Expression of inducible nitric oxide synthase in the brains of scrapie-infected mice

Thoracic trauma in the elderly population constitutes a major challenge for both thoracic and trauma surgeons as their presentation and outcomes differ from the adult population in addition to their high morbidity and mortality. One hundred and one patients, 60 years of age or older, with thoracic trauma were treated at Dicle University School of Medicine during a 6-year period. Eighty-five per cent were male and 15% were female with a mean age of 64.5 years. The cause of thoracic injury was blunt in 77.2% and penetrating in 22.8% of the patients. Sixty-two patients (61.4%) had isolated thoracic injuries. The median Injury Severity Score (ISS) was 23. The morbidity rate was 23.8%. The mortality rate was 16.8%. Seven of 10 patients (70%) who had an ISS greater than 25 died, whereas six of 24 (25%) patients with an ISS between 17 and 25, and four of 67 (5.9%) patients with an ISS less than 16 died. In the elderly the morbidity and mortality rates were higher for blunt trauma compared with penetrating trauma. For ISS greater than 25 the mortality rate was 71.4% for blunt and 66.6% for penetrating trauma. As the morbidity and mortality rate are significantly higher in the elderly patients the approach to these patients should include recognition of their high risk for morbidity and mortality, especially for those who had an ISS greater than 25.     

Results of treatment of multiple trauma in 130 children

Trauma remains the leading cause of death in the pediatric age group, despite recent advances in prevention and treatment. We retrospectively analyzed 130 cases of multiple trauma among 725 pediatric patients with injuries treated here during 1988-1989. Road accidents and falls from heights were the most common causes of injury. Mean age was 7 years (range 0.5-15) and the male to female ratio 2.7:1.0. Overall mortality was 9.2%. 57 patients (44%) did not get any prehospital medical care and 5 of them with injury severity scores (ISS) greater than 25 died. In contrast 11/18 (61%) of patients with ISS greater than 25 who were treated by medical teams survived. On arrival at the emergency room, 15% were hypothermic ( < 34 degrees C), and 6 were in hypovolemic shock--5 of whom died. Most common injuries were head trauma (91), limb injuries (69), abdominal trauma (34) and thoracic trauma (34). In 39 injury was severe, with pediatric trauma score (PTS) 6 or less, 12 of whom died. All deaths except 1 were associated with severe head injury and with ISS more than 25. There was no mortality in those with PTS more than 7 or ISS less than 25. Thus, the prehospital care of pediatric patients with head injury is associated with high mortality. Absence of mortality in patients with PTS of more than 7 emphasizes the importance of designated trauma centers for these patients.     

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.     

Management of blunt liver trauma in children

INTRODUCTION: Management of liver trauma in childhood represents a rare but formidable challenge. METHODS: Clinical presentation, grade of liver injury and Injury Severity Score (ISS) were studied in 11 cases of blunt liver trauma to examine factors influencing outcome. RESULTS: Seven of the 11 children were injured severely and had an ISS greater than 16. Seven who were haemodynamically stable were treated without operation, but four required surgery for grade III, IV and V liver injuries. Two children had primary repair of hepatic lacerations. Perihepatic packing was employed in two other cases (grade IV and V injury) for uncontrollable haemorrhage. Delayed debridement and thrombectomy plus vena cava repair with suturing of liver lacerations in these patients obviated heroic efforts at primary repair. Nine children survived. There were two deaths from head and neck trauma. DISCUSSION: Selected children with liver trauma can be managed non-operatively using established trauma guidelines. Perihepatic packing is recommended in unstable patients with complex injuries, followed by delayed definitive repair.     

Driveway crush injuries in young children: a highly lethal, devastating, and potentially preventable event

BACKGROUND/PURPOSE: The aim of this study was to investigate driveway-related injuries in children, identify associated risk factors, and evaluate outcome compared with other mechanisms of blunt trauma. METHODS: A 6-year review (1991 to 1996) of pediatric (age less than 18 years) pedestrian injuries treated at two urban trauma centers was conducted: one regional pediatric trauma center and one level I trauma center with pediatric commitment. Five hundred twenty-seven children injured in pedestrian accidents were identified from the trauma registry; 51 children (10%) sustained traumatic injuries as a result of being struck in their driveway. Data are reported as mean +/- SEM. RESULTS: Children less than 5 years of age (n = 41) had an injury severity score (ISS) of 12.3+/-2.3, 15 (37%) sustained closed head injury, 13 (37%) had torso trauma, 19 (46%) skeletal trauma, and eight (20%) died. Children > or = 5 years old (n = 10) had an ISS of 10.7+/-2.4, three (30%) sustained closed head injury, four (40%) torso trauma, six (60%) skeletal trauma, and none died. In contrast, all other pediatric pedestrian accidents analyzed over the same time period had a mortality rate of only 2% (11 of 476). CONCLUSIONS: Pediatric driveway trauma carries a significant risk of head injury and a 10-fold increase in mortality in children under 5 years of age when compared with all other pediatric pedestrian accidents. More emphasis must be placed on injury prevention and public education to prevent this devastating mechanism of injury in these young, vulnerable children.     

