Cow-related trauma: A 10-year review of injuries admitted to a single institution

Introduction

Bovine-related injuries to farmers are common in rural communities. Many injuries are significant requiring hospital admission and surgery. We reviewed all cattle-related injuries admitted to a regional trauma centre over 10 years and detail the nature of the injuries.

Method

A retrospective review was undertaken, using hospital inpatient coding system (HIPE) to identify patients admitted following cow-related trauma for the last 10 years. From retrieved charts mechanism of injury was identified, demographics recorded and Injury Severity Score (ISS) and Trauma Injury Severity Score (TRISS) calculated based on the injuries sustained.

Results

47 patients were identified, with a median age of 53 years. 4 injuries occurred in children, and 12 in patients over 65 years old. Three-quarters of those injured were male. Kicking was the most common mechanism of injury (n = 21), but charge/head-butt injuries and trampling injuries were associated with more serious injury scores. 72% of patients were admitted under Orthopaedics as their primary care team, 25% under General Surgeons, with one patient admitted medically. Mean ISS score was 6.9 (range 1-50). 41 operative interventions were performed on 30 patients during their admission. 6.3% of patients required admission to Intensive Care with a mean length of stay of 12.3 days (range 2-21 days). There was no mortality.

Conclusion

Cow-related trauma is a common among farming communities and is a potentially serious mechanism of injury that appears to be under-reported in a hospital context. Bovine-related head-butt and trampling injuries should be considered akin to high-velocity trauma.     

Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries

Introduction

Pancreatic injuries occur in up to 10% of paediatric patients who suffer blunt trauma. Initial amylase and lipase measurements have not been helpful as a screening tool to detect pancreatic injuries. However, one primarily adult study suggests that a delayed measurement may be useful.

Materials and methods

A retrospective chart review was conducted of patients admitted to a Level I paediatric trauma centre from April 1996 to November 2006 with traumatic pancreatic injuries.

Results

The trauma database identified 51 patients with traumatic pancreatic injuries. Inclusion and exclusion criteria were met by 26 patients.Patients with initial amylase and lipase levels measured greater than 2 h post-injury were more consistently elevated compared to those patients who had levels measured at 2 h or less post-injury. There was a significant association between time of measurement and an increased amylase level (p = 0.012). No significant association was found for lipase measurements (p = 0.178).

Discussion and conclusions

In children with blunt pancreatic injury, elevated serum amylase levels were seen in a significantly higher percentage of patients with initial measurements at greater than 2 h post-injury compared to those measured at 2 h or less. Lipase measurements demonstrated a similar trend. Delayed amylase and lipase measurements may be helpful to detect pancreatic injuries, but further study is needed.     

Television tip-overs: The Starship Children's Hospital experience and literature review

Background

Injuries sustained from television (TV) sets tipping over onto children are uncommon when compared to other forms of trauma, ^{[4] and [5]} but because of the weight of some TVs relative to the size of small children, severe and sometimes fatal injuries can result. The international literature is limited in describing this form of trauma and none is available for the Australasian region.

Aim

The aims of the present paper are to describe the characteristics and immediate outcomes of children admitted to Starship Children's Hospital following TV tip-overs and review the international literature on this topic.

Methods

Patients admitted to Starship Hospital were identified retrospectively from the Paediatric Trauma database, and the case notes reviewed. Structured telephone interviews were then conducted with each of the families involved.

Results

Over the 28-month period (June 2006-October 2008) reviewed, 13 children under 15 years of age were identified, with an almost even sex distribution. 5 required admission to the Paediatric Intensive Care Unit (PICU). 9/13 sustained head injuries and 1 patient died from their injuries. Mechanism of injury was in keeping with behaviour to be expected of toddlers. Parents and caregivers were unaware of the dangers posed by TV sets and no precautions had been taken to prevent injury.

Conclusions

The injuries sustained by children from TV tip-overs are often serious and most commonly involve the head and upper body. This is a common finding in all papers reviewed, but numbers of patients studied are still limited. There is a need for both education of families and improvement in the design of TV sets, to prevent this form of trauma in the paediatric population.     

Road use pattern and risk factors for non-fatal road traffic injuries among children in urban India

Objective

We assessed the road use pattern and incidence and risk factors of non-fatal road traffic injuries (RTI) among children aged 5-14 years in Hyderabad, India.

Methods

In a cross-sectional population-based survey, data were collected on 2809 participants aged 5-14 years (98.4% participation) selected using multi-stage cluster sampling. Participants recalled non-fatal RTI during the previous 3 and 12 months. RTI was defined as an injury resulting from a road traffic crash irrespective of severity and outcome.

