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.     

The costs and benefits of helicopter emergency ambulance services in England and Wales

BACKGROUND: Following the introduction of Helicopter Emergency Ambulance Services (HEAS) in the United Kingdom in the last ten years this paper examines the costs and benefits of three contrasting services in Cornwall, London and Sussex. METHODS: Pre-hospital processes of care were compared between helicopter attended patients and land ambulance patients in all three studies, and health outcomes were compared between helicopter and land ambulance patients in the Cornwall and London studies. A review of the literature on the benefits of HEAS has also been undertaken. RESULTS: There were no improvements in response times and the time on scene was longer for helicopter attended patients. Survival of trauma or cardiac patients attended by helicopter was not improved. In London there was some evidence of worse residual disability in helicopter attended survivors, but in Cornwall residual disability was better in helicopter attended patients. There was no improvement in general health status or aspects of daily living in the helicopter attended patients. The overall total operational costs for these services were [symbol: see text] 55 000 p.a. in Sussex, [symbol: see text] 600 000 in Cornwall and [symbol: see text] 1.2 million in London. CONCLUSION: The analysis suggests that Helicopter Emergency Ambulance Services are costly, the health benefits are small, and there are limited circumstances in which the pre-hospital performance of an ambulance service in England and Wales can be improved.     

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.     

The outcome of patients with upper airway obstruction transported to a regional paediatric intensive care unit

Two cases of nodular hidradenoma of the breast with possibly different origins are reported. Case 1 is of a 58-year-old female with a breast mass in the left, outer lower-quadrant. A histogenetical origin in the skin adnexal glands was suspected due to its superficial location and immunohistochemical findings. Case 2 is of a 44-year-old male with a subareolar nodule and nipple discharge. Histological examination demonstrated that the tumor was located deep in the breast tissue, was surrounded by dilated mammary ducts and exhibited intraductal extensions, which are all features mimicking those of breast cancer. Immunohistochemical positivity against gross cystic disease fluid protein-15 was weakly identified and negativity for endoplasmic reticulum was observed. This case can be interpreted as arising in the mammary ducts. It is well known that various kinds of skin adnexal tumors arise in the breast tissue; however, nodular hidradenoma of the breast is still a rare benign neoplasm. Clinically, nodular hidradenoma of the breast tends to occur in the nipple or subareolar region of the female breast. It should be kept in mind that nodular hidradenoma may occur in mammary ducts and it should be included when differential diagnoses are made of subareolar breast tumors.     

Imaging vividness and the outcome of in vivo and imagined scene desensitization.

Reexamined the role of imaging vividness in desensitization success. Scores on the Betts Questionnaire on Mental Imagery were used to divide 48 snake-phobic Ss into high, medium, and low vivid groups, who were assigned to imagined scene or in vivo desensitization treatments. The Fear Survey Schedule was used to measure general fearfulness. Imaging vividness was assessed at scheduled points during therapy. Significant decreases in behavioral and self-reported fear were observed after both treatments, although in vivo desensitization produced significantly greater fear reduction. In therapy, imaging vividness scores were significantly correlated with therapeutic success and were superior to pretherapy ratings as predictors of outcome. (2 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hypoxemia and arterial hypotension at the accident scene in head injury

OBJECTIVE: To quantify the occurrence of arterial hypotension and arterial oxygen desaturation in a series of patients with head trauma rescued by helicopter. DESIGN: Prospective, observational study. MATERIALS AND METHODS: Arterial HbO2 was measured before tracheal intubation at the accident scene in 49 consecutive patients with head injuries. Arterial pressure was measured using a sphygmomanometer. MAIN RESULTS: Mean arterial saturation was 81% (SD 24.24); mean arterial systolic pressure was 112 mm Hg (SD 37.25). Airway obstruction was detected in 22 cases. Twenty-seven patients showed an arterial saturation lower than 90% on the scene, and 12 had a systolic arterial pressure of less than 100 mm Hg. The outcome was significantly worse in cases of hypotension, desaturation, or both. CONCLUSIONS: Hypoxemia and shock are frequent findings on patients at the accident scene. Hypoxemia is more frequently detected and promptly corrected, white arterial hypotension is more difficult to control. Both insults may have a significant impact on outcome.     

A comparison of psychopathology in eating disorder patients from France and the United States

Patients with osteoarthritis of the hip were treated with a conservative therapy of heel lifting. Orthoses were applied on 35 hips in 33 subjects and the cases were followed for 23 months on average. Dramatic pain relief was reported, but the time required to reduce or completely relieve pain increased according to the stage of osteoarthritis. The radiological results were not satisfactory. During the follow-up, only two hips showed improvement, 22 showed no change, and 11 deteriorated. The mechanism of heel lifting in relation to the hip joint was analysed, showing that pelvic obliquity was achieved and the trunk stabilized. In conclusion this simple orthosis was effective as a palliative therapy for osteoarthritis of the hip.     

Abdominal trauma and pelvic injury in the growth period

Children with pelvic fractures usually are polytraumatized. Concomitant abdominal and pelvic injuries are not uncommon. Medical records and X-rays of 54 children, in which a pelvic fracture was diagnosed at our institution from 1974-1993, were reviewed. Children ages < or = 16 years and treated as in-patients were included in this study. The fractures were classified according to the AO-Classification. 47 patients (87.0%) had concomitant injuries. The mean Polytrauma Score was 23.7 (mean Injury Severity Score 30.5). Nine Children sustained an open pelvic fracture with rectal and/or vaginal tear. 15 genitourinary lesions were found in 13 children. 18 patients underwent laparotomy. A large pelvic/retroperitoneal hematoma was found in 11 cases. There were 7 liver lacerations, 7 splenic injuries, 2 mesenteric tears, 2 kidney injuries and 1 small bowel lesion. Eight children (14.8%) died with 5 of them due to retroperitoneal or/and abdominal bleeding complications. A recent follow-up examination (81.8%) with a mean follow-up of 11.3 years showed that long-term morbidity usually was attributed to pelvic concomitant injuries.     

Severe head injury combined with orthopedic and vascular trauma of the limbs

From 1982 to 1992, 2766 brain injury patients were admitted to the University Hospital San Cecilio of Granada, Spain. In 873 cases head injury was concomitant with other injuries but the association of severe head injury and combined orthopedic and vascular trauma of the limbs was observed only in 23 cases (incidence 2%). Thirteen patients were scheduled for revascularization, and of these secondary amputation was mandatory in two cases to keep rising intracranial pressure under control. Except for epidural hematomas which constitute an absolute neurosurgical emergency, combined orthopedic and vascular trauma of the limbs can be treated before head injury. However, we prefer to work with two operating teams simultaneously. Physical examination and judicious arteriography provide means for prompt diagnosis and treatment of the injured limb. The compartment syndrome should be anticipated and fasciotomy should be used routinely. Vascular repairs normally using reverse autogenous vein are the first priority, but we must always bear in mind the deleterious effects of the revascularization syndrome which expose the brain to a second aggression, and amputation, when necessary, should be undertaken to reduce mortality.     

Noninvasive positive pressure ventilation: successful outcome in patients with acute lung injury/ARDS

A still unknown tricyclic heterocyclic system (5) was synthesized from 6-hydroxy-2-methylpyridazin-3-one and its structure identified as 2,8-dichloro-6-methylpyrrolo[1,2-b:3,4-d']dipyridazin-5(6H)- one by spectroscopic investigations. Selective condensation of 5 with 2-[4-(2-substituted-phenyl)piperazin-1-yl]ethylamine gave the 2-arylpiperazinylethylamino-8-chloro derivatives 6a-c, which were investigated in binding studies toward the three alpha1-adrenergic and 5-HT1A-serotonergic receptor subtypes. They displayed high potency on all the assays and some selectivity for alpha1a and alpha1d subtypes.     

A study of patient-related characteristics and outcome after moderate injury

The purpose of all injury care is to restore patients' pre-injury functioning and to facilitate the return to normal activities. The aim of this prospective study was to describe and analyse psychiatric factors and other patient-related characteristics which influence long-term results after moderate injuries. One hundred and sixty-nine injured patients were randomized to go through a comprehensive psychosocial research protocol and to participate in the 12 month follow up. The 49 patients lost to follow-up differed significantly from all other patients. They were more often single, blue-collar workers with a lower educational level and had a less favourable psychosocial background, including alcohol abuse. The 120 patients who completed the follow-up were divided in two groups: the non-recovered group (NR, N = 58), patients reporting limitations in performing their work and/or limitations in carrying out housework and/or in social life, and the recovered group (R, N = 62), patients reporting full recovery or only minor limitations in exercise or sports 12 months after the injury. The NR patients were older (P < 0.05), had a slightly higher injury Severity Score (P < 0.01) and showed signs of depression both during the acute post-injury period and at 1 year follow up (P < 0.001). The multivariate analysis showed that measurements of pain and depression during the acute post-injury period were associated with the functional outcome after 12 months. Co-operation between injury and psychiatric units should be developed to identify patients needing psychosocial or psychiatric support during the early phase of rehabilitation.     

