and quality. Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Cardiac and great vessel injuries after chest trauma: our 10-year experience.

PubMed

Onan, Burak; Demirhan, Recep; Öz, Kürşad; Onan, Ismihan Selen

2011-09-01

Cardiovascular injuries after trauma present with high mortality. The aim of the study was to present our experience in cardiac and great vessel injuries after chest trauma. During the 10-year period, 104 patients with cardiac (n=94) and great vessel (n=10) injuries presented to our hospital. The demographic data, mechanism of injury, location of injury, other associated injuries, timing of surgical intervention, surgical approach, and clinical outcome were reviewed. Eighty-eight (84.6%) males presented after chest trauma. The mean age of the patients was 32.5±8.2 years (range: 12-76). Penetrating injuries (62.5%) were the most common cause of trauma. Computed tomography was performed in most cases and echocardiography was used in some stable cases. Cardiac injuries mostly included the right ventricle (58.5%). Great vessel injuries involved the subclavian vein in 6, innominate vein in 1, vena cava in 1, and descending aorta in 2 patients. Early operations after admission to the emergency were performed in 75.9% of the patients. Thoracotomy was performed in 89.5% of the patients. Operative mortality was significantly high in penetrating injuries (p=0.01). Clinicians should suspect cardiac and great vessel trauma in every patient presenting to the emergency unit after chest trauma. Computed tomography and echocardiography are beneficial in the management of chest trauma. Operative timing depends on hemodynamic status, and a multidisciplinary team approach improves the patient's prognosis.

A review of patients who suddenly deteriorate in the presence of paramedics.

PubMed

Boyle, Malcolm J; Smith, Erin C; Archer, Frank

2008-07-26

The report of the Ministerial Review of Trauma and Emergency Services in Victoria, Australia, recommended that paramedics be permitted to divert to the closest hospital in incidences of life threatening situations prior to and during transport. An audit of patients that suddenly deteriorated in paramedic care was recommended by the Ministerial Review. The objective of the study was to identify the number and outcome of patients who suddenly deteriorated in the presence of paramedics. A retrospective cohort study of trauma patients who suddenly deteriorated in the presence of paramedics during 2002. As there was no standard definition, sudden deterioration was defined using a predetermined set of physiological criteria. Patient care record data of patients who suddenly deteriorated were compared with the State Trauma Registry to determine those who sustained hospital defined major trauma. Patient care records where hospital bypass was undertaken were identified and analysed. Ethics committee approval was obtained. There were 2,893 patients that suddenly deteriorated according to predefined criteria. 2,687 (5.1% of the total trauma patients for 2002) were suitable for further analysis. The majority of patients had a sudden decrease in BP (n = 2,463) with 4.3% having hospital defined major trauma. For patients with a sudden decrease in conscious state or a total GCS score of less than 13 (n = 77), 37.7% had hospital defined major trauma; and a sudden increase/decrease in pulse rate and sudden decrease in BP (n = 65), 26.2% had hospital defined major trauma. Only 28 documented incidents of hospital bypass were identified. This study suggests that the incidents of patients suddenly deteriorating in the presence of paramedics are low and the incidence of hospital bypass is not well documented.

The role of shock index as a predictor of multiple-trauma patients' pathways.

PubMed

Toccaceli, Andrea; Giampaoletti, Andrea; Dignani, Lucia; Lucertini, Carla; Petrucci, Cristina; Lancia, Loreto

2016-03-01

This research was conducted with the aim of investigating the accuracy of the shock index (SI) in distinguishing which multiple-trauma patients should be admitted to an intensive care unit (ICU) after treatment in an emergency room (ER). The SI is an easily obtained indicator, as it corresponds to an arithmetic ratio between the two parameters that are always measured during the first-aid treatment of multiple-trauma patients: heart rate (HR) and systolic blood pressure (SBP). There are many studies examining the SI in the multiple-trauma patients as a possible predictor of the destination unit. The SI is evaluated both at the trauma scene (pre-hospital SI-pH) and in the emergency room (SI-ER). An observational study with a retrospective approach was conducted on 158 adult patients with multiple trauma. The mean SI-pH and SI-ER values were higher in ICU patients than in-patients discharged or admitted to a normal ward, but the difference between these two patient groups was significant only for the SI-ER. Analysis of the receiver operating characteristic (ROC) curves confirmed that only the SI-ER is significant as a reliable indicator for ICU admission with a best cut-off of 1·05. However, a threshold value of 0·75 was still able to establish the correct type of destination for multiple-trauma patients, with a sensitivity of 57·3% and a specificity of 62·5%. This research showed that the SI-pH and SI-ER values are correlated, but only the SI-ER has shown statistical significance in terms of distinguishing the type of destination of multiple-trauma patient (ICU, ordinary ward or discharge) after initial treatment in the ER. The results of this study suggest the possibility of using SI in multiple-trauma patients as a triage indicator to assess the patients' care complexity and to guide the choice of proper clinical paths. © 2015 British Association of Critical Care Nurses.

Geriatric trauma.

PubMed

Adams, Sasha D; Holcomb, John B

2015-12-01

The landscape of trauma is changing due to an aging population. Geriatric patients represent an increasing number and proportion of trauma admissions and deaths. This review explores recent literature on geriatric trauma, including triage criteria, assessment of frailty, fall-related injury, treatment of head injury complicated by coagulopathy, goals of care, and the need for ongoing education of all surgeons in the care of the elderly. Early identification of high-risk geriatric patients is imperative to initiate early resuscitative efforts. Geriatric patients are typically undertriaged because of their baseline frailty being underappreciated; however, centers that see more geriatric patients do better. Rapid reversal of anticoagulation is important in preventing progression of brain injury. Anticipation of difficult disposition necessitates early involvement of physical therapy for rehabilitation and case management for appropriate placement. Optimal care of geriatric trauma patients will be based on the well established tenets of trauma resuscitation and injury repair, but with distinct elements that address the physiological and anatomical challenges presented by geriatric patients.

Hips don't lie: Waist-to-hip ratio in trauma patients.

PubMed

Joseph, Bellal; Zangbar, Bardiya; Haider, Ansab Abbas; Kulvatunyou, Naroung; Khalil, Mazhar; Tang, Andrew; O'Keeffe, Terence; Friese, Randall S; Orouji Jokar, Tahereh; Vercruysse, Gary; Latifi, Rifat; Rhee, Peter

2015-12-01

Obesity measured by body mass index (BMI) is known to be associated with worse outcomes in trauma patients. Recent studies have assessed the impact of distribution of body fat measured by waist-hip ratio (WHR) on outcomes in nontrauma patients. The aim of this study was to assess the impact of distribution of body fat (WHR) on outcomes in trauma patients. A 6-month (June to November 2013) prospective cohort analysis of all admitted trauma patients was performed at our Level 1 trauma center. WHR was measured in each patient on the first day of hospital admission. Patients were stratified into two groups: patients with WHR of 1 or greater and patients with WHR of less than 1. Outcome measures were complications and in-hospital mortality. Complications were defined as infectious, pulmonary, and renal complications. Regression and correlation analyses were performed. A total of 240 patients were enrolled, of which 28.8% patients (n = 69) had WHR of 1 or greater. WHR had a weak correlation with BMI (R = 0.231, R = 0.481). Eighteen percent (n = 43) of the patients developed complications, and the mortality rate was 10% (n = 24). Patients with a WHR of 1 or greater were more likely to develop in-hospital complications (32% vs. 13%, p = 0.001) and had a higher mortality rate (24% vs. 4%, p = 0.001) compared with the patients with a WHR of less than 1. In multivariate analysis, a WHR of 1 or greater was an independent predictor for the development of complications (odds ratio, 3.1; 95% confidence interval 1.08-9.2; p = 0.03) and mortality (odds ratio, 13.1; 95% confidence interval, 1.1-70; p = 0.04). Distribution of body fat as measured by WHR independently predicts mortality and complications in trauma patients. WHR is better than BMI in predicting adverse outcomes in trauma patients. Assessing the fat distribution pattern in trauma patients may help improve patient outcomes through focused targeted intervention. Prognostic study, level II.

Are the paradigms in trauma disease changing?

