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.     

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.     

Trauma registry database

Trauma registry is vital for every trauma center. In 1995, data on all injured patients who reached our trauma unit were collected. 3.040 patients were hospitalized, of whom 416 were transferred from other hospitals. We describe the distribution of the patients to in-patient wards and present the relationship between mortality and injury severity score. 1102 hospitalized patients underwent a total of 1599 operations with an overall mortality of 2.63%.     

Pediatric all-terrain vehicle trauma: a 5-year statewide experience

BACKGROUND/PURPOSE: This is a retrospective review of the pediatric all-terrain vehicle trauma victims who presented to the five major trauma centers serving the state of West Virginia during the 5-year period from January 1991 to December 1995. The purpose of this research is to characterize the nature of the injuries and the individuals injured to better appreciate the magnitude of the problem of ATV-related injuries in the pediatric population. METHODS: This study is a retrospective review of these 218 consecutive pediatric patients from trauma registry data and their medical records. RESULTS: Two hundred eighteen patients between the ages of 2 years and 16 years presented during the study period. Boys outnumbered girls three to one. The average Injury Severity Score (ISS) was 8.76, the average Glasgow Coma Score (GCS) was 14.4, and the average Trauma Score (TS) was 15.2. The most common injuries were orthopedic followed by head and facial injuries. The majority of the children did not wear helmets, and their injuries resulted in an average hospital length of stay of 4.3 days. Thirty-eight percent of the children required surgery. There were a total of four deaths for a mortality rate of 1.8%. The estimated total hospitalization cost for the 218 patients was $1,918,400.00. CONCLUSIONS: All-terrain vehicle-related trauma remains an ongoing safety concern facing society today. Every physician who cares for children should address this important issue when talking to children and parents about safety issues and injury prevention.     

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.     

A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene

INTRODUCTION: Comprehensive emergency medical services and helicopter aeromedical transport systems have been developed based on the principle that early definitive care improves outcome. The purpose of this study was to compare outcomes between patients transported by helicopter and those transported by ground. METHODS: Data were obtained from the North Carolina Trauma Registry for the period between 1987 and 1993 on all patients transported by helicopter and ground admitted to one of the eight state designated trauma centers. Study patients included only those who were transported directly from the scene of injury to the trauma center (interhospital transfers were excluded). Mortality (outcome) was compared after patient stratification by injury severity and transport time, using Cochran-Mantel-Haenszel statistics and logistic regression-derived probabilities of survival. RESULTS: One thousand three hundred forty-six patients (7.3% of the total) were transported from scene to trauma center by helicopter and 17,144 were transported by ground. In patients transported by helicopter, the mean Trauma Score was lower (12 +/- 3.6) versus 14.3 +/- 3.6 (p < 0.001) and the mean Injury Severity Score was higher (17 +/- 11.1) versus 10.8 +/- 8.4 (p < 0.001). A trend toward increased survival was observed among patients transported by helicopter with a higher Injury Severity Score. Statistical significance was achieved only for patients with a Trauma Score between 5 and 12 and Injury Severity Score between 21 and 30. CONCLUSION: The large majority of trauma patients transported by both helicopter and ground ambulance have low injury severity measures. Outcomes were not uniformly better among patients transported by helicopter. Only a very small subset of patients transported by helicopter appear to have any chance of improved survival based on their helicopter transport. This study suggests that further effort should be expended to try to better identify patients who may benefit from this expensive and risky mode of transport.     

Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage

OBJECTIVE: This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA: Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS: Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS: One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS: Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.     

Modeling injury outcomes using time-to-event methods

BACKGROUND: Mortality is an important measurement of injury outcomes, but measurements reflecting disability or cost are also important. Hospital length of stay (LOS) has been used as an outcome variable, but reduced LOS could be achieved either by improved care or by increased mortality. A solution to this statistical problem of "competing risks" would enable injury outcomes based on LOS to be modeled using time-to-event methods. METHODS: Time-to-event methodology was applied to 2,106 cases with complete data from the 1991-1994 registry of a regional trauma center. LOS was used as the outcome variable, modified by assigning an arbitrarily long LOS to any fatal case. A combination of proportional hazards and logistic regression models was used to explore the effects of potential predictive variables, including Trauma Score (TS), Injury Severity Score (ISS), components of TS or ISS, age, sex, alcohol use, and whether a patient was transferred. RESULTS: The "TRISS" combination of TS, ISS, and age previously shown to predict mortality also predicted "modified LOS" (Wald p value less than 0.001 for each variable). Models using only age and certain components of ISS or TS fit our data even better, with fewer parameters. Other variables were not predictive. Modified Kaplan-Meier plots provided easily interpreted graphical results, combining both mortality and LOS information. CONCLUSIONS: With a simple modification to allow for competing risks, time-to-event methods enable more informative modeling of injury outcomes than binary (lived/died) methods alone. Such models may be useful for describing and comparing groups of hospitalized trauma patients.     

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.     

Trauma patient outcome after the Prehospital Trauma Life Support program

BACKGROUND: We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program. METHODS: Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS, n = 350). RESULTS: Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%). Length of stay and disability were statistically significantly decreased post-PHTLS. Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre-PHTLS mortality. CONCLUSIONS: Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome.     

Regional audit of pedestrian accident care

In all, 160 serious pedestrian accidents (ISS > 15 or death), were recorded during a 12-month prospective study of all trauma in a population of 3.2 million. Of these, 35 died at scene, 125 arrived at hospital alive and 68 (54 per cent) subsequently died. There were 35 (22 per cent) children, and 62 per cent (39) were more than 60 years of age. Prehospital care significantly delayed transfer to hospital. In the accident and emergency department, only 38 per cent of those unconscious had a cervical collar applied, and only 67 per cent were intubated. Of those transferred for neurosurgical care, 34 per cent were not intubated. The Median Injury Severity Score for each outcome group was similar between age groups. The Revised Trauma Score and APACHE II score showed significant differences between those who lived and died. TRISS analysis revealed that 32 per cent of deaths and 12 per cent of survivors were unexpected. ATLS treatment protocols should be instituted for prehospital care and in all accident and emergency departments (A&E).     

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.     

A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group

PURPOSE: To develop a classification system for mechanical injuries of the eye. METHODS: The Ocular Trauma Classification Group, a committee of 13 ophthalmologists from seven separate institutions, was organized to discuss the standardization of ocular trauma classification. To develop the classification system, the group reviewed trauma classification systems in ophthalmology and general medicine and, in detail, reports on the characteristics and outcomes of eye trauma, then established a classification system based on standard terminology and features of eye injuries at initial examination that have demonstrated prognostic significance. RESULTS: This system classifies both open-globe and closed-globe injuries according to four separate variables: type of injury, based on the mechanism of injury; grade of injury, defined by visual acuity in the injured eye at initial examination; pupil, defined as the presence or absence of a relative afferent pupillary defect in the injured eye; and zone of injury, based on the anteroposterior extent of the injury. This system is designed to be used by ophthalmologists and nonophthalmologists who care for patients or conduct research on ocular injuries. An ocular injury is classified during the initial examination or at the time of the primary surgical intervention and does not require extraordinary testing. CONCLUSIONS: This classification system will categorize ocular injuries at the time of initial examination. It is designed to promote the use of standard terminology and assessment, with applications to clinical management and research stud ies regarding eye injuries.     

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.     

Prehospital resuscitation of hypotensive trauma patients with 7.5% NaCl versus 7.5% NaCl with added dextran: a controlled trial

Small volume infusions of hypertonic saline combined with dextran are very effective in resuscitating animals that have been subjected to hemorrhagic shock, and seem to be effective in resuscitating trauma patients with severe injuries. In this study, the contribution of the dextran component was investigated in a prospective, three-armed, double-blind, randomized trial. Trauma patients transported by ambulance to the hospital with a systolic blood pressure of 90 mm Hg or less were given 250 mL of (1) normal saline (NS); (2) 7.5% NaCl (HS, for hypertonic saline); or (3) 7.5% NaCl in 6% dextran 70 (HSD). Infusion of the study solution was followed by administration of conventional isotonic fluids as the patients' conditions indicated. By predetermined hypothesis, the observed survival rates in the three treatment groups were compared with the predicted survival rates from the TRISS methodology. The 7.5% NaCl solution significantly improved upon the predicted survival for the entire cohort and for high-risk patients when compared with the survival estimates from the TRISS methodology. The addition of a colloid, in the form of 6% dextran 70, did not offer any additional benefit, at least in this setting of rapid urban transport.     

Preferential benefit of implementation of a statewide trauma system in one of two adjacent states

BACKGROUND: Implementation of Oregon's trauma system was associated with a reduction in the risk of death for hospitalized injured patients. An alternative explanation for improved outcome, however, is favorable concurrent temporal trends, e.g., new technologies and treatments. PATIENTS AND METHODS: To control for temporal trends, seriously injured hospitalized patients in Oregon and Washington were compared before either state had a trauma system (1985-1988) and when only the Oregon trauma system had been implemented (1990-1993). The study group consisted of hospitalized injured patients aged 16 to 79 years with one or more index injuries in six body regions, i.e., head, chest, spleen/liver, femur or pelvis fracture, and burns. Hospital discharge claims data were analyzed, converting International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis codes to Abbreviated Injury Scale scores and Injury Severity Scores using a conversion algorithm. Multivariate logistic regression models were used to estimate the differential risk-adjusted odds of death in Oregon compared with Washington after adjustment for demographics, injury type, and injury severity. RESULTS: Findings indicated no difference in the risk-adjusted odds of death between Oregon and Washington while both states functioned under an ad hoc trauma system (1985-1988). A significant reduction in the risk of death, however, was noted in Oregon for patients with an index injury and an Injury Severity Score > 15 compared with Washington (adjusted odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.70-0.91) after trauma system implementation in Oregon (1990-1993). Specifically, reductions in the risk of death were demonstrated for patients with head injuries (adjusted OR = 0.70, 95% CI = 0.59-0.82) or liver/spleen injuries (adjusted OR = 0.73, 95% CI = 0.54-0.99). CONCLUSION: Assuming that the two states demonstrated similar concurrent temporal trends, the findings support the conclusion that improved outcomes among injured patients in Oregon may be attributed to the institution of a statewide trauma system.     

Genitourinary trauma in the pediatric patient

Trauma is the major source of mortality in the pediatric population. A retrospective review was performed on patients admitted to the Children's Hospital and Health Center Trauma Program, San Diego, California, from August 1984 to May 1990. The purpose of this review was to evaluate pediatric trauma and to determine the best treatment and evaluation for genitourinary injuries. Blunt trauma was responsible for 98 percent of the injuries, with renal injuries being the most common. Bladder (7) and male urethral (2) injuries, and vaginal lacerations (8) also occurred. The most severe renal injuries (70%) and all significant bladder and urethral injuries were associated with gross hematuria. Hypotension was present in 31 percent of patients but rarely required surgical exploration for correction. Eighty-six patients underwent radiographic imaging. Computerized tomography (CT) scans demonstrated the most information about intra-abdominal solid organ injuries but was inaccurate in detecting bladder or urethral injuries. Genitourinary injury is common in children but rarely requires surgical management. CT scan is the best study to determine extent of solid-organ injury but is inferior to cystourethrography to diagnose bladder or urethral injuries.     

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.     

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.     

Trauma after radial keratotomy and photorefractive keratectomy

A 25-year-old man sustained bilateral ocular trauma from an explosion, which resulted in ocular injuries from the blast, mineral projections, and heat. Before the accident, the patient had eight-incision radial keratotomy in the left eye followed 1 week later by photorefractive keratectomy in the right eye. After the accident, the left cornea had a full-thickness rupture of four incisions; the fellow cornea had a full-thickness laceration from a mineral projection. Five months after the accident, the left eye had an uncorrected visual acuity of 20/25; the right eye did not achieve an acuity of 20/200 until 20 months after the accident.