A comparison of posttraumatic stress disorder in veterans with and without spinal cord injury.

The authors assessed effects of paraplegic and quadriplegic spinal cord injuries (SCls) on posttraumatic stress disorder (PTSD) by comparing severity and prevalence of PTSD in these groups to a sample of controls who experienced traumatic injuries other than SCI. The authors found that veterans with quadriplegia reported significantly less severe current PTSD symptoms than controls who were not significantly different from veterans with paraplegia. These results suggest that sustaining a quadriplegic SCI decreases risk of current PTSD, whereas sustaining a paraplegic SCI is associated with greater risk of PTSD, although the risk is no greater than that incurred from experiencing the trauma itself. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Analysis of heart-rate variability: a noninvasive predictor of death and poor outcome in patients with severe head injury

BACKGROUND: Analysis of heart-rate variability (HRV) is a promising new technique for noninvasive quantification of autonomic function. We measured HRV in patients with severe head injury to assess its potential as a monitoring tool. METHODS: Analysis of HRV was prospectively done on all intensive care unit patients. Concurrent data on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were collected. Registry data were reviewed to identify patients with severe head injury, defined as Head/Neck Abbreviated Injury Scale score > or = 4. Mortality, likelihood of discharge to home, ICP, and CPP were compared between patients with abnormal HRV and those without. RESULTS: Low HRV was associated with increased mortality and decreased rate of discharge to home. Abnormal HRV was associated with episodes of increased ICP and decreased CPP. CONCLUSION: Assessment of HRV is a noninvasive method that can be widely used. Abnormal HRV was associated with poor outcome and altered cerebral perfusion. Monitoring of HRV may improve outcome by allowing earlier detection and treatment of intracranial pathology.     

A comparison of sonographic examinations for trauma performed by surgeons and radiologists

BACKGROUND: It has been demonstrated that surgeons and surgery residents, trained in the focused abdominal sonographic examination, are able to accurately and reliably evaluate trauma patients. Despite this, radiologists have objected to surgeon-performed sonography for several reasons. We set out to compare the accuracy of sonographic examinations performed by surgery residents and radiologists. METHODS: A retrospective review of medical records of all trauma patients who received focused ultrasound examinations from January 1, 1995, through June 30, 1996, at one of two American College of Surgeons-verified Level I trauma centers in the same city was undertaken. Ultrasound examinations were performed by surgery residents at trauma center A (TCA) and by radiologists or radiology residents at trauma center B (TCB). Findings for each patient were compared with the results of computed tomography, diagnostic peritoneal lavage, operative exploration, or observation. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for each group of patients. Comparison of patient charges for the trauma ultrasound examinations at each of the trauma centers was also made. RESULTS: Patient populations at the two centers were similar except that the mean Injury Severity Score at TCB was higher than at TCA (11.74 vs. 9.6). Sensitivity, specificity, accuracy, or negative predictive value were not significantly different between the two cohorts. A significantly lower positive predictive value for examinations performed by surgery residents was noted and attributed to a lower threshold of the surgery residents to confirm their findings by computed tomography. Billing data revealed that the average charge for trauma sonography by radiologists (TCB) was $406.30. At TCA, trauma sonography did not generate a specific charge; however, a $20.00 sum was added to the trauma activation fee to cover ultrasound machine maintenance and supplies. CONCLUSION: Focused ultrasound examination in the trauma suite can be as safely and accurately performed by surgery residents as by radiologists and radiology residents and should be a routine part of the initial trauma evaluation process.     

A comparison of Queen's and Minnesota Kent-Rosanoff word association norms.

Compared a new set of queen's norms (for responses to 100 words from the kent-rosanoff word association test) collected in kingston, canada with minnesota norms reported by D. S. Palermo and J. J. Jenkins (see pa, vol. 39:17) for the 1st 9 primaries plus a 10th category for all other responses. Out of the 20 words compared, 19 were significantly different. In the light of previous evidence, word associations seem to have both a time and a place specificity, but its degree does not appear to be attributable to environmental-cultural differences between canada and the united states. (PsycINFO Database Record (c) 2010 APA, all rights reserved)