PubMed

Alted López, E

2015-01-01

Despite an annual trauma mortality of 5 million people worldwide, resulting in countless physical disabilities and enormous expenses, there are no standardized guidelines on trauma organization and management. Over the last few decades there have been very notorious improvements in severe trauma care, though organizational and economical aspects such as research funding still need to be better engineered. Indeed, trauma lags behind other serious diseases in terms of research and organization. The rapid developments in trauma care have produced original models available for research projects, initial resuscitation protocols and radiological procedures such as CT for the initial management of trauma patients, among other advances. This progress underscores the need for a multidisciplinary approach to the initial management and follow-up of this complicated patient population, where intensivists play a major role in both the patient admission and subsequent care at the trauma unit. Copyright © 2015 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Implementation of a CT Scan Practice Guideline for Pediatric Trauma Patients Reduces Unnecessary Scans Without Impacting Outcomes.

PubMed

McGrew, Patrick R; Chestovich, Paul J; Fisher, Jay D; Kuhls, Deborah A; Fraser, Douglas R; Patel, Purvi P; Katona, Chad W; Saquib, Syed; Fildes, John J

2018-05-04

Computed Tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the utility of CT scan guidelines in the management of pediatric trauma. This study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT utilization before and after CT-guideline implementation. Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis utilizing published criteria from the Pediatric Emergency Care and Research Network (PECARN). There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age<15) trauma patients seen in our TC from 2010-2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay (LOS), readmissions, and mortality. Categorical and continuous variables were analyzed with Chi-square and Wilcoxon rank-sum tests, respectively. P<0.05 was considered significant. We identified 1934 patients: 1106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8% respectively (p<0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged. Implementation of a pediatric CT guideline significantly decreases CT utilization, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children. Level IV, Therapeutic Study.

Outcome differences in adolescent blunt severe polytrauma patients managed at pediatric versus adult trauma centers.

PubMed

Rogers, Amelia T; Gross, Brian W; Cook, Alan D; Rinehart, Cole D; Lynch, Caitlin A; Bradburn, Eric H; Heinle, Colin C; Jammula, Shreya; Rogers, Frederick B

2017-12-01

Previous research suggests adolescent trauma patients can be managed equally effectively at pediatric and adult trauma centers. We sought to determine whether this association would be upheld for adolescent severe polytrauma patients. We hypothesized that no difference in adjusted outcomes would be observed between pediatric trauma centers (PTCs) and adult trauma centers (ATCs) for this population. All severely injured adolescent (aged 12-17 years) polytrauma patients were extracted from the Pennsylvania Trauma Outcomes Study database from 2003 to 2015. Polytrauma was defined as an Abbreviated Injury Scale (AIS) score ≥3 for two or more AIS-defined body regions. Dead on arrival, transfer, and penetrating trauma patients were excluded from analysis. ATC were defined as adult-only centers, whereas standalone pediatric hospitals and adult centers with pediatric affiliation were considered PTC. Multilevel mixed-effects logistic regression models assessed the adjusted impact of center type on mortality and total complications while controlling for age, shock index, Injury Severity Score, Glasgow Coma Scale motor score, trauma center level, case volume, and injury year. A generalized linear mixed model characterized functional status at discharge (FSD) while controlling for the same variables. A total of 1,606 patients met inclusion criteria (PTC: 868 [54.1%]; ATC: 738 [45.9%]), 139 (8.66%) of which died in-hospital. No significant difference in mortality (adjusted odds ratio [AOR]: 1.10, 95% CI 0.54-2.24; p = 0.794; area under the receiver operating characteristic: 0.89) was observed between designations in adjusted analysis; however, FSD (AOR: 0.38, 95% CI 0.15-0.97; p = 0.043) was found to be lower and total complication trends higher (AOR: 1.78, 95% CI 0.98-3.32; p = 0.058) at PTC for adolescent polytrauma patients. Contrary to existing literature on adolescent trauma patients, our results suggest patients aged 12-17 presenting with polytrauma may experience improved overall outcomes when managed at adult compared to pediatric trauma centers. Epidemiologic study, level III.

Lead-Time Bias and Interhospital Transfer after Injury: Trauma Center Admission Vital Signs Underpredict Mortality in Transferred Trauma Patients.

PubMed

Holena, Daniel N; Wiebe, Douglas J; Carr, Brendan G; Hsu, Jesse Y; Sperry, Jason L; Peitzman, Andrew B; Reilly, Patrick M

2017-03-01

Admission physiology predicts mortality after injury, but may be improved by resuscitation before transfer. This phenomenon, which has been termed lead-time bias, may lead to underprediction of mortality in transferred patients and inaccurate benchmarking in centers receiving large numbers of transfer patients. We sought to determine the impact of using vital signs on arrival at the referring center vs on arrival at the trauma center in mortality prediction models for transferred trauma patients. We performed a retrospective cohort study using a state-wide trauma registry including all patients age 16 years or older, with Abbreviated Injury Scale scores ≥ 3, admitted to level I and II trauma centers in Pennsylvania, from 2011 to 2014. The primary outcomes measure was the risk-adjusted association between mortality and interhospital transfer (IHT) when adjusting for physiology (as measured by Revised Trauma Score [RTS]) using the referring hospital arrival vital signs (model 1) compared with trauma center arrival vital signs (model 2). After adjusting for patient and injury factors, IHT was associated with reduced mortality (odds ratio [OR] 0.85; 95% CI 0.77 to 0.93) using the RTS from trauma center admission, but with increased mortality (OR 1.15; 95% CI 1.05 to 1.27) using RTS from the referring hospital. The greater the number of transfer patients seen by a center, the greater the difference in center-level mortality predicted by the 2 models (β -0.044; 95% CI -0.044 to -0.0043; p ≤ 0.001). Trauma center vital signs underestimate mortality in transfer patients and may lead to incorrect estimates of expected mortality. Where possible, benchmarking efforts should use referring hospital vital signs to risk-adjust IHT patients. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Helicopter emergency medical services (HEMS) over-triage and the financial implications for major trauma centres in NSW, Australia.

PubMed

Taylor, Colman B; Curtis, Kate; Jan, Stephen; Newcombe, Mark

2013-07-01

In NSW Australia, a formal trauma system including the use of helicopter emergency medical services (HEMS) has existed for over 20 years. Despite providing many advantages in NSW, HEMS patients are frequently over-triaged; leading to financial implications for major trauma centres that receive HEMS patients. The aim of this study was to investigate the financial implications of HEMS over-triage from the perspective of major trauma centres in NSW. The study sample included all trauma patients transported via HEMS to 12 major trauma centres in NSW during the period: 1 July 2008 to 30 June 2009. Clinical data were gathered from individual hospital trauma registries and merged with financial information obtained from casemix units at respective hospitals. HEMS over-triage was estimated based on the local definition of minor to moderate trauma (ISS≤12) and hospital length of stay of less than 24 hrs. The actual treatment costs were determined and compared to state-wide peer group averages to obtain estimates of potential funding discrepancies. A total of 707 patients transported by HEMS were identified, including 72% pre-hospital (PH; n=507) and 28% inter-hospital (IH; n=200) transports. Over-triage was estimated at 51% for PH patients and 29% for IH patients. Compared to PH patients, IH patients were more costly to treat on average (IH: $42,604; PH: $25,162), however PH patients were more costly overall ($12,329,618 [PH]; $8,265,152 [IH]). When comparing actual treatment costs to peer group averages we found potential funding discrepancies ranging between 4% and 32% across patient groups. Using a sensitivity analysis, the potential funding discrepancy increased with increasing levels of over-triage. HEMS patients are frequently over-triaged in NSW, leading to funding implications for major trauma centres. In general, HEMS patient treatment costs are higher than the peer group average and the potential funding discrepancy varies by injury severity and the type of transport performed. Although severely injured HEMS patients are more costly to treat, HEMS patients with minor injuries make up the majority of HEMS transports and have larger relative potential funding discrepancies. Future episode funding models need to account for the variability of trauma patients and the proportion of patients transported via HEMS.

Utility of plain radiographs and MRI in cervical spine clearance in symptomatic non-obtunded pediatric patients without high-impact trauma.

PubMed

Moore, Justin M; Hall, Jonathan; Ditchfield, Michael; Xenos, Christopher; Danks, Andrew

2017-02-01

The optimal imaging modality for evaluating cervical spine trauma and optimizing management in the pediatric population is controversial. In pediatric populations, there are no well-established guidelines for cervical spine trauma evaluation and treatment. Currently, there is virtually no literature regarding imaging and management of symptomatic pediatric patients who present with cervical spine trauma without high-impact mechanism. This study aims to establish an optimal imaging strategy for this subgroup of trauma patients. We performed a retrospective review of pediatric patients (aged below 18 years) who were admitted to Monash Medical Centre, Melbourne, Australia between July 2011 and June 2015, who did not suffer a high-impact trauma but were symptomatic for cervical spine injury following cervical trauma. Imaging and management strategies were reviewed and results compared. Forty-seven pediatric patients were identified who met the inclusion criteria. Of these patients, 46 underwent cervical spine series (CSS) plain radiograph imaging. Thirty-four cases underwent magnetic resonance imaging (MRI) and 9 patients underwent CT. MRI was able to detect 4 cases of ligamentous injury, which were not seen in CSS imaging and was able to facilitate cervical spine clearance in a further two patients whose CSS radiographs were abnormal. In this study, MRI has a greater sensitivity and specificity when compared to CSS radiography in a symptomatic pediatric low-impact trauma population. Our data call in to question the routine use of CSS radiographs in children.

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.

Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma

PubMed Central

Chou, Yi-Pin; Lin, Hsing-Lin; Wu, Tzu-Chin

2015-01-01

Purpose of review In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs. Recent findings In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes. Summary Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively. PMID:25978625

Analyzing fat embolism syndrome in trauma patients at AIIMS Apex Trauma Center, New Delhi, India

PubMed Central

Gupta, Babita; D’souza, Nita; Sawhney, Chhavi; Farooque, Kamran; Kumar, Ajeet; Agrawal, Pramendra; Misra, M C

2011-01-01

Background: Fat embolism syndrome (FES) is a constellation of symptoms and signs subsequent to orthopedic trauma. Materials and Methods: The clinical profile of FES in the trauma population was studied over 2 years and 8 months. Results: The incidence of FES among all patients with long bone and pelvic fractures was 0.7% (12). The mean injury severity score was 10.37 (SD 1.69) (range 9-14). The diagnosis of FES was made by clinical and laboratory criteria. Hypoxia was the commonest presentation (92%). The average days of onset of symptoms were 3.5 (SD1.29) days. Management included ventilator support in 75%, average ventilator days being 7.8 (SD 4.08) days. The average ICU stay and hospital stay were 9.1 days and 29.7 days, respectively. A mortality of 8.3% (1) was observed. Conclusion: Fat embolism remains a diagnosis of exclusion and is a clinical dilemma. Clinically apparent FES is unusual and needs high index of suspicion, especially in long bone and pelvic fractures. PMID:21887021

Association of Trauma from Occlusion with Localized Gingival Recession in Mandibular Anterior Teeth

PubMed Central

Kundapur, Pratibha Panduranga; Bhat, Khandige Mahalinga; Bhat, Giliyar Subraya

2009-01-01

Background: There have been passing references in history that excessive occlusal forces might be a causative factor in gingival recession. The purpose of the present cross-sectional study was to explore the role of trauma from occlusion on the development of gingival recession. Methods: Three hundred patients reporting to the department of Periodontics were screened for the presence of gingival recession in the lower incisors. A single trained examiner carried out clinical examination for signs of trauma from occlusion, such as fremitus test, presence of wear facets and mobility. The data were analyzed by chi square test. Results: No statistically significant relationship was observed between the presence of a positive fremitus and wear facets with gingival recession. However, a significant association was observed between patients who experienced mobility and gingival recession. Conclusion: There does appear to be a relationship between fremitus and tooth wear with gingival recession based on the results of the present study, though not conclusive. However, the sign of tooth mobility, which is a feature of trauma from occlusion, appeared to be a predictor of positive association with gingival recession. PMID:21528034

Radionuclide evaluation of lung trauma

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

Lull, R.J.; Tatum, J.L.; Sugerman, H.J.

1983-07-01

Nuclear medicine imaging procedures can play a significant role in evaluating the pulmonary complications that are seen in trauma patients. A quantitative method for measuring increased pulmonary capillary permeability that uses Tc-99m HSA allows early diagnosis of acute respiratory distress syndrome (ARDS) and accurately differentiates this condition from pneumonia or cardiogenic pulmonary edema. This technique may be of great value in following the response to therapy. The use of 133Xe to diagnose inhalation injury remains an important diagnostic tool, particularly at hospitals with specialized burn units. Regional decreases in ventilation-perfusion images reliably localize aspirated foreign bodies. Radionuclide techniques that aremore » used to demonstrate gastropulmonary aspiration remain controversial and require further clinical evaluation. Pulmonary perfusion imaging, although nonspecific, may provide the earliest clue for correct diagnosis of fat embolism, air embolism, contusion, or laceration. Furthermore, the possibility of perfusion abnormality due to these uncommon conditions must be remembered whenever trauma patients are evaluated for pulmonary thromboembolism with scintigraphy. Occasionally, liver or spleen scintigraphy may be the most appropriate procedure when penetrating chest trauma also involves these subdiaphragmatic organs.« less

Effectiveness of trauma team on medical resource utilization and quality of care for patients with major trauma.

PubMed

Wang, Chih-Jung; Yen, Shu-Ting; Huang, Shih-Fang; Hsu, Su-Chen; Ying, Jeremy C; Shan, Yan-Shen

2017-07-24

Trauma is one of the leading causes of death in Taiwan, and its medical expenditure escalated drastically. This study aimed to explore the effectiveness of trauma team, which was established in September 2010, on medical resource utilization and quality of care among major trauma patients. This was a retrospective study, using trauma registry data bank and inpatient medical service charge databases. Study subjects were major trauma patients admitted to a medical center in Tainan during 2009 and 2013, and was divided into case group (from January, 2011 to August, 2013) and comparison group (from January, 2009 to August, 2010). Significant reductions in several items of medical resource utilization were identified after the establishment of trauma team. In the sub-group of patients who survived to discharge, examination, radiology and operation charges declined significantly. The radiation and examination charges reduced significantly in the subcategories of ISS = 16 ~ 24 and ISS > 24 respectively. However, no significant effectiveness on quality of care was identified. The establishment of trauma team is effective in containing medical resource utilization. In order to verify the effectiveness on quality of care, extended time frame and extra study subjects are needed.

Advanced Implant-Prosthetic Rehabilitation: How to Obtain a Correct Restoration of Both Functions and Aesthetics in Patients with Complex Combined Dental and Maxillofacial Trauma: A Case Report and Topical Review of the Literature.

PubMed

Figliuzzi, M M; Giudice, A; Fortunato, L

2017-01-01

Aim . This study aims to explain the main steps that characterize the implant-prosthetic rehabilitation in complex combined dental and maxillofacial trauma. Material and Methods . A 20-year-old patient reported an extensive facial trauma which also involved the alveolar process of the maxillary bone. The patient reported a maxillofacial fracture and the loss of teeth 1.3, 1.2, 1.1, and 2.1. A "Le Fort" type 2 fracture was also reported, with the malar bone involvement. After reduction and containment of bone fractures, through appropriate mounting plates, appropriate functional and aesthetic rehabilitation of the patient were replaced thanks to a temporary removable prosthesis. After 6 months, the patient performed numerous clinical investigations, aimed at a proper planning of implant-prosthetic rehabilitation of the upper dental arch. Conclusion . With the planning of the case, as well as respecting the surrounding biological structures, the surgery of implants can be carried out with the most appropriate procedure. Lastly, new dental implants with highly bioactive surfaces have been developed, providing an excellent and rapid bone integration.

A trauma network with centralized and local health care structures: Evaluating the effectiveness of the first certified Trauma Network of the German Society of Trauma Surgery

PubMed Central

Koller, Michael; Zeman, Florian; Kerschbaum, Maximilian; Hilber, Franz; Diepold, Eva; Loss, Julika; Herbst, Tanja; Nerlich, Michael

2018-01-01

Background Trauma is a global burden of disease and one of the main causes of death worldwide. Therefore, many countries around the world have implemented a wide range of different initiatives to minimize mortality rates after trauma. One of these initiatives is the bundling of treatment expertise in trauma centers and the establishment of trauma networks. Germany has a decentralized system of trauma care medical centers. Severely injured patients ought to receive adequate treatment in both level I and level II centers. This study investigated the effectiveness of a decentralized network and the question whether level I and level II centers have comparable patient outcome. Materials and methods In 2009, the first trauma network DGU® in Germany was certified in the rural area of Eastern Bavaria. All patients admitted to the 25 participating hospitals were prospectively included in this network in the framework of a study sponsored by the German Federal Ministry of Education and Research between March 2012 and February 2014. 2 hospitals were level I centers (maximal care centers), 8 hospitals were level II centers, and 15 hospitals were level III centers. The criterion for study inclusion was an injury severity score (ISS) ≥ 16 for patients´ primarily admitted to a level I or a level II center. Exclusion criteria were transferal to another hospital within 48 h, an unknown revised injury severity classification II score (RISC II), or primary admittance to a level III center (n = 52). 875 patients were included in the study. Univariate analyses were used regarding the preclinical and clinical parameters, the primary endpoint mortality rate, and the secondary endpoints length of stay, organ failure, and neurological outcome (GOS). The primary endpoint was additionally evaluated by means of multivariable analysis. Results Indices for injury severity (GCS, AISHead, ISS, and NISS) as well as the predicted probability of death (RISC II) were higher in level I centers than in level II centers. No significant differences were found between the mortality rate of the unadjusted analysis [level I: 21.6% (CI: 16.5, 27.9), level II: 18.1% (CI: 14.4, 22.5), p = 0.28] and that of the adjusted analysis [level I SMR: 0.94 (CI: 0.72, 1.21), level II SMR: 1.18 (CI 0.95, 1.48) SMR: expected vs. calculated mortality rate according to RISC II]. Multivariable analysis showed a survival advantage of patients admitted to a level I center with a probability of death of 13% (RISC II). The number need to treat was 10 patients. Discussion This study showed that a rural trauma network with centralized and local structures may achieve equivalent results with regard to mortality rates to those obtained in level I and level II centers. These results were furthered by a certain preclinical centralization (24/7 air rescue) of patients. The study also showed a survival advantage of patients admitted to a level I center with a probability of death of 13%. Preclinical and initial clinical evaluation with regard to probable mortality rates should be further improved to identify patients who would benefit from admittance to a level I center. PMID:29538456

Influence of prehospital fluid resuscitation on patients with multiple injuries in hemorrhagic shock in patients from the DGU trauma registry

PubMed Central

Huβmann, Björn; Lefering, Rolf; Taeger, Georg; Waydhas, Christian; Ruchholtz, Steffen

2011-01-01

Background: Severe bleeding as a result of trauma frequently leads to poor outcome by means of direct or delayed mechanisms. Prehospital fluid therapy is still regarded as the main option of primary treatment in many rescue situations. Our study aimed to assess the influence of prehospital fluid replacement on the posttraumatic course of severely injured patients in a retrospective analysis of matched pairs. Materials and Methods: We reviewed data from 35,664 patients recorded in the Trauma Registry of the German Society for Trauma Surgery (DGU). The following patients were selected: patients having an Injury Severity Score >16 points, who were ≥16 years of age, with trauma, excluding those with craniocerebral injuries, who were admitted directly to the participating hospitals from the accident site. All patients had recorded values for replaced volume and blood pressure, hemoglobin concentration, and units of packed red blood cells given. The patients were matched based on similar blood pressure characteristics, age groups, and type of accident to create pairs. Pairs were subdivided into two groups based on the volumes infused prior to hospitalization: group 1: 0-1500 (low), group 2: ≥2000 mL (high) volume. Results: We identified 1351 pairs consistent with the inclusion criteria. Patients in group 2 received significantly more packed red blood cells (group 1: 6.9 units, group 2: 9.2 units; P=0.001), they had a significantly reduced capacity of blood coagulation (prothrombin ratio: group 1: 72%, group 2: 61.4%; P≤0.001), and a lower hemoglobin value on arrival at hospital (group 1: 10.6 mg/dL, group 2: 9.1 mg/dL; P≤0.001). The number of ICU-free days concerning the first 30 days after trauma was significantly higher in group 1 (group 1: 11.5 d, group 2: 10.1 d; P≤0.001). By comparison, the rate of sepsis was significantly lower in the first group (group 1: 13.8%, group 2: 18.6%; P=0.002); the same applies to organ failure (group 1: 36.0%, group 2: 39.2%; P≤0.001). Conclusion: The high amounts of intravenous fluid replacement was related to early traumatic coagulopathy, organ failure, and sepsis rate. PMID:22090739

Association between helicopter with physician versus ground emergency medical services and survival of adults with major trauma in Japan

PubMed Central

2014-01-01

Introduction Helicopter emergency medical services with a physician (HEMS) has been provided in Japan since 2001. However, HEMS and its possible effect on outcomes for severe trauma patients have still been debated as helicopter services require expensive and limited resources. Our aim was to analyze the association between the use of helicopters with a physician versus ground services and survival among adults with serious traumatic injuries. Methods This multicenter prospective observational study involved 24,293 patients. All patients were older than 15 years of age, had sustained blunt or penetrating trauma and had an Injury Severity Score (ISS) higher than 15. All of the patient data were recorded between 2004 and 2011 in the Japan Trauma Data Bank, which includes data from 114 major emergency hospitals in Japan. The primary outcome was survival to discharge from hospitals. The intervention was either transport by helicopter with a physician or ground emergency services. Results A total of 2,090 patients in the sample were transported by helicopter, and 22,203 were transported by ground. Overall, 546 patients (26.1%) transported by helicopter died compared to 5,765 patients (26.0%) transported by ground emergency services. Patients transported by helicopter had higher ISSs than those transported by ground. In multivariable logistic regression, helicopter transport had an odds ratio (OR) for survival to discharge of 1.277 (95% confidence interval (CI), 1.049 to 1.556) after adjusting for age, sex, mechanism of injury, type of trauma, initial vital signs (including systolic blood pressure, heart rate and respiratory rate), ISS and prehospital treatment (including intubation, airway protection maneuver and intravenous fluid). In the propensity score–matched cohort, helicopter transport was associated with improved odds of survival compared to ground transport (OR, 1.446; 95% CI, 1.220 to 1.714). In conditional logistic regression, after adjusting for prehospital treatment (including intubation, airway protection maneuver and intravenous fluid), similar positive associations were observed (OR, 1.230; 95% CI, 1.017 to 1.488). Conclusions Among patients with major trauma in Japan, transport by helicopter with a physician may be associated with improved survival to hospital discharge compared to ground emergency services after controlling for multiple known confounders. PMID:25008159

A study on the evaluation of pneumothorax by imaging methods in patients presenting to the emergency department for blunt thoracic trauma.

PubMed

Kaya, Şeyhmus; Çevik, Arif Alper; Acar, Nurdan; Döner, Egemen; Sivrikoz, Cumhur; Özkan, Ragıp

2015-09-01

Pneumothorax (PNX) is the collection of air between parietal and visceral pleura, and collapsed lung develops as a complication of the trapped air. PNX is likely to develop spontaneously in people with risk factors. However, it is mostly seen with blunt or penetrating trauma. Diagnosis is generally confirmed by chest radiography [posteroanterior chest radiography (PACR)]. Chest ultrasound (US) is also a promising technique for the detection of PNX in trauma patients. There is not much literature on the evaluation of blunt thoracic trauma (BTT) and pneumothorax (PNX) in the emergency department (ED). The aim of this study was to investigate the effectiveness of chest US for the diagnosis of PNX in patients presenting to ED with BTT. This study was carried out for a period of nine months in the ED of a university hospital. The chest US of patients was performed by emergency physicians trained in the field. The results were compared with anteroposterior chest radiography and/or CT scan of the chest. The APCR and chest CT results were evaluated by a radiology specialist blind to US findings. The evaluation of the radiology specialist was taken as the gold standard for diagnosis by imaging methods. Clinical follow-up was taken into consideration for the diagnosis of PNX in patients on whom CT scan was not performed. Chest US was performed on all two hundred and twelve patients (144 female and 68 male patients; mean age 45.8) who participated in this study. The supine APCR was performed on two hundred and ten (99%) patients and chest CT was performed on one hundred and twenty (56.6%). Out of the twenty-five (11.8%) diagnosed cases of PNX, 22 (88%) were diagnosed by chest US and 8 were diagnosed by APCR. For the detection of PNX, compared to clinical follow-up and chest CT, the sensitivity of chest US was 88%, specificity 99.5%, positive predictive value 95.7% and negative predictive value 98.4%. Chest US has not superseded supine and standing chest radiography for PNX diagnosis yet in many healthcare centers, but it is performed by emergency physicians and it is an effective and important method for early and bedside diagnosis of PNX.

Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes.

PubMed

Wandling, Michael W; Nathens, Avery B; Shapiro, Michael B; Haut, Elliott R

2016-11-01

Rapid transport to definitive care ("scoop and run") versus field stabilization in trauma remains a topic of debate and has resulted in variability in prehospital policy. We aimed to identify trauma systems frequently using a true "scoop and run" police transport approach and to compare mortality rates between police and ground emergency medical services (EMS) transport. Using the National Trauma Databank (NTDB), we identified adult gunshot and stab wound patients presenting to Level 1 or 2 trauma centers from 2010 to 2012. Hospitals were grouped into their respective cities and regional trauma systems. Patients directly transported by police or ground EMS to trauma centers in the 100 most populous US trauma systems were included. Frequency of police transport was evaluated, identifying trauma systems with high utilization. Mortality rates and risk-adjusted odds ratio for mortality for police versus EMS transport were derived. Of 88,564 total patients, 86,097 (97.2%) were transported by EMS and 2,467 (2.8%) by police. Unadjusted mortality was 17.7% for police transport and 11.6% for ground EMS. After risk adjustment, patients transported by police were no more likely to die than those transported by EMS (OR = 1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit). Within these trauma systems, unadjusted mortality was 19.9% for police transport and 13.5% for ground EMS. Risk-adjusted mortality was no different (OR = 1.01, 95% CI: 0.68-1.50). Using trauma system-level analyses, patients with penetrating injuries in urban trauma systems were found to have similar mortality for police and EMS transport. The majority of prehospital police transport in penetrating trauma occurs in three trauma systems. These cities represent ideal sites for additional system-level evaluation of prehospital transport policies. Prognostic/epidemiologic study, level III.

Terror attacks increase the risk of vascular injuries.

PubMed

Heldenberg, Eitan; Givon, Adi; Simon, Daniel; Bass, Arie; Almogy, Gidon; Peleg, Kobi

2014-01-01

Extensive literature exists about military trauma as opposed to the very limited literature regarding terror-related civilian trauma. However, terror-related vascular trauma (VT), as a unique type of injury, is yet to be addressed. A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from 09/2000 to 12/2005 were included. The subgroup of patients with documented VT (N = 1,545) was analyzed and further subdivided into those suffering from terror-related vascular trauma (TVT) and non-terror-related vascular trauma (NTVT). Both groups were analyzed according to mechanism of trauma, type and severity of injury and treatment. Out of 2,446 terror-related trauma admissions, 243 sustained TVT (9.9%) compared to 1302 VT patients from non-terror trauma (1.1%). TVT injuries tend to be more complex and most patients were operated on. Intensive care unit admissions and hospital length of stay was higher in the TVT group. Penetrating trauma was the prominent cause of injury among the TVT group. TVT group had a higher proportion of patients with severe injuries (ISS ≥ 16) and mortality. Thorax injuries were more frequent in the TVT group. Extremity injuries were the most prevalent vascular injuries in both groups; however NTVT group had more upper extremity injuries, while the TVT group had significantly much lower extremity injuries. Vascular injuries are remarkably more common among terror attack victims than among non-terror trauma victims and the injuries of terror casualties tend to be more complex. The presence of a vascular surgeon will ensure a comprehensive clinical care.

The types and management of dental trauma during military service in Finland.

PubMed

Antikainen, Atte; Patinen, Pertti; Päkkilä, Jari; Tjäderhane, Leo; Anttonen, Vuokko

2018-04-01

All Finnish males must attend compulsory military service that lasts from 6 months to 1 year. About 25 000 males (approximately 80% of each age cohort) and 400 volunteer females complete the service annually. The aim of the study was to investigate the types of dental trauma occurring among Finnish conscripts during their military service. The article also focused on how dental trauma is treated in the Finnish Defence Forces. All dental records in the Defence Forces' patient register concerning dental trauma during the years 2011 and 2012 were analysed by tooth number, treatment procedures and number of visits. According to the patient register, 361 conscripts suffered an oral trauma during their military service; thus, the average annual incidence was 7.2 trauma per 1000 conscripts. A total of 483 teeth were traumatized in the 2-year period. The most frequently traumatized teeth were the maxillary central incisors (61%), and the most common findings were enamel or enamel-dentin fractures (63% of all findings). Severe trauma was not common, and the most severe ones occurred during off-duty hours. The most common treatment was direct filling (n = 189 patients). Only 53 patients had soft tissue injuries (bruises, wounds). Among patients with dental trauma, the mean number of visits to the Defence Forces' dental clinic was 1.9. Great variation exists in recording findings concerning dental and oral trauma. Minor trauma is common. In all cases, recording trauma and treatments should be performed carefully. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Trauma-Informed Medical Care: Patient Response to a Primary Care Provider Communication Training

PubMed Central

Green, Bonnie L.; Saunders, Pamela A.; Power, Elizabeth; Dass-Brailsford, Priscilla; Schelbert, Kavitha Bhat; Giller, Esther; Wissow, Larry; Hurtado de Mendoza, Alejandra; Mete, Mihriye

2016-01-01

Trauma exposure predicts mental disorders and health outcomes; yet there is little training of primary care providers about trauma’s effects, and how to better interact with trauma survivors. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), to evaluate its feasibility and preliminary efficacy. We randomized four primary care sites to training or wait-list conditions; PCPs at wait-list sites were trained after reassessment. Primary care providers (PCPs) were Family Medicine residents (n = 17; 2 sites) or community physicians (n = 13; 2 sites). Outcomes reported here comprised a survey of 400 actual patients seen by the PCPs in the study. Patients, mostly minority, completed surveys before or after their provider received training. Patients rated PCPs significantly higher after training on a scale encompassing partnership issues. Breakdowns showed lower partnership scores for those with trauma or posttraumatic stress symptoms. Future studies will need to include more specific trauma-related outcomes. Nevertheless, this training is a promising initial approach to teaching trauma-informed communication skills to PCPs. PMID:27721673

Are severely injured trauma victims in Norway offered advanced pre-hospital care? National, retrospective, observational cohort.

PubMed

Wisborg, T; Ellensen, E N; Svege, I; Dehli, T

2017-08-01

Studies of severely injured patients suggest that advanced pre-hospital care and/or rapid transportation provides a survival benefit. This benefit depends on the disposition of resources to patients with the greatest need. Norway has 19 Emergency Helicopters (HEMS) staffed by anaesthesiologists on duty 24/7/365. National regulations describe indications for their use, and the use of the national emergency medical dispatch guideline is recommended. We assessed whether severely injured patients had been treated or transported by advanced resources on a national scale. A national survey was conducted collecting data for 2013 from local trauma registries at all hospitals caring for severely injured patients. Patients were analysed according to hospital level; trauma centres or acute care hospitals with trauma functions. Patients with an Injury Severity Score (ISS) > 15 were considered severely injured. Three trauma centres (75%) and 17 acute care hospitals (53%) had data for trauma patients from 2013, a total of 3535 trauma registry entries (primary admissions only), including 604 victims with an ISS > 15. Of these 604 victims, advanced resources were treating and/or transporting 51%. Sixty percent of the severely injured admitted directly to trauma centres received advanced services, while only 37% of the severely injured admitted primarily to acute care hospitals received these services. A highly developed and widely distributed HEMS system reached only half of severely injured trauma victims in Norway in 2013. © 2017 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.

The effect of both a thoracic trauma and a soft-tissue trauma on fracture healing in a rat model

PubMed Central

2011-01-01

Background and purpose There is some clinical evidence that fracture healing is impaired in multiply injured patients. Nothing is known, however, about the effects of various types of injuries and their contribution to a possible disturbance of the fracture-healing process. We investigated the effect of a thoracic trauma and an additional soft-tissue trauma on fracture healing in a rat tibia model. Methods 3 groups of rats were operated: group A with a simple fracture of the tibia and fibula, group B with a fracture and an additional thoracic trauma, and group C with a fracture, thoracic trauma, and an additional soft-tissue trauma. The fracture and the soft-tissue injury were produced by a special guillotine-like device and the thoracic trauma by a blast wave generator. After one day, the serum level of IL-6 was quantified, and at the end of the study (28 days) the mechanical properties and the callus volume of the healed tibia were determined. Results Increasing the severity of the injury caused IL-6 levels to more than double 1 day after injury. It halved the load to failure in mechanical tests and led to reduced callus volume after 28 days of healing. Interpretation Fracture healing is impaired when additional thoracic trauma and soft tissue trauma occurs. PMID:21463222

Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center.

PubMed

Kansas, Bryan T; Eddy, Michael J; Mydlo, Jack H; Uzzo, Robert G

2004-10-01

Patients with penetrating trauma often have multiorgan involvement that may complicate the management of any single organ system. Here we review the incidence of associated injuries in patients with penetrating renal trauma and our extended experience treating these patients at a busy inner city trauma center. All trauma cases presenting to Temple University Trauma Center during a 6-year period were identified through our institutional databases and were reviewed (5,276). Penetrating trauma represented 41% of all cases (2,163). Of these we identified 123 patients with penetrating renal trauma (5.7%). A total of 93 cases were available for review. Multiorgan injury was staged in the operating room if patients were hemodynamically unstable or radiographically if they were stable. Renal injuries were staged by high dose, single shot excretory urogram in patients taken immediately to surgery or by computerized tomography if stable. Renal injuries were classified using the American Association for Surgery of Trauma (AAST) grading system. AAST classifications were subcategorized for purposes of streamlining. Grade 1 and 2 injuries were grouped as low grade, grades 3 and 4 nonvascular injuries were grouped as intermediate grade, and AAST grade 4 vascular and grade 5 injuries were grouped as high grade. Demographic, clinical and intraoperative variables, as well as number and severity of associated injuries, were then assessed to determine the relationship with various renal surgical outcomes including the requirement of surgical intervention, type of surgical intervention, need for nephrectomy and associated adverse outcomes. The median age of injured patients was 28 years (range 14 to 80). The majority of victims were male (93%). The mechanism of injury was predominantly gunshot wound (GSW, 86%) while 14% were due to stab wounds. Renal injuries were low grade (19%), intermediate grade (44%) and high grade (37%). Nearly all patients with penetrating renal injury had associated multiorgan injury (94.6%). Associated injuries for penetrating renal trauma on the right side predominately involved the liver, small bowel and vertebra while injury to the left kidney was most often associated with trauma to the stomach, colon and spleen. Patients suffered extensive renal injury as evidenced by the high rate of intraoperative urinomas (30.1%) and hematomas (97.5%) identified. In the absence of an expanding hematoma and/or hemodynamic instability, associated injuries by themselves did not increase the risk of nephrectomy. Despite multiorgan penetrating injury 54% of kidneys were salvageable. Isolated penetrating trauma to the kidney is rare. The majority of patients with penetrating renal trauma have associated adjacent organ injuries that may complicate treatment. In the absence of an expanding hematoma with hemodynamic instability, associated multiorgan injuries did not increase the risk of nephrectomy. With appropriate radiographic and/or surgical staging, it is possible to repair and salvage many of these kidneys despite extensive associated intraabdominal trauma.

Use of laparoscopy in trauma at a level II trauma center.

PubMed

Barzana, Daniel C; Kotwall, Cyrus A; Clancy, Thomas V; Hope, William W

2011-01-01

Enthusiasm for the use of laparoscopy in trauma has not rivaled that for general surgery. The purpose of this study was to evaluate our experience with laparoscopy at a level II trauma center. A retrospective review of all trauma patients undergoing diagnostic or therapeutic laparoscopy was performed from January 2004 to July 2010. Laparoscopy was performed in 16 patients during the study period. The average age was 35 years. Injuries included left diaphragm in 4 patients, mesenteric injury in 2, and vaginal laceration, liver laceration, small bowel injury, renal laceration, urethral/pelvic, and colon injury in 1 patient each. Diagnostic laparoscopy was performed in 11 patients (69%) with 3 patients requiring conversion to an open procedure. Successful therapeutic laparoscopy was performed in 5 patients for repair of isolated diaphragm injuries (2), a small bowel injury, a colon injury, and placement of a suprapubic bladder catheter. Average length of stay was 5.6 days (range, 0 to 23), and 75% of patients were discharged home. Morbidity rate was 13% with no mortalities or missed injuries. Laparoscopy is a seldom-used modality at our trauma center; however, it may play a role in a select subset of patients.

Insuring the uninsured: potential impact of Health Care Reform Act of 2010 on trauma centers.

PubMed

Shafi, Shahid; Ogola, Gerald; Fleming, Neil; Rayan, Nadine; Kudyakov, Rustam; Barnes, Sunni A; Ballard, David J

2012-11-01

Viability of trauma centers is threatened by cost of care provided to patients without health insurance. The health care reform of 2010 is likely to benefit trauma centers by mandating universal health insurance by 2014. However, the financial benefit of this mandate will depend on the reimbursement provided. The study hypothesis was that compensation for the care of uninsured trauma patients at Medicare or Medicaid rates will lead to continuing losses for trauma centers. Financial data for first hospitalization were obtained from an urban Level I trauma center for 3 years (n = 6,630; 2006-2008) and linked with clinical information. Patients were grouped into five payments categories: commercial (29%), Medicaid (8%), Medicare (20%), workers' compensation (6%), and uninsured (37%). Prediction models for costs and payments were developed for each category using multiple regression models, adjusting for patient demographics, injury characteristics, complications, and survival. These models were used to predict payments that could be expected if uninsured patients were covered by different insurance types. Results are reported as net margin per patient (payments minus total costs) for each insurance type, with 95% confidence intervals, discounted to 2008 dollar values. Patients were typical for an urban trauma center (median age of 43 years, 66% men, 82% blunt, 5% mortality, and median length of stay 4 days). Overall, the trauma center lost $5,655 per patient, totaling $37.5 million over 3 years. These losses were encountered for patients without insurance ($14,343), Medicare ($4,838), and Medicaid ($15,740). Patients with commercial insurance were profitable ($5,295) as were those with workers' compensation ($6,860). Payments for the care of the uninsured at Medicare/Medicaid levels would lead to continued losses at $2,267 to $4,143 per patient. The health care reforms of 2010 would lead to continued losses for trauma centers if uninsured are covered with Medicare/Medicaid-type programs. Economic analysis, level II.

Pancreatic and duodenal injuries: keep it simple.

PubMed

Rickard, Matthew J F X; Brohi, Karim; Bautz, Peter C

2005-07-01

The management of pancreatic and duodenal trauma has moved away from complex reconstructive procedures to simpler methods in keeping with the trend towards organ-specific, damage control surgery. A retrospective case note review was undertaken over a 30-month period to evaluate a simplified protocol for the management of these injuries. Of 100 consecutive patients there were 51 with pancreatic injury, 30 with a duodenal injury and 19 with combined pancreaticoduodenal trauma. Overall mortality was 18.0%, with a late mortality (after 24 h) of 9.9%. This is comparable to previous studies. Morbidity from abscesses, fistulas and anastomotic breakdown was acceptably low. The concept of staged laparotomy can be successfully applied to wounds of the pancreas and duodenum. Debridement of devitalized tissue and drainage can be employed for most cases of pancreatic trauma. Most duodenal injuries can be managed with debridement and primary repair. Temporary exclusion and reoperation should be employed for unstable patients.

[Intensive care treatment of traumatic brain injury in multiple trauma patients : Decision making for complex pathophysiology].

PubMed

Trimmel, H; Herzer, G; Schöchl, H; Voelckel, W G

2017-09-01

Traumatic brain injury (TBI) and hemorrhagic shock due to uncontrolled bleeding are the major causes of death after severe trauma. Mortality rates are threefold higher in patients suffering from multiple injuries and additionally TBI. Factors known to impair outcome after TBI, namely hypotension, hypoxia, hypercapnia, acidosis, coagulopathy and hypothermia are aggravated by the extent and severity of extracerebral injuries. The mainstays of TBI intensive care may be, at least temporarily, contradictory to the trauma care concept for multiple trauma patients. In particular, achieving normotension in uncontrolled bleeding situations, maintenance of normocapnia in traumatic lung injury and thromboembolic prophylaxis are prone to discussion. Due to an ongoing uncertainty about the definition of normotensive blood pressure values, a cerebral perfusion pressure-guided cardiovascular management is of key importance. In contrast, there is no doubt that early goal directed coagulation management improves outcome in patients with TBI and multiple trauma. The timing of subsequent surgical interventions must be based on the development of TBI pathology; therefore, intensive care of multiple trauma patients with TBI requires an ongoing and close cooperation between intensivists and trauma surgeons in order to individualize patient care.

Etiopathology and management challenges of blunt chest trauma in Nigeria.

PubMed

Thomas, Martins Oluwafemi; Ogunleye, Ezekiel O

2009-12-01

Blunt chest trauma had not been roundly studied in Nigeria. This study was conducted to determine the etiopathological and management challenges of chest trauma in a developing country. In a prospective multicenter hospital-based study of 10-years duration in the city of Lagos, the data of 896 patients were recorded. The male-to-female ratio was 8 : 1, and the mean age was 27.1 years. The majority of patients (76.9%) were aged 20-39 years. Road traffic accidents caused 98.1% of the injuries. Lung parenchymal injuries occurred in 66% of patients, and cardiac trauma in 0.1%. Isolated chest trauma was found in 85% of patients, and 134 had associated injuries. The incidence of blunt chest trauma could be reduced if the number of road traffic accidents in Nigeria is reduced.

Challenges in the Management of Geriatric Trauma: A Case Report.

PubMed

Gaebel, Ashley; Keiser, Megan

This article describes geriatric trauma and commonly associated difficulties emphasizing both the epidemiology and assessment of geriatric trauma. There is little data guiding decisions for trauma patients 65 years or older, as there are many unique characteristics to the geriatric population, including comorbidities, medications, and the aging physiology. The geriatric population in the United States has been steadily climbing for the last 20 years and is projected to continue on this trend. Although each patient presents differently, there remains a need for the consistent utilization of standard guidelines to help dictate care for geriatric patients, particularly for patients not receiving care at a trauma center. This review uses a case study about an elderly woman with many comorbidities, followed by a comprehensive discussion of geriatric trauma and the challenges that result from a lack of guideline utilization to direct management.

Paying a Premium: How Patient Complexity Affects Costs and Profit Margins

PubMed Central

Taheri, Paul A.; Butz, David A.; Greenfield, Lazar J.

1999-01-01

Objective and Background Tertiary medical centers continue to be under extreme pressure to deliver high-complexity care, but paradoxically there is considerable pressure within these institutions to reduce their emphasis on tertiary care and refocus their efforts to develop a more community-like practice. The genesis of this pressure is the perceived profitability of routine surgical activity when compared with more complex care. The purpose of this study is to assess how the total cost and profit (loss) margin can vary for an entire trauma service. The authors also evaluate payments for specific trauma-related diagnostic-related groups (DRGs) and analyze how hospital margins were affected based on mortality outcome. Materials and Methods The authors analyzed the actual cost of all trauma discharges (n = 692) at their level I trauma center for fiscal year 1997. Data were obtained from the trauma registry and the hospital cost accounting system. Total cost was defined as the sum of the variable, fixed, and indirect costs associated with each patient. Margin was defined as expected payments minus total cost. The entire population and all DRGs with 10 or more patients were stratified based on survival outcome, Injury Severity Score, insurance status, and length of stay. The mean total costs for survivors and nonsurvivors within these various categories and their margins were evaluated. Results The profit margin on nonsurvivors was $5898 greater than for survivors, even though the mean total cost for nonsurvivors was $28,821 greater. Within the fixed fee arrangement, approximately 44% of transfers had a negative margin. Both survivors and nonsurvivors become increasingly profitable out to 20 days and subsequently become unprofitable beyond 21 days, but nonsurvivors were more profitable than survivors. Conclusions There is a wide variance in both the costs and margins within trauma-related DRGs. The DRG payment system disproportionately reimburses providers for nonsurvivors, even though on average they are more costly. Because payers are likely to engage in portfolio management, patients can be transferred between hospitals based on the contractual relationship between the payer and the provider. This payment system potentially allows payers to act strategically, sending relatively low-cost patients to hospitals where they use fee-for-service reimbursement and high-cost patients to hospitals where their reimbursement is contractually capped. Although specific to the authors’ trauma center and its payer mix, these data demonstrate the profitability of maintaining a level I trauma center and preserving the mission of delivering care to the severely injured. PMID:10363894

Novel Sternal Protection Device for Cardiac Surgery Via Median Sternotomy Incision

PubMed Central

Marasco, Silvana F.; McGiffin, David C.; Zimmet, Adam D.; Solis, Pablo C.; Bingham, Judy M.; Moshinsky, Randall A.

2017-01-01

Objective Sternal bleeding during cardiac surgery is currently controlled using bone wax or other chemical substances that may result in adverse effects and affect wound healing and recovery. The purpose of this study was to identify a safe, cost-effective, and easy-to-use technique to reduce sternal bleeding and sternal trauma during cardiac surgery. Methods After sternotomy, a sternal protection device was placed over each hemisternal section before insertion of the retractor and remained in situ until the end of surgery. Sternal bleeding and ease of use were assessed and recorded during surgery. Sternal trauma was assessed and recorded within 5 minutes of removal of the device, and overall satisfaction (Global Impression) and any intraoperative adverse events or device malfunction were reported at surgery completion. Patients were followed up 24 hours and 4 weeks after surgery. Results Twelve patients completed the study. Adverse events reported were not considered related to the device. No sternal trauma was identified in any patient. In 9 of 11 patients, sternal bleeding was reduced after insertion of the device. The device was generally considered easy to use, although some difficulty was encountered when used with the Internal Mammary Artery retractor. Conclusions Our data suggest that the device is safe and able to reduce sternal bleeding during surgery using sternal retractors. We recommend further studies in a larger population of patients with a control group to evaluate the device's ability to reduce the morbidity associated with sternal bleeding and sternal trauma. PMID:29023352

Development of a Middle-Age and Geriatric Trauma Mortality Risk Score A Tool to Guide Palliative Care Consultations.

PubMed

Konda, Sanjit R; Seymour, Rachel; Manoli, Arthur; Gales, Jordan; Karunakar, Madhav A

2016-11-01

This study aimed to develop a tool to quantify risk of inpatient mortality among geriatric and middleaged trauma patients. This study sought to demonstrate the ability of the novel risk score in the early identification of high risk trauma patients for resource-sparing interventions, including referral to palliative medicine. This retrospective cohort study utilized data from a single level 1 trauma center. Regression analysis was used to create a novel risk of inpatient mortality score. A total of 2,387 low energy and 1,201 high-energy middle-aged (range: 55 to 64 years of age) and geriatric (65 years of age or odler) trauma patients comprised the study cohort. Model validation was performed using 37,474 lowenergy and 97,034 high-energy patients from the National Trauma Databank (NTDB). Potential hospital cost reduction was calculated for early referral of high risk trauma patients to palliative medicine services in comparison to no palliative medicine referral. Factors predictive of inpatient mortality among the study and validation patient cohorts included; age, Glasgow Coma Scale, and Abbreviated Injury Scale for the head and neck and chest. Within the validation cohort, the novel mortality risk score demonstrated greater predictive capacity than existing trauma scores [STTGMALE-AUROC: 0.83 vs. TRISS 0.80, (p < 0.01), STTGMAHE-AUROC: 0.86 vs. TRISS 0.85, (p < 0.01)]. Our model demonstrated early palliative medicine evaluation could produce $1,083,082 in net hospital savings per year. This novel risk score for older trauma patients has shown fidelity in prediction of inpatient mortality; in the study and validation cohorts. This tool may be used for early intervention in the care of patients at high risk of mortality and resource expenditure.

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma

PubMed Central

Hong, Zhi-Jie; Chen, Cheng-Jueng; Yu, Jyh-Cherng; Chan, De-Chuan; Chou, Yu-Ching; Liang, Chia-Ming; Hsu, Sheng-Der

2016-01-01

Abstract We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT. Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome. Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients’ time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06–0.75, P = 0.016). Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma. PMID:27631215

Early decreased neutrophil responsiveness is related to late onset sepsis in multitrauma patients: An international cohort study.

PubMed

Groeneveld, Kathelijne M; Koenderman, Leo; Warren, Brian L; Jol, Saskia; Leenen, Luke P H; Hietbrink, Falco

2017-01-01

Severe trauma can lead to the development of infectious complications after several days, such as sepsis. Early identification of patients at risk will aid anticipating these complications. The aim of this study was to test the relation between the acute (<24 hours) inflammatory response after injury measured by neutrophil responsiveness and the late (>5 days) development of septic complications and validate this in different trauma populations. Two prospective, observational, cohort series in the Netherlands and South Africa, consisting of severely injured trauma patients. Neutrophil responsiveness by fMLF-induced active FcγRII was measured in whole blood flowcytometry, as read out for the systemic immune response within hours after trauma. Sepsis was scored daily. Ten of the 36 included Dutch patients developed septic shock. In patients with septic shock, neutrophils showed a lower expression of fMLF-induced active FcγRII immediately after trauma when compared to patients without septic shock (P = 0.001). In South Africa 11 of 73 included patients developed septic shock. Again neutrophils showed lower expression of fMLF induced active FcγRII (P = 0.001). In the combined cohort, all patients who developed septic shock demonstrated a decreased neutrophil responsiveness. Low responsiveness of neutrophils for the innate stimulus fMLF immediately after trauma preceded the development of septic shock during admission by almost a week and did not depend on a geographical/racial background, hospital protocols and health care facilities. Decreased neutrophil responsiveness appears to be a prerequisite for septic shock after trauma. This might enable anticipation of this severe complication in trauma patients.

The implementation of a national trauma registry in Greece. Methodology and preliminary results.

PubMed

Katsaragakis, Stylianos; Theodoraki, Maria E; Toutouzas, Kostas; Drimousis, Panagiotis G; Larentzakis, Antreas; Stergiopoulos, Spiros; Aggelakis, Christos; Lapidakis, George; Massalis, Ioannis; Theodorou, Dimitrios

2009-12-01

Trauma is a leading cause of death worldwide and a major health problem of the modern society. Trauma systems are considered the gold standard of managing patients with trauma. An integral part of any trauma system is a trauma registry. In Europe, and particularly in Greece, trauma registries and systems are in an embryonic stage. In this study, we present an attempt to record trauma in Greece. The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. In succeeding meetings of the representatives, the reporting form was developed and the inclusion criteria were defined meticulously. Inclusion criteria were defined as patients with trauma requiring admission, transfer to a higher level center, or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic database, and analyzed. Thirty-two hospitals receiving patients with trauma participated in the country, representing 40% of the country's healthcare facilities and serving 40% of the country's population. In 12 months time, (October 2005 to September 2006), 8,862 patients were included in the study. Of them, 66.9% were men and 31.3% were women. The compilation rate of the reporting forms was surprisingly high, considering that the final reporting form included 150 data points and that there were no independent personnel in charge of filling the forms. Trauma registries are feasible even in health care systems where funding of medical research is sparse.

Trauma Quality Improvement: Reducing Triage Errors by Automating the Level Assignment Process.

PubMed

Stonko, David P; O Neill, Dillon C; Dennis, Bradley M; Smith, Melissa; Gray, Jeffrey; Guillamondegui, Oscar D

2018-04-12

Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution. A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart. This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma. The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis. Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13 overtriaged) following implementation of the web tool (p = 0.017 for combined errors). Overtriage dropped further from baseline to 10/150 after the second test of change (p = 0.005). The total number of triaged patients dropped from 92.3/week to 75.5/week after the second test of change. There was no statistically significant change in the undertriage rate. The combination of web tool implementation and protocol refinement decreased the combined triage error rate by over 50% (from 16.7%-7.9%). We developed and tested a web tool that improved triage accuracy, and provided a sustainable method to enact future quality improvement. This web tool and QI framework would be easily expandable to other hospitals. Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Arterial injury associated with acute compartment syndrome of the thigh following blunt trauma.

PubMed

Suzuki, Takashi; Moirmura, Naoto; Kawai, Kousei; Sugiyama, Mitsugi

2005-01-01

Acute compartment syndrome of the thigh is a rare condition, and the basic causes of high pressure within a muscle compartment have been considered to be intramuscular haematoma and soft-tissue oedema. However, the importance of arterial injury has not been well recognized. Among 3658 blunt trauma patients admitted to our Level 1 Trauma Centre between 1994 and 2001, there were eight patients (nine thighs) who had undergone emergency fasciotomy and these were the subjects of the present study. Arteriography of the proximal lower limb had been performed after the fasciotomy in patients with prolonged hypotension and persistent bleeding from the fasciotomy wound. All the patients had sustained high-energy trauma, systemic hypotension and local trauma to the proximal lower limb. Among them, four (five thighs) had undergone arteriography and four (four thighs) were confirmed as having sustained arterial injuries. In those patients with definitive arterial injuries, the time from injury to the onset of the compartment syndrome was less than 5 h. Acute compartment syndrome of the thigh in blunt trauma patients may be the result of associated arterial injuries. It is suggested that patients with local trauma to the proximal lower limb who exhibit an acute compartment syndrome together with haemodynamic instability should undergo arteriography soon after fasciotomy.

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.

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.

Diagnosis and management of colonic injuries following blunt trauma

PubMed Central

Zheng, Yi-Xiong; Chen, Li; Tao, Si-Feng; Song, Ping; Xu, Shao-Ming

2007-01-01

AIM: To retrospectively evaluate the preoperative diagnostic approaches and management of colonic injuries following blunt abdominal trauma. METHODS: A total of 82 patients with colonic injuries caused by blunt trauma between January 1992 and December 2005 were enrolled. Data were collected on clinical presentation, investigations, diagnostic methods, associated injuries, and operative management. Colonic injury-related mortality and abdominal complications were analyzed. RESULTS: Colonic injuries were caused mainly by motor vehicle accidents. Of the 82 patients, 58 (70.3%) had other associated injuries. Laparotomy was performed within 6 h after injury in 69 cases (84.1%), laparoscopy in 3 because of haemodynamic instability. The most commonly injured site was located in the transverse colon. The mean colon injury scale score was 2.8. The degree of faecal contamination was classified as mild in 18 (22.0%), moderate in 42 (51.2%), severe in 14 (17.1%), and unknown in 8 (9.8%) cases. Sixty-seven patients (81.7%) were treated with primary repair or resection and anastomosis. Faecal stream diversion was performed in 15 cases (18.3%). The overall mortality rate was 6.1%. The incidence of colonic injury-related abdominal complications was 20.7%. The only independent predictor of complications was the degree of peritoneal faecal contamination (P = 0.02). CONCLUSION: Colonic injuries following blunt trauma are especially important because of the severity and complexity of associated injuries. A thorough physical examination and a combination of tests can be used to evaluate the indications for laparotomy. One stage management at the time of initial exploration is most often used for colonic injuries. PMID:17278234

Clinical features of olfactory disorders in patients seeking medical consultation

PubMed Central

Chen, Guowei; Wei, Yongxiang; Miao, Xutao; Li, Kunyan; Ren, Yuanyuan; Liu, Jia

2013-01-01

Background Olfactory disorders are common complaints in ENT clinics. We investigated causes and relevant features of olfactory disorders and the need for gustatory testing in patients with olfactory dysfunction. Material/Methods A total of 140 patients seeking medical consultations were enrolled. All patients were asked about their olfactory disorders in a structured interview of medical history and underwent thorough otolaryngologic examinations and imaging of the head. Results Causes of olfactory disorders were classified as: upper respiratory tract infection (URTI), sinonasal diseases (NSD), head trauma, idiopathic, endoscopic sinus surgery, congenital anosmia, and other causes. Each of the various causes of olfactory dysfunction had its own distinct clinical features. Nineteen of 54 patients whose gustation was assessed had gustatory disorders. Conclusions The leading causes of olfactory dysfunction were URTI, NSD, head trauma, and idiopathic causes. Gustatory disorders were fairly common in patients with olfactory dysfunction. High priority should be given to complaints of olfactory disorders. PMID:23748259

New and emerging patient-centered CT imaging and image-guided treatment paradigms for maxillofacial trauma.

PubMed

Dreizin, David; Nam, Arthur J; Hirsch, Jeffrey; Bernstein, Mark P

2018-06-20

This article reviews the conceptual framework, available evidence, and practical considerations pertaining to nascent and emerging advances in patient-centered CT-imaging and CT-guided surgery for maxillofacial trauma. These include cinematic rendering-a novel method for advanced 3D visualization, incorporation of quantitative CT imaging into the assessment of orbital fractures, low-dose CT imaging protocols made possible with contemporary scanners and reconstruction techniques, the rapidly growing use of cone-beam CT, virtual fracture reduction with design software for surgical pre-planning, the use of 3D printing for fabricating models and implants, and new avenues in CT-guided computer-aided surgery.