Results

Boys (11.5) had a higher mean number of road trips per day than girls (9.6), and the latter were more likely to walk and less likely to use a cycle (p < 0.001). With increasing household income quartile, the proportion of trips using cycles or motorised two-wheeled vehicles increased while trips as pedestrians decreased (p < 0.001). Based on the 3-month recall period, the age-sex-adjusted annual rate of RTI requiring recovery period of >7 days was 5.8% (95% CI 4.9-6.6). Boys and girls had similar RTI rates as pedestrians but boys had a three times higher rate as cyclists. Considering the most recent RTI in the last 12 months, children of the highest household income quartile were significantly less likely to sustain pedestrian RTI (0.26, 95% CI 0.08-0.86). The odds of overall RTI were significantly higher for those who rode a cycle (2.45, 95% CI 1.75-3.42) and who currently drove a motorised two-wheeled vehicle (2.83, 95% CI 1.60-5.00).

Conclusion

These findings can assist in planning appropriate road safety initiatives to reduce cycle and pedestrian RTI among children to reduce RTI burden in India.     

ACS trauma centre designation and outcomes of post-traumatic ARDS: NTDB analysis and implications for trauma quality improvement

Background

Several authors have examined the relationship between outcomes following severe trauma and American College of Surgeons (ACS) trauma centre designation. Little is known, however, about the association between ACS level and outcomes following complications of trauma.

Methods

The National Trauma Databank (NTDB, v. 5.0) was queried to identify adult (Age ≥18) trauma patients developing post-traumatic ARDS, who were admitted to either ACS level 1 or level 2 trauma centres from 2000 to 2004. Patients transferred between institutions and injuries following burns were excluded. Univariate analysis was used to assess differences between those patients admitted to ACS level 1 and level 2 facilities. Adjusted mortality was derived using logistic regression analysis.

Results

A total of 902 adult trauma patients with ARDS after 48 h of mechanical ventilation were identified from the NTDB. Five hundred and thirty six patients were admitted to a level 1 ACS verified centre and 366 to a level 2 facility. Univariate analysis revealed no statistical differences in clinical and demographic characteristics between the two groups. On univariate comparison, patients admitted to level 1 facilities had longer mean hospital and ICU length of stay and higher hospital related charges than level 2 counterparts. Patients admitted to a level 1 centre were, however, significantly more likely to achieve discharge to home. Using multivariate logistic regression, ACS level designation was shown to have no statistical effect on mortality. Hypotension on admission and age greater than 55 were the only independent predictors of mortality.

Conclusion

ACS trauma centre designation level is not an independent predictor of mortality following post-traumatic ARDS.     

Does thoracic injury impair the predictive value of base deficit in trauma patients?

Introduction

Base deficit (BD) has been shown to be a valuable indicator to be predictive of complications and mortality after trauma. Arterial carbon dioxide (PaCO₂) may be influenced by thoracic injuries, potentially diminishing the predictive value of BD. Therefore, the aim of this study was to assess the predictive value of admission BD for mortality and complications in trauma patients with thoracic injuries.

Methods

By a prospective database analysis of patients with an injury to the chest admitted to the University Medical Center Utrecht between 2000 and 2004 were studied. All patients with a blood gas analyses were included. Absolute BD was used for analyses. Clinical outcome parameters were recorded.

Results

The BD was higher in the non-surviving patients compared to the survivors (7.5 vs. 3.8, p < 0.001). Mortality rate of patients with an admission BD of ≥6 was increased in thoracic trauma patients (BD < 6 mortality rate 7%, BD ≥ 6 mortality rate 27%; p < 0.001). In patients who required ICU admittance the BD was increased compared to patients without ICU admission (5.2 vs. 2.9, p < 0.001). Within the subgroup of patients admitted to the ICU, the BD was higher in patients who required ventilation (3.8 vs. 5.5, p = 0.025). Patients who developed chest related complications had increased BD compared with those without complications (4.9 vs. 4.0, p = 0.025), the BD was particularly increased in patients who developed acute respiratory distress syndrome (ARDS) (4.1 vs. 6.4, p = 0.004). Carbon dioxide (PaCO₂) showed a predictive value for mortality (44 vs. 53, p < 0.001), ICU admission (42 vs. 46, p = 0.003) and hospital stay.

Conclusion

Admission BD is a predictive factor in thoracic trauma patients for mortality and chest related complications. Furthermore it is a predictive factor for ICU admission, required ventilation and hospital stay. The use of BD in thoracic trauma patients can potentially identify patients who require additional monitoring or early aggressive therapy.     