Splenic injury in children: a 10 year experience

The aim of this report was to review retrospectively the management of splenic trauma at a major Australian tertiary referral centre (Westmead Hospital) over a 10 year period. Forty-nine patients (0-15 years of age) with documented blunt splenic trauma were identified. The causes of splenic injury were road trauma (73%) and falls (27%). There were 22 minor injuries (Injury severity score [ISS] < 16) and 27 severe injuries (ISS > or = 16). All nine deaths were related to road trauma (mean ISS = 59). The investigation most commonly used was CT scanning (47%). Peritoneal lavage was performed in six patients (12%). Management involved non-operative care in 29 patients (57%), exploratory laparotomy alone in 5 (10%), splenic salvage in 2 (4%) and splenectomy in 13 (26%). This experience supports the view that non-operative management of splenic injury in haemodynamically stable children is safe and is the preferred treatment. Experienced assessment and meticulous observation is necessary. Laparotomy is indicated if there is continuing haemodynamic instability despite resuscitation. Operative management is aimed at splenic salvage with splenectomy being reserved for uncontrolled haemorrhage.     

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.     

Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study

OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest trauma (94 multiple injured patients with chest trauma, nine patients with isolated chest trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center. RESULTS: In 67 patients (65%) TCT detected major chest trauma complications that have been missed on CXR (lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005), and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement, chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of respiratory failure, adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with multiple trauma and with blunt chest trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group. CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualzing lung contusions, pneumothorax, and hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with multiple injuries and with suspected chest trauma because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.     

Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms

OBJECTIVES: By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms. METHODS: The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management. RESULTS: Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13. A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)). The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries). In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography. Twenty patients (SIG, 2.8) were successfully embolized. In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0). A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts. Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy. CONCLUSIONS: Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).     

Blunt abdominal trauma. A review of 637 patients

Although blunt abdominal trauma continues to cause significant morbidity and mortality, the care of these patients has improved significantly over the past 30 years. In order to evaluate the current status of management, we have reviewed retrospectively the medical records of all such patients admitted to the University of Mississippi Medical Center over a ten- year period (October 1, 1981 - September 30, 1991). Of the total of 637 patients, 61% were male and 39% female; 40% were between the ages of 20 and 29 years. Motor vehicle accidents accounted for approximately 80% of these injuries. Of the total, 399(62.6%) underwent laparotomy, 12 (3%) of which were nontherapeutic. The operative mortality rate was 13% and the overall mortality for the 637 patients was 8.5%. These results are compared with four previous series of blunt abdominal trauma patients. Women comprised a greater proportion in the two most recent series. The liver and spleen are the most commonly injured intra-abdominal organs; however, liver injuries have been reported in increasing numbers of patients in the most recent series. The incidence of nontherapeutic laparotomy is less with each succeeding series. Mortality rates have declined significantly and the 8.5% mortality in our patients is certainly indicative of this trend.     

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definitions of the systemic inflammatory response syndrome and allied disorders in relation to critically injured patients

OBJECTIVES: To determine the frequency of the proposed definitions for the systemic inflammatory response syndrome (SIRS), sepsis and septic shock, and to further define severe SIRS and sterile shock as determined at 24 hrs of admission to an intensive care unit (ICU) in critically ill trauma patients without head injury, and their relationships to mechanism of injury, Acute Physiology and Chronic Health Evaluation (APACHE) II score, risk of death, Injury Severity Score (ISS), number of organ failures, and mortality rate. DESIGN: Prospective, inception cohort analysis. SETTING: Sixteen-bed surgical ICU in a teaching hospital. PATIENTS: Four hundred fifty critically injured patients without associated head trauma. Penetrating trauma accounted for 70% (gunshot 202; stab 113) and nonpenetrating trauma for 30% (motor vehicle collision 103; blunt 32) of admissions. Three hundred ninety-four (88%) patients underwent surgical procedures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Infective and noninfective insults were distinguished by the need for therapeutic or prophylactic antibiotics, respectively, based on an established antibiotic policy. Three hundred ninety-five (87.8%) patients fulfilled a definition of the SIRS criteria. The frequency of the definitive categories was SIRS 21.8%, sepsis 14.4%, severe SIRS 8.4%, severe sepsis 13.6%, sterile shock 9.3%, and septic shock 20.2%. Patients with penetrating trauma had a significantly higher frequency of sepsis, severe sepsis, and septic shock (p < .01). The APACHE II score, risk of death, and number of organ failures increased significantly in both infective and noninfective groups with increasing severity of the inflammatory response. Sterile shock was associated with a significantly higher APACHE II score (p < .02), risk of death (p < .01), and number of organ failures (p = .03) compared with septic shock. Only sterile shock was associated with a significantly higher ISS (p < .01). Organ system failure was significantly (p < .001) higher in nonsurvivors compared with survivors in all categories. The only significant (p < .001) difference in mortality rate was found between patients in shock and all other categories. CONCLUSIONS: The current definitions of SIRS, sepsis, and related disorders in critically injured patients without head trauma show a significant association with physiologic deterioration and increasing organ dysfunction. The only significant association with mortality, however, is the presence of shock. The definitions require refinement, with the possible inclusion of more objective gradations of organ system failure, if they are to be used for stratifying severity of illness in seriously injured patients.     

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.     

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.     

Malformations of neocortical development: magnetic resonance imaging correlates

BACKGROUND: The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients. METHODS: The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2). RESULTS: The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient. CONCLUSIONS: Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.     

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.     

Does free fluid on abdominal computed tomographic scan after blunt trauma require laparotomy?

BACKGROUND: Abdominal computed tomographic (CT) scans are used in the evaluation of blunt trauma. The purpose of this study was to determine if isolated intraperitoneal fluid seen on CT scan necessitates laparotomy. METHODS: Trauma registry records of patients who underwent abdominal computed tomography from January 1994 through January 1997 were studied. Data were reviewed for age, gender, CT scan interpretation, associated injuries, and operative findings. RESULTS: Abdominal injury was identified in 126 patients. Seventy-eight patients had evidence of solid-organ injury and 17 patients had extraperitoneal injury. Isolated intraperitoneal fluid was identified in 31 patients. All patients with isolated fluid underwent laparotomy; 29 of these procedures (94%) were therapeutic. Bowel injuries occurred in 18 patients and mesenteric injuries in 8 patients. Five patients had intraperitoneal bladder rupture, and undetected solid-organ injuries were found in two patients. Other organs injured included the stomach, pancreas, ovary, and uterus. CONCLUSION: Exploratory laparotomy was therapeutic in 94% of patients. Isolated intraperitoneal fluid on CT scan after blunt trauma mandates laparotomy.     

Solid viscus injury predicts major hollow viscus injury in blunt abdominal trauma

BACKGROUND: As nonoperative management of blunt abdominal trauma has become more popular, reliable models for predicting the likelihood of concomitant hollow viscus injury in the hemodynamically stable patient with a solid viscus injury are increasingly important. METHODS: The Pennsylvania Trauma Systems Foundation registry was reviewed for the period from January 1992 to December 1995 for all adult (age > 12 years) patients with blunt trauma and an Abbreviated Injury Scale (AIS) score > or = 2 for a solid viscus (kidney, liver, pancreas, spleen). Patients with an initial systolic blood pressure < 90 mm Hg were excluded. Hollow viscus injuries included only lacerations or perforations of the gallbladder, gastrointestinal tract, or urinary tract. RESULTS: In the 4-year period, 3,089 patients sustained solid viscus injuries, 296 of whom had a hollow viscus injury (9.6%). The mean age was 35.6 years, mean Injury Severity Score was 22.2, and mean Revised Trauma Score was 7.3; 63.3% of the patients were male. A solitary solid viscus injury occurred in 2,437 patients (79%), 177 of whom (7.3%) had a hollow viscus injury. The frequency of hollow viscus injury increased with the number of solid organs injured: 15.4% of patients with two solid viscus injuries (n = 547) and 34.4% of patients with three solid viscus injuries (n = 96) suffered a concomitant hollow viscus injury (p < 0.001 vs. one organ). A hollow viscus injury was 2.3 times more likely for two solid viscus injuries and 6.7 times more likely for three solid viscus injuries compared with a solitary solid viscus injury. For solitary solid viscus injury, the frequency of hollow viscus injury varied little with increasing AIS score (AIS score 2, 6.6%; AIS score 3, 8.2%; AIS score 4, 9.2%; AIS score 5, 6.2%) (p = 0.27 between groups), suggesting that the incidence of hollow viscus injury is related more to the number of solid visceral injuries than the severity of individual organ injury. Also, when the sum of the AIS scores for solid viscus injuries was <6, the mean rate of hollow viscus injury was 7.8%. This increased to 22.8% when the sum of the AIS scores for solid viscus injury was > or =6 (p < 0.001). A pancreatic injury in combination with any other solid viscus injury had a rate of hollow viscus injury of >33%. CONCLUSION: A model of organ injury scaling predicted hollow viscus injury. Multiple solid viscus injuries, particularly pancreatic, or abdominal solid viscus injuries with an AIS score > or = 6, were predictive of hollow viscus injury. Identification of these injury patterns should prompt consideration for early operative intervention.     

Review of liver trauma management in Tasmania: an analysis of risk factors for mortality and morbidity

A review of liver trauma treated by the major trauma care facilities of Tasmania in the 5 year period between 1989 and 1993 is presented. The aim of this retrospective review was to provide an audit of the management of liver trauma in the island of Tasmania and to analyse the risk factors contributing to mortality and major morbidity. Thirty-seven patients were treated with a median Injury Severity Score (ISS) of 14 (range 9-34). The overall mortality rate of this series was 5.8%. Age, mechanism of injury (blunt or penetrating), delay prior to hospital presentation and modality of treatment (operative or non-operative) were not significant risk factors for mortality and morbidity; however, transfusion requirement of over 10 units of blood (P < 0.005), ISS score of over 20 (P < 0.0005), haemodynamic instability at presentation (P < 0.05) and a Hepatic Injury Score (HIS) grade of 3 or more (P < 0.05) were statistically significant risk factors.     

Three phenylethanoid glycosides and an iridoid glycoside from Picrorhiza scrophulariiflora

To identify risk factors associated with death in traumatized children, we prospectively studied 507 consecutive patients (7+/-4 yr) admitted to a level I pediatric trauma center over a 3-yr period. Pediatric Trauma Score (PTS), Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS) were calculated. Age, injury mechanism, injury pattern, and initial critical care were recorded. Univariate and multivariate analyses were performed for potential risk factors associated with mortality. Receiver operating characteristic curves were used to determine threshold values of variables identified by univariate analysis. Most children suffered from blunt trauma (99.6%), and head trauma was noted in 85%. Median values (range) of GCS scores, PTS, and ISS were 10 (3-15), 7 (-4 to 12), and 16 (3-75), respectively. The mortality rate was 12%. Using multivariate analysis, death was significantly associated with an ISS > or = 25 (odds ratio [OR] 22.2, 95% confidence interval 2.8-174.9), GCS score < or = 7 (OR 4.77, 1.8-12.7), emergency blood transfusion > or = 20 mL/kg (OR 4.3, 2.1-9.1), and PTS < or = 4 (OR 3.7, 1.4-9.7). An ISS > or = 25, GCS score < or = 7, immediate blood transfusion > or = 20 mL/kg, and PTS < or = 4 were significant and independent risk factors of death in an homogenous population of severely injured children. The probability of traumatic death was therefore 0 (95% confidence interval 0-0.0135) in children with no one of these threshold values in the four predictive factors and 0.63 (95% confidence interval 0.47-0.76) in those children with all the threshold values. IMPLICATIONS: Methods used for evaluating outcome of trauma patients have essentially been derived from adult series, and attempts to apply them to children have usually been inaccurate. Univariate and multivariate analyses were performed to identify risk factors associated with death in severely traumatized children, and Receiver operating characteristic curves were used to determine threshold values.     

Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma

A recent retrospective analysis of femur fractures concluded that early surgical fixation in patients who have sustained blunt thoracic trauma (AIS score for Thorax > or = 2) was a risk factor for postoperative pulmonary failure. We conducted a review of all femur fractures admitted to a level I trauma center from November, 1988 to May, 1993. Inclusion criteria were ISS > or = 18, mid-shaft femur fractures treated with reamed intramedullary fixation, and no mortalities secondary to head trauma or hemorrhagic shock. One hundred thirty-eight patients met these criteria. Four patient groups were created: N1--no thoracic trauma (AIS score for thorax < 2), and early surgical fixation (< 24 hours after injury, n = 49); N2--no thoracic trauma and delayed fixation (> or = 24 hours, n = 8); T1--thoracic trauma (AIS score for Thorax > or = 2) and early fixation (n = 56); T2--thoracic trauma and delayed fixation (n = 25). There were no significant differences in age, Injury Severity Score, or Glasgow Coma Scale score between the four groups. Mortality rate, length of stay (LOS), LOS in the TICU, and duration of mechanical ventilation tended to be greater in patients with delayed fracture fixation, however, this was not statistically significant. The N2 patients had a pneumonia rate of 38% compared with 10% in group N1 (p = 0.07). The T2 patients had a pneumonia rate of 48% compared with 14% in group T1 (p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)