A critical analysis of on-scene helicopter transport on survival in a statewide trauma system

BACKGROUND: Recently, questions have been raised regarding the effectiveness of helicopters in trauma care. We conducted a retrospective study to evaluate the effect of on-scene helicopter transport on survival after trauma in a statewide trauma system. METHODS: Data were obtained from a statewide trauma registry of 162,730 patients treated at 28 accredited trauma centers. Patients transported from the scene by helicopter (15,938) were compared with those transported by ground with advanced life support (ALS) (6,473). Interhospital transfers and transports without ALS were excluded. Statistical analysis was performed using one-way analysis of variance and logistic regression. RESULTS: Patients transported by helicopter were significantly (p < 0.01) younger, were more seriously injured, and had lower blood pressure. They were also more likely to be male and to have systolic blood pressure < 90 mm Hg. Logistic regression analysis revealed that when adjusting for other risk factors, transportation by helicopter did not affect the estimated odds of survival. CONCLUSION: A reappraisal of the cost-effectiveness of helicopter triage and transport criteria, when access to ground ALS squads is available, may be warranted.     

Multicenter, randomized, prospective trial of early tracheostomy

OBJECTIVES: Determine the effect of early (days 3-5) or late (days 10-14) tracheostomy on intensive care unit length of stay (ICU LOS), frequency of pneumonia, and mortality, and evidence of short-term or long-term pharyngeal, laryngeal, or tracheal injury in head trauma, non-head trauma, and critically ill nontrauma patients. STUDY DESIGN: Randomized, prospective. SETTING: Five Level I trauma centers. METHODS: Data were obtained prospectively and included Acute Physiology and Chronic Health Evaluation III score (AIII), Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, type of endotracheal tube or tracheostomy, level of positive end-expiratory pressure, and peak inspiratory pressure. Patients were to undergo laryngoscopy for detection of injury according to the Lindholm criteria at the time of endotracheal tube or tracheostomy removal and be reevaluated at 3 to 5 months after discharge. RESULTS: One hundred fifty-seven patients were entered, 127 to early randomization (3-5 days) and 28 to late randomization (10-14 days); however, only 112 patients with early and 14 with late randomization had completed data forms for the primary study goals. An additional 22 patients from the early entry groups were rerandomized late. Early randomization data: the AIII score was higher (p < 0.05) in the head trauma tracheostomy (65 +/- 4) than in the nontracheostomy group (51 +/- 4) and in the nontrauma tracheostomy (92 +/- 6) than in the nontracheostomy group (68 +/- 7), but was equivalent in the non-head trauma group. Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, positive end-expiratory pressure, and peak inspiratory pressure were not significantly different in any of the groups. There were no significant differences in ICU LOS, frequency of pneumonia, or death in any of the groups after either early or late tracheostomy compared with continued endotracheal intubation. Only 83 patients underwent postextubation laryngoscopy. There were no significant differences between the groups; however, there were trends to more vocal cord ulceration and subglottic inflammation in the continued intubation group. No patient was seen in this study with late vocal cord or laryngeal stenosis; there were no tracheal-innominate artery fistulae. Seven of the patients with abnormal findings at extubation had normal 3- to 5-month postextubation laryngoscopy. CONCLUSION: Physician bias limited patient entry into the study. Although there were higher AIII scores in the head trauma early tracheostomy patients, there were no differences in the primary end points of ICU LOS, pneumonia, or death in any of the groups studied. Long-term endoscopic follow-up was poor, but no known late tracheal stenosis was seen.     

Is colostomy always necessary in the treatment of open pelvic fractures?

BACKGROUND: Wound management in open pelvic fractures has used fecal diversion, debridement, and closure by secondary intention to prevent pelvic sepsis. Colostomy care and takedown adds to the morbidity and resource utilization of this approach. We reviewed our experience to determine if a selective approach to fecal diversion based on wound location was possible. METHODS: Retrospective analysis of patients admitted to a Level I trauma center during an 8-year period. Fractures were classified as open if the fracture was in continuity with the wound. Wounds were classified as perineal if they involved the rectum, ischiorectal fossa, or genitalia, and as nonperineal if they involved the pubis anteriorly, iliac crest, or anterior thigh. Pelvic sepsis was defined as cellulitis, fasciitis, or infection of a pelvic hematoma. Diversion consisted of loop or end colostomy. RESULTS: Eighteen patients with open fractures were identified. Four died from closed head injury and blood loss. The remaining 14 were treated as follows. Five patients with perineal wounds had diversion of their fecal stream. Their Injury Severity Score was 34 +/- 8.3 and their Revised Trauma Score was 7.69 +/- 0.15. No patient developed pelvic sepsis. Nine patients with nonperineal wounds did not undergo diversion. Their Injury Severity Score was 28.6 +/- 5.3 and their Revised Trauma Score was 7.36 +/- 0.45. No patients developed pelvic sepsis in the nondiverted group. CONCLUSION: No patients with anterior wounds and an intact fecal stream developed pelvic sepsis. Colostomy may not be necessary in all patients with open pelvic fracture. Protocols using fecal diversion based on wound location appear to be safe and may decrease resource utilization and subsequent morbidity related to colostomy closure.     

IL-12 is an effective adjuvant for induction of mucosal immunity

OBJECTIVE: To define those physiologic and clinical variables that have a positive or negative predictive value in discriminating survivors from nonsurvivors with traumatic injuries and a Trauma Score of 5 or less. METHODS: A retrospective review of 2,622 trauma patients transported by an air medical service from the scene of injury to a Level I trauma center was performed. Demographic, physiologic, and clinical variables were evaluated. RESULTS: One hundred thirty-six patients were studied; 14 patients survived trauma resuscitation. Survivors had statistically significant improvement in the Glasgow Coma Scale from the field to arrival in the emergency room. Revised Trauma Score, probability of survival, pulse, respiratory rate, cardiac rhythm, central nervous system activity, and signs of life were statistically more favorable in survivors. CONCLUSION: In patients who survived to discharge, signs of central nervous system activity in the field was a positive predictor of survival, and severe head injury served as a negative predictor of survival.     

Epidemiology of immediate and early trauma deaths at an urban Level I trauma center

The objective of this study is to identify and differentiate the injury patterns and causes of death among patients who died within the 1st hour and those in the period between 1 and 48 hours after hospital admission. Information was collected from the 1994 to 1996 trauma data base at an urban Level I trauma center. The records of 155 trauma patients who died within the 1st hour (immediate trauma death, ITD) and between 1 and 48 hours (early trauma death, ETD) were examined retrospectively. Total and constituent Injury Severity Score (ISS), Trauma Score (TS), and Glasgow Coma Score were analyzed. ITDs constituted 49 per cent of all deaths within 48 hours. Blunt mechanisms accounted for 37 per cent of ITDs and 40 per cent of ETDs (not significant), whereas penetrating trauma accounted for 59 per cent of ITDs and 56 per cent of ETDs (not significant). Exsanguination most commonly caused death among ITDs (54%) and head injury (51%) among ETDs (P < 0.01). Patients who died within the 1st hour had higher ISS (42.6 +/- 23.2, P < 0.03), lower TS (1.7 +/- 1.9, P < 0.0001), and lower Glasgow Coma Score (3.1 +/- 1.1, P < 0.0001) than those who died after the 1st hour. Patients with ITD had a significantly worse chest ISS than those with ETD (47.4 +/- 28.6 vs 19.0 +/- 19.1, P < 0.0001). We conclude that 1) ITD is caused primarily by exsanguination, whereas ETD is largely due to the sequelae of severe neurologic injury; 2) ITD has a significantly lower TS and higher ISS than ETD; and 3) thoracic injuries are more severe among patients with ITDs than among those with ETDs. The severity of thoracic injury among ITDs suggests that rapid surgical intervention is critical during the resuscitation of these severely injured patients.     

Trauma patients 75 years and older: long-term follow-up results justify aggressive management

BACKGROUND: Long-term survival rate and functional status after trauma for one of the fastest growing segments of the population, patients 75 years and older, is poorly documented. METHODS: Trauma patients 75 years and older who were discharged from our Level I trauma center between June 1988 and July 1992 (n = 279) were contacted by mail or phone. Public death records were used to identify patients who had died. A stepwise logistic regression analysis was performed to determine predictors of poor outcome (death within 6 months). Main outcome measures included mortality and self-assessed functional status. RESULTS: A minimum 4-year follow-up was obtained for 81% of the 279 study patients. The mean follow-up period was 5.4 +/- 1.1 years. Mean age at time of injury was 81 +/- 5 years (range, 75-101 years); mean Injury Severity Score was 9.4 +/- 7.7. At follow-up, 132 patients (47%) had died, 93 patients (33%) were contacted, and 54 patients (19%) could not be located. Twelve percent of patients survived less than 6 months after discharge. Poor survival was predicted by preexisting diseases (dementia, p = 0.001; hypertension, p = 0.02; and chronic obstructive pulmonary disease, p = 0.05) and not by age or severity of injury. The mean age of patients still living was 85 +/- 3.9 years (range, 79-99 years), and 77 of 93 patients were living in an independent setting (33 alone, 44 with spouse or family); of these, 57% reported no difficulties in performing 12 of 14 activities of daily living. CONCLUSION: Despite higher than expected mortality after discharge, aggressive management of trauma patients 75 years and older is justified by the favorable long-term outcome.     

Intestinal permeability correlates with severity of injury in trauma patients

BACKGROUND: Increased intestinal permeability (IP) and the release of toxic intraluminal materials have been implicated in the systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) observed in patients after severe trauma. Previous studies of intestinal permeability have failed to demonstrate a correlation between early measurements of IP and indicators of injury severity. This study examines the relationship between standard measures of injury severity and the early (day 1) and delayed (day 4) changes in IP. Associations between IP and the development of SIRS, MOF, and infectious complications were also studied. METHODS: The metabolically inactive markers lactulose (L) and mannitol (M) were used to measure IP in 29 consecutive patients who sustained injuries that required admission to the surgical intensive care unit and in 10 healthy control subjects. Measurements were made within 24 hours of admission and on hospital day 4. Severity of injury was assessed by A Severity Characterization of Trauma (ASCOT), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Postinjury infections and parameters of SIRS and MOF were recorded. RESULTS: The IP of healthy volunteers (L/M, 0.025 +/- 0.008) was within the normal range (L/M < or = 0.03), whereas the average IP in injured patients was increased both within 24 hours (L/M, 0.139 +/- 0.172) and on the fourth hospital day (L/M, 0.346 +/- 0.699). No significant correlation between severity of injury and increased IP was seen within 24 hours of injury. A significant correlation was seen on hospital day 4, however, with all severity indices measured (ASCOT: r = 0.93, R2 = 0.87, p < 0.001; TRISS: r = 0.93, R2 = 0.87, p < 0.001; ISS: r = 0.84, R2 = 0.70, p < 0.001; RTS: r = 0.68, R2 = 0.47, p = 0.002; APACHE II score: r = 0.51, R2 = 0.26, p = 0.04). Patients with markedly increased IP (L/M > or = 0.100) experienced a significant increase in the development of SIRS (83 vs. 44%; p = 0.03) and subsequent infectious complications (58 vs. 13%; p = 0.01) and showed close correlation with the multiple organ dysfunction scores (r = 0.87, R2 = 0.76, p < 0.001). CONCLUSION: These observations demonstrate that the increased IP observed after trauma correlates with severity of injury only after 72 to 96 hours and not within the initial 24 hours of injury. A large increase in IP is associated with the development of SIRS, multiple organ dysfunction, and an increased incidence of infectious complications.     

Comparison between of TRISS and ASCOT methods--in Tainan area. Trauma and Injury Severity Score. A Severity Characterization of Trauma

In this study, we compare the Trauma and Injury Severity Score (TRISS) and A Severity Characterization of Trauma (ASCOT) models by using NCKUH trauma registry to assess the performance of correct prediction in terms of sensitivity, specificity and misclassification rate. The database has accumulated to 5,672 cases, NCKUH 2,490; Chi-Mei 3,182 respectively. Blunt trauma mechanism was composed of 4, 892 (86.2%) while 552 (9.7%) were pertinent to penetrating. The male/female ratio is 2.4:1. Traffic accident is the major cause of injury (3, 472-(61.2%)), followed by work injury (723-(12.7%)); fall (702-(12.4%)) and burn injuries (160-(2.8%)). The category of traffic accident is comprised of motorcycle-related, (1,257-(69.14%)), followed by automobile-related was (301-(16.56%)) and bicycle injuries (123-(6.8%)). The category of working injury comprised by machine crushed cases (332-(45.92%)) followed by cutting (148-(20.47%)) and impacts (69-(9.5%)). The overall mortality rate in our registry was 8.3%. ASCOT and TRISS were compared using sensitivity, specificity and misclassification rates. Each method had disadvantages in predicting outcomes of particular subgroups of patients. ASCOT tends to underestimate the probability of survival among patients with head/spinal injuries; while TRISS had a similar effect on multiple trauma victims. In conclusion, ASCOT is superior to TRISS in correctly predicting severe head trauma cases. However, both methods have their limitations in terms of accurate prediction. It is our hope to develop a mixed, revised model to better predict patients survival probability. Therefore, it is feasible to adopt ASCOT methodology in prediction of trauma patients in Taiwan. Expanded database and better methodology need to be developed in further study.     

Trauma in pregnancy: the role of interpersonal violence

OBJECTIVE: Our purpose was to determine what role interpersonal violence as intentional injury plays in the pregnant trauma victim. STUDY DESIGN: We performed a retrospective review of medical records. RESULTS: During a 9-year period in a single university medical and trauma center, 203 pregnant women were treated for a physically traumatic event. Sixty-four women (31.5%) were victims of intentional injury, in most cases by the husband or boyfriend. Although the mean Injury Severity Score was higher in women with fetal death than in women with successful pregnancy outcomes (7.25 vs 1.74, respectively; p < 0.01), 5 of the 8 women with fetal losses incurred these despite an apparent absence of physical injury (maternal Injury Severity Score = 0). CONCLUSIONS: Interpersonal violence during pregnancy is a frequent and increasingly common cause of maternal injury. The inconsistent relationship between Injury Severity Score and serious fetal injury or death is underscored by the loss of 5 fetuses despite an Injury Severity Score of 0.     

Six-year experience with Swan neck presternal peritoneal dialysis catheter

Airway control is the initial priority in the management of the injured patient. The purpose of this investigation was to evaluate the experience of an aeromedical transport team in the utilization of rapid sequence induction (RSI) for endotracheal intubation in the prehospital setting. Records of a consecutive series of injured patients undergoing RSI between June 1988 and July 1992 by a university-based aeromedical transport team were reviewed for demographics, intubation mishaps, and pulmonary complications. The relationship between intubation mishaps and pulmonary complications was analyzed. Eighty-four patients were studied with a mean age of 30.8 +/- 15.3 years. The mean Revised Trauma Score was 11.3 +/- 2.4, and the mean Injury Severity Score (ISS) was 19.6 +/- 11.5. Intubation mishaps occurred in 15 patients (18%), and pulmonary complications developed in 22 (29%) of the 75 patients surviving longer than 24 hours. There was no relationship between intubation mishaps and pulmonary complications. Abbreviated Injury Scale (AIS) face score was significantly higher in patients with intubation mishaps, compared with patients without mishaps (1.1 +/- 1.2 and 0.5 +/- 0.9, respectively, P < .05, Wilcoxon rank-sum). ISS and AIS chest were higher in patients with pulmonary complications, compared with those without (25.7 +/- 12.6 and 17.4 +/- 10.3 and 2.2 +/- 1.8 and 1.0 +/- 1.5, ISS and AIS respectively; P < .05, Wilcoxon rank-sum). Eighty-one patients (96%) underwent successful RSI, 73 (87%) on the first attempt. Failure to intubate occurred in three patients (4%). Performed under strict protocol by appropriately trained aeromedical transport personnel, RSI is an effective means to facilitate endotracheal intubation in the injured patient requiring definitive airway control. Pulmonary complications were related to injury severity and not to intubation mishaps.     

Pediatric trauma registry: analysis of 1200 cases

OBJECTIVES: We developed the first Spanish Pediatric Trauma Registry in order to collect and evaluate information concerning aspects of injuries in our pediatric population. METHODS: From January'95 to September'97, 28,713 children younger than 16 years were treated in our Hospital for acute injury: 1,200 were admitted and included in our database. Our file-registry consists of 108 data points including: patient identification, type, place and mechanism of injury, pre-hospital care, transport, assessment on admission, severity scores, diagnostic studies, injuries, treatments and morbidity-mortality. RESULTS: Accidents were more frequent in males (69%) than in females. The age-group predominantly was 12-15 years old (34%). Accidents were more frequent in the street (35.3%) than at home (18.7%) or school (14%). Falls and traffic-related accidents were the leading cause of injury (38 and 21.1%, respectively). The 16.7% of cases had Pediatric Trauma Score < or = 8 (n = 201). The 3.6% of this sustained multiple trauma (43 cases with Injury Severity Score > or = 15). Musculoskeletal and head trauma was the most frequent (62 and 42.3%, respectively). Surgical or orthopedic procedures were performed in 678 patients (56.5%). Average length of stay were 4.8 days (range 1-93 days), and functional impairments at discharge were found in 33.9% of patients older than 3 years (n = 338). Mortality rate in our series was 0.5% (n = 6), and 13.9% in children with ISS > or = 15. CONCLUSIONS: The utility of this Registry is to know the epidemiology of our injured pediatric population, to review patient care, to develop prevention programs and to compare results with other centers so potential deficiencies can be identified and corrected.     

Differential performance of TRISS-like in early and late blunt trauma deaths

OBJECTIVES: (1) To independently validate the Trauma and Injury Severity Score-Like (TRISS-Like) model derived by Offner et al. (Revision of TRISS for intubated patients. J Trauma. 1992;32:32-35) in a population of Canadian blunt trauma victims, and (2) to compare the ability of this model to predict mortality in early and late trauma deaths. STUDY POPULATION: Prospective cohort of blunt trauma cases with Injury Severity Score > 12 identified from the Ontario Trauma Registry over a 5-year period. STUDY DESIGN: The TRISS-Like model consisting of age, Injury Severity Score, systolic blood pressure, and best motor response of the Glasgow Coma Scale was evaluated as to its ability to predict mortality by determining the sensitivity, specificity, and the area under the receiver operating characteristic curve. The sample was then divided into early (< or = 7 days) and late mortality subgroups in which model performance was evaluated with respect to time of death. RESULTS: A total of 7,703 patients were included in this analysis. The overall mortality was 12.3%. The TRISS-Like model allowed for assessment of an additional 23% of patients than would standard TRISS and performed with a sensitivity of 97.1%, specificity of 39.8% and an area under the receiver operating characteristic curve of 0.873. Analysis of mortality with respect to time demonstrated that 75% of deaths occurred by day 7. The specificity and receiver operating characteristic area increased in the early (< or = 7 days) subgroup, 46.5% and 0.935, respectively, compared with 20.8% and 0.778 in the late mortality group. CONCLUSIONS: TRISS-Like demonstrated similar performance to that reported with the standard TRISS model but with the additional advantage that it is more generalizable because it can be applied to intubated patients. TRISS-Like demonstrated substantially superior performance in early trauma deaths compared with those that occurred late. This differential performance may be because the model does not include risk factors for late mortality.     

Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death

BACKGROUND: Elderly patients suffer higher mortality rates after trauma than younger patients. This increased mortality is attributable to age, preexisting disease, and complications as well as injury severity. METHODS: Records from 5,139 adult patients from a Level I trauma center were retrospectively reviewed. Injury Severity Score (ISS), Revised Trauma Score (RTS), early mortality (<24 hours), and late mortality (>24 hours) were determined for elderly (> or =65 years) and younger (16-64 years) patients. Preexisting diseases and complications were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis coding. RESULTS: Mortality in elderly patients was twice that in younger patients despite equivalent injury severity (p < 0.001), and elderly patients were more likely to suffer later death than younger patients (p < 0.005). The prevalence of preexisting disease was greater in the elderly, as was the incidence of complications. Using logistic regression, ISS, RTS, preexisting cardiovascular or liver disease, the development of cardiac, renal, or infectious complications, and geriatric status were all independently predictive of late mortality (p < 0.05). CONCLUSION: Elderly trauma patients more frequently suffer late mortality than younger patients because of the combination of injury and increased preexisting disease and complications after injury. Aggressive treatment of the elderly trauma patient is warranted; however, in the face of significant preexisting disease or complications, survival is less likely. Predictive models of survival can be developed, taking into account preexisting disease and complications as well as admission parameters such as age, ISS, and RTS, and specific risk of mortality quantitated.     

Quantitative ultrasound of the tibia: a novel approach for assessment of bone status

We prospectively investigated the appropriateness of Mechanism of Injury as an exclusive indicator for trauma center triage. For all patients transported to our level 1 trauma center, EMS personnel identified applicable American College of Surgeons' Committee on Trauma field triage guidelines. A total of 112 questionnaires were completed. Mechanism of injury was the only reason for trauma center transport in 29. Neither intubation nor emergent surgery was required in any of these patients, and all survived. Only two had an ISS > 15. The remaining 83 patients had an 11% mortality rate. Fourteen (16.9%) had ISS scores > 15. Defining an ISS of 16 or greater as severe injury, mechanism of injury alone had a positive predictive value of only 6.9%. Mechanism of injury may not, by itself, justify bypass of local hospitals in favor of trauma centers.     

Bioavailability of iron in cottonseed meal, ferric sulfate, and two ferrous sulfate by-products of the galvanizing industry

BACKGROUND: The aim of this study was to compare the outcome of severe blunt trauma in children receiving prehospital care from either physician-staffed advanced life support (ALS) units, or from basic life support (BLS) units staffed by emergency medical technicians. METHODS: The records of 288 children with severe blunt trauma who required intensive care in the regional level 1 trauma center or who died from their injuries were analyzed retrospectively. Patients were excluded if resuscitation at the scene was not attempted, if the level of prehospital care was unspecified, or if arrival at the level 1 trauma center was delayed beyond 150 minutes. Seventy-two patients met the inclusion criteria of BLS-, and 49 the criteria of ALS-prehospital care. RESULTS: A reduced mortality rate (22.4% v 31.9%) was seen in the ALS group, which was more apparent in a "salvageable but high-risk" subgroup, characterized by Glasgow Coma of Scale 4 through 8, Pediatric Trauma Score of 0 through 5, and Injury Severity Score (ISS) of 25 through 49. However, a statistically significant difference was only seen when trauma severity was evaluated by the ISS. CONCLUSION: An improved outcome in children with severe blunt trauma has been demonstrated when prehospital care is provided by physician-staffed ALS units compared with BLS units.     

Delayed complications of nonoperative management of blunt adult splenic trauma

OBJECTIVE: To determine the incidence and type of delayed complications from nonoperative management of adult splenic injury. DESIGN: Retrospective medical record review. SETTING: University teaching hospital, level I trauma center. PATIENTS: Two hundred eighty patients were admitted to the adult trauma service with blunt splenic injury during a 4-year period. Men constituted 66% of the population. The mean (+/-SEM) age was 32.2+/-1.0 years and the mean (+/-SEM) Injury Severity Score was 22.8+/-0.9. Fifty-nine patients (21%) died of multiple injuries within 48 hours and were eliminated from the study. One hundred thirty-four patients (48%) were treated operatively within the first 48 hours after injury and 87 patients (31%) were managed nonoperatively. MAIN OUTCOME MEASURES: We reviewed the number of units of blood transfused, intensive care unit length of stay, overall length of stay, outcome, and complications occurring more than 48 hours after injury directly attributable to the splenic injury. RESULTS: Patients managed nonoperatively had a significantly lower Injury Severity Score (P<.05) than patients treated operatively. Length of stay was significantly decreased in both the number of intensive care unit days as well as total length of stay (P<.05). The number of units of blood transfused was also significantly decreased in patients managed nonoperatively (P<.05). Seven patients (8%) managed nonoperatively developed delayed complications requiring intervention. Five patients had overt bleeding that occurred at 4 days (3 patients), 6 days (1 patient), and 8 days (1 patient) after injury. Three patients underwent splenectomy, 1 had a splenic artery pseudoaneurysm embolization, and 1 had 2 areas of bleeding embolization. Two patients developed splenic abscesses at approximately 1 month after injury; both were treated by splenectomy. CONCLUSION: Significant numbers of delayed splenic complications do occur with nonoperative management of splenic injuries and are potentially life-threatening.     

Pediatric hepatic trauma: does clinical course support intensive care unit stay?

PURPOSE: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. METHODS: A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. RESULTS: Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. CONCLUSIONS: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.     

Retinal detachment with vitreous hemorrhage

The aim of this study was to assess the influence of prehospital advanced life support (PALS) on the survival of victims of severe trauma in our hospital. During a period of 24 months, 46 patients with severe trauma were admitted to our Emergency Department after receiving PALS; this included endotracheal intubation and ventilatory support (IVS) in 35 cases, and cardiopulmonary resuscitation (CPR) in 11. The severity of the trauma in this group of patients was confirmed by assessing the clinical condition on admission and the Glasgow Coma Scale score (mean = 4.0, median = 3), the Revised Trauma score (mean = 4.1, median = 4) and the Injury Severity Score (mean = 44.5 and median = 41 in blunt trauma; mean = 58.3 and median = 75 in penetrating trauma). The overall survival was 41%. The survival rate was 48% in patients with prehospital IVS rate and 18% in those receiving CPR. We conclude that PALS in severe trauma was able to save the lives of many patients at high risk of dying before reaching hospital.     

Outcome and cost of trauma among the elderly: a real-life model of a single-payer reimbursement system

BACKGROUND: As our population ages, the number of elderly trauma patients (age > or = 65 years) increases. Studies have demonstrated increased mortality and cost for a given injury severity in the elderly compared with younger patients. The financial viability of trauma centers in the United States has been an area of concern for many years. As reimbursement diminishes for privately insured patients, the ability to finance the care of the indigent is jeopardized. Medicare, the single-payer insurance plan for the elderly, reimburses at a lower rate than standard private insurance carriers. We examined the differences in outcome and cost between the elderly and younger patients and the financial burden imposed by care for elderly trauma. Our hypothesis was that elderly trauma patients would have poorer outcomes, higher cost, and generate greater financial losses than younger patients. METHODS: All patients admitted to the University of Virginia Trauma Service from July 1, 1994, to July 1, 1997 were included. Trauma registry and patients records were examined. Patients with incomplete financial data (cost, reimbursement, and payer source) were excluded. Patients were grouped by age (18-64 and > or =65 years), Injury Severity Score, and payer source. RESULTS: One thousand one hundred twenty-seven patients met the entry criteria. One hundred forty patients had incomplete financial or patient data and were excluded. Nine hundred eighty-seven patients were included in the study, of which 159 were elderly and 828 were 18 to 64 years of age. Injury Severity Scores were significantly higher in the elderly group. Only 2% of elderly patients were uninsured (76% were insured by Medicare), whereas 25% of younger patients were uninsured. Medicare reimbursement rates actually exceeded those of all other carriers (114% of costs). Elderly patients had a higher mortality rate, but the z score did not reach significance. The W score, however, indicated that there were more unexpected, negative outcomes among elderly patients. As injury severity increased, profit per case increased in the elderly and decreased in the younger group. CONCLUSION: Despite higher injury severity and lower survival probability for the elderly, the length of hospital and intensive care unit stays, as well as the percentage of admissions to the intensive care unit, were similar. The per capita cost of hospital care for the elderly was lower than for younger patients, whereas reimbursement was higher, primarily because 98% of elderly patients were insured. Medicare, the single-payer insurance plan for the elderly, adequately reimburses for elderly trauma care. This implies that universal insurance coverage for all trauma patients would be desirable, even if reimbursement rates decreased significantly. The increased mortality in the elderly requires continued study and diligence.     

Regulation of whole blood tumor necrosis factor production upon endotoxin stimulation after severe blunt trauma

BACKGROUND: Trauma has been recognized to be accompanied by alterations of leukocyte functions such as cytokine release. The regulatory principles involved in these changes are still poorly defined. To further characterize leukocyte function after multiple trauma, endotoxin-stimulated tumor necrosis factor (TNF) production of trauma patients' whole blood and a possible regulatory mechanism were studied. METHODS: Endotoxin responsiveness in trauma patients (n = 18, Injury Severity Score = 24 +/- 7) was assayed ex vivo using a whole blood model. TNF release and TNFalpha mRNA levels were determined during a 14-day period. Furthermore, the influence of patients' sera on whole blood TNF production was evaluated. MAIN RESULTS: The capacity of trauma patients' whole blood to produce TNF was reduced for 2 to 6 days after trauma and was equally evident for both TNF release and TNFalpha mRNA levels. The reduction of TNF coincides with the appearance of an inhibitory activity for TNF production in trauma patients' sera. No correlation was found between the inhibitory activity and soluble TNF receptors, endotoxin-neutralizing molecules, inhibitory cytokines (interleukin 10 and transforming growth factor beta), or prostaglandins. CONCLUSIONS: Major trauma leads to the appearance of a circulating inhibitory activity for TNF synthesis that may potentially contribute to an anti-inflammatory response in patients with multiple trauma. The elucidation of its structural and functional properties may contribute to the understanding of the pathogenesis of severely injured patients.