Occult pneumomediastinum in blunt chest trauma: Clinical significance

Introduction

Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or “overt pneumomediastinum”, raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or “occult pneumomediastinum”. Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population.

Methods

A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated.

Results

Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest (p < 0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common (p < 0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0-0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam.

Conclusion

Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.     

The risk of child abuse in infants and toddlers with lower extremity injuries

Purpose

The aim of this study was to assess the risk of child abuse in children younger than 18 months admitted to a pediatric trauma service with lower extremity injuries.

Methods

An Institutional Review Board-approved retrospective case series of children admitted to a regional pediatric trauma center with lower extremity injuries from 1998 to 2002 (n = 5497) was performed. Factors analyzed included age, injuries, and injury mechanism.

Results

Among 5497 trauma patients, the incidence of abuse was 104 (2%) of 4942 children 18 months or older and 175(32%) of 555 children younger than 18 months (odds ratio [OR], 21.4 ± 2.9, P < .001). There were 1252 (23%) patients with lower extremity injuries in the entire sample, and 66 of these were younger than 18 months. In the extremity trauma group, for patients 18 months or older, 16 (1%) of 1186 were abused compared with 44 (67%) of 66 patients younger than 18 months (OR, 146 ± 53, P < .001). Among all trauma patients younger than 18 months, 41 of 55 lower extremity fractures were linked to abuse, whereas 134 of 500 other injuries were caused by abuse (OR, 8.0 ± 2.6, P < .001). Among the 41 abuse-related fractures, femur fracture was the most common (22), followed by tibia fracture (14).

Conclusions

Among children 18 months or older, abuse is an uncommon cause of lower extremity trauma. In children younger than 18 months, lower extremity injuries, particularly fractures, are highly associated with child abuse. Clinicians must thoroughly investigate lower extremity injuries in this age group.     

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization

Background

The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation.

Methods

The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications.

Results

One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications.

Conclusions

Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.     

Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center

Background

Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality.

Methods

A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded.

Results

A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 ± 9.33 (range, 15-54) years. The mean LOS was 10.65 ± 8.30 (range, 5-65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 ± 9.92 days; stab wound, 8.76 ± 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 ± 36.702 mm Hg) compared with those who survived (83.96 ± 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% (n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01), ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01) and SBP (p = 0.001) were associated with mortality.

Conclusion

Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.     

Thermal injury within the first 4 months of life

Aim

To determine the incidence, magnitude of injury, fluid management, role of surgery and outcome in newborns and infants under 4 months of age admitted to a Burns Unit.

Method

Retrospective analysis of patient records.

Results

86 patients under the age of 4 months were admitted over a 37 year period (0.34% of admissions). Their injuries were caused by hot water in 45 and fire in 38, primitive heating devices in 2 and non-accidental paraffin burn in 1. Twenty-eight sustained superficial partial thickness burns, 12 deep partial thickness and 46 full thickness injuries. The total body surface area ranged from 1 to 55% with an average of 11.5%. Bacterial contamination of the burn wounds was present on admission in 52.3% and consisted of both gram positive and gram negative organisms. The resuscitation formula of 3.5 ml/kg/% burn on the first day and 1.5 ml/kg/% burn on the second day plus maintenance fluid at 30-120 ml/kg/day was not always adequate in maintaining haemodynamic stability. Three surgical methods were employed in 59 patients (69%). These included early tangential excision in 25, excision with or without allograft and delayed grafting in 27, and conventional therapy with eventual grafting in 7 patients. Releasing escharotomies were required in 9 children. Nineteen children required amputations. Three craniectomies, 2 tracheostomies and 1 colostomy were additional procedures. The mortality was 9.3%. Three causes of death were identified: magnitude of injury, sepsis and inhalation injury.

Conclusion

Neonates and infants are very vulnerable and preventable environmental factors are often implicated. Fire and hot water are the most common causes resulting in significant physical trauma. Resuscitation especially during the first few days of life can be problematic. Wound infection and sepsis are common and surgery should be individualised. Long-term outcome is very satisfactory for those with small burns however those with larger burns may remain permanently disfigured.     

Pre-hospital trauma care resources for road traffic injuries in a middle-income country—A province based study on need and access in Iran

Background

Access to pre-hospital trauma care can help minimize many of traffic related mortality and morbidity in low- and middle-income countries with high rate of traffic deaths such as Iran. The aim of this study was to assess if the distribution of pre-hospital trauma care facilities reflect the burden of road traffic injury and mortality in different provinces in Iran.

Methods

This national cross-sectional study is based on ecological data on road traffic mortality (RTM), road traffic injuries (RTIs) and pre-hospital trauma facilities for all 30 provinces in Iran in 2006. Lorenz curves and Gini coefficients were used to describe the distributions of RTM/RTIs and pre-hospital trauma care facilities across provinces. Spearman rank-order correlation was performed to assess the relationship between RTM/RTI and pre-hospital trauma care facilities.

Results

RTM and RTIs as well as pre-hospital trauma care facilities were distributed unequally between different provinces. There was no significant association between the rate of RTM and RTIs and the number of pre-hospital trauma care facilities across the country.

Conclusions

The distribution of pre-hospital trauma care facilities does not reflect the needs in terms of RTM and RTIs for different provinces. These results suggest that traffic related mortality and morbidity could be reduced if the needs in terms of RTM and RTIs were taken into consideration when distributing pre-hospital trauma care facilities between the provinces.     

Non-operative management of right side thoracoabdominal penetrating injuries—The value of testing chest tube effluent for bile

Introduction

While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients’ chest tube effluent.

Patients and methods

We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury.

Results

Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3 ± 4.1 mg/dL) and was always higher than both serum bilirubin (p < 0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p < 0.05). One RST injury patient died of line sepsis.

Conclusion

Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.     

Ureteral trauma: Patterns and mechanisms of injury of an uncommon condition

Background

Traumatic ureteral injuries are uncommon, thus large series are lacking.

Methods

We performed a retrospective analysis of the National Trauma Data Bank (2002-2006).

Results

Of the 22,706 genitourinary injuries, 582 ureteral injury patients were identified (38.5% blunt, 61.5% penetrating). Patients were 84% male, 38% white, and 37% black (mean age, 31 y). Blunt trauma patients had a median Injury Severity Score of 21.5 versus 16.0 for penetrating injury (P < .001). Mortality rates were 9% blunt, and 6% penetrating (P = .166). Penetrating trauma patients had a higher incidence of bowel injuries (small bowel, 46%; large bowel, 44%) and vascular injuries (38%), whereas blunt trauma patients had a higher incidence of bony pelvic injuries (20%) (P < .001).

Conclusions

Ureteral injuries are uncommon, seen in approximately 3 per 10,000 trauma admissions, and occur more in penetrating than in blunt trauma. The most common associated injury for blunt ureteral trauma is pelvic bone fracture, whereas penetrating ureteral trauma patients have more hollow viscus and vascular injuries.     

Traumatic urethral injuries: Does the digital rectal examination really help us?

Introduction

The digital rectal examination (DRE) has been commonly employed as a trauma screening tool since the inception of the ATLS program. Because of weak evidence, its utility as a screening test has recently been questioned. The primary goal of this study was to identify the sensitivity of the DRE for detecting blunt urethral injuries in a level 1 trauma center. The secondary goal was to evaluate the interaction of DRE with additional clinical indices of urethral trauma.

Methods

A retrospective review of all blunt injured patients diagnosed with a urethral disruption at an urban level 1 trauma center from 1995 to 2008 was performed. Urethral injuries were diagnosed by retrograde urethrogram, urethroscopy and operative exploration. Demographics and injury data were collected. The value of the DRE in diagnosing urethral trauma was assessed (p = 0.05).

Results

Urethral injuries were diagnosed in 41 male patients (mean age = 39 years), 34 (83%) of whom were injured via a motor vehicle (median ISS = 21). Associated injuries were present in 40 (95%) patients, including 39 (95%) pelvic fractures. No clinical signs of urethral injury were evident on initial examination in 25 (61%) patients. All patients had hematuria after catheter insertion. An abnormal prostate on DRE, blood at the urethral meatus, and hematuria prior to catheter insertion was present in 1 (2%), 8 (20%) and 7 (17%) patients, respectively. Both meatal blood and hematuria were better screening tests than the DRE (p < 0.05).

Discussion

The sensitivity of the DRE for identifying urethral disruption is 2%. The majority of patients with urethral trauma undergo urinary catheterization prior to diagnosis of the injury. Additional signs of disruption including meatal blood and hematuria detected prior to catheter insertion are also infrequent. While the DRE remains clinically indicated in patients with penetrating trauma in the vicinity of the rectum, pelvic fractures, and spinal cord injuries, it appears to be insensitive for detecting blunt urethral injuries.     

The significance of contrast blush on computed tomography in children with splenic injuries

Purpose

Most children and adults with blunt splenic injuries are treated nonoperatively by well-established management protocols. The “blush sign” is an active pooling of contrast material within or around the spleen seen during intravenous enhanced computed tomography (CT) scan. Adult treatment algorithms often include the “blush sign” as an indication for embolization or surgical intervention. This study was designed to evaluate the implications of the “blush sign” in children with blunt splenic injuries.

Methods

A review was performed of all children with blunt splenic injuries treated between January 1996 and December 2001 at a level I pediatric trauma center using an established solid organ injury protocol. The demographic, CT imaging, and outcome data were recorded. Treatment was categorized as operative or nonoperative. A single pediatric radiologist retrospectively reviewed all available CT scans to confirm injury grade and the presence or absence of a “blush sign.”

Results

There were 133 eligible children admitted with blunt splenic trauma, with a mean age of 9.1 years (range, 1 to 15), including 86 children with an abdominal CT available for review. A “blush sign” on initial CT scan was noted in 6 children, all with grade 3 or above splenic injuries, 5 of who were treated nonoperatively. In this series, the single child with a “blush sign” who did not respond to nonoperative treatment had a severe polytrauma requiring urgent splenectomy and left nephrectomy. None of the children died of their splenic injury.

Conclusions

Although associated with higher grades of injury, the blush sign did not mandate embolization or surgical intervention in children with blunt splenic trauma in this series. Severe splenic injuries with a blush sign on the initial CT scan may be successfully treated nonoperatively when using an established treatment protocol. Management should be based primarily on physiological response to injury rather than the radiologic features of the injury.     

Exhaust burns in children

Background

Contact thermal injuries appear the second most frequent cause for burns in children seen at our unit. Burns caused by hot exhaust systems represent an important subgroup, as these injuries carry the potential for considerable morbidity.

Methods

A retrospective review of the Burns Unit database was conducted from January 2003 to January 2008. All patients referred to our unit with burns caused by contact with an exhaust system were included. The morbidity associated with each injury was determined by recording the need for surgical intervention, days taken to heal and the number of hospital visits required.

Results

A total of 97 patients were identified, of which 71 were male (M:F; 2.7:1). Age ranged from 5 months to 15 years. The mechanisms involved were contacts with the exhaust systems of motorbikes, including mini-bikes and Pee-Wee bikes (77), cars (14), lawnmowers (5) and quad-bikes (1). The injuries most commonly occurred during the summer holiday months (n = 36, 37%). The Total Body Surface Area (TBSA) ranged from 0.5% to 8%, although injuries measuring 1% or less accounted for 60% of the total. More than two-thirds of the injuries were located on the lower extremity, with the calf being the most common site. Surgical intervention was required in 33% of the cases. The average time taken for complete healing was 20 days with an average of 3.5 visits made for each injury.

Conclusions

The rate of surgical intervention and days to healing clearly demonstrate the morbidity associated with these injuries. In addition the time, effort and money spent for their management appear considerable. A concerted effort must be made to raise public awareness regarding these injuries with a focus on educating people on the hazards of the equipment and the use of appropriate protective gear.     

Is dopexamine superior to dopamine in the treatment of multiple trauma patients—A prospective, double-blind, randomised study

Background

The goal of this prospective, randomised, double-blind clinical trial study was to assess the effects of dopexamine hydrochloride on organ failure, inflammatory mediators and splanchnic oxygenation in blunt multiple trauma patients at high risk of multiple organ dysfunction syndrome (MODS).

Methods

We performed a prospective randomised controlled trial on 30 consecutive blunt multiple trauma patients with ISS ≥ 16, age 18-60 years and initial blood pressure ≥120 mmHg initially admitted to our level I trauma centre. Patients were randomised to treatment with dopamine (n = 15) or dopexamine (n = 15) for 48 h after admission. Outcome in terms of mortality, MODS, splanchnic perfusion, complications, duration of stay was statistically analysed.

Results

Dopexamine treatment was associated with impaired organ function and an increased duration of ventilation and ICU stay compared with patients who received dopamine treatment. The acute inflammatory response was increased in the Dopexamine group while a decreased pHi and MEGX formation and increased serum lactate levels were measured.

Conclusions

The indication to use dopexamine hydrochloride appears questionable. In the absence of an antiinflammatory effect, dopexamine demonstrated a disadvantageous ICU course in regards to the organ function and the duration of treatment. In addition, a decreased pHi and MEGX formation suggested a deterioration of splanchnic oxygenation.     

Local complications following pancreatic trauma

Background

Major trauma to the pancreas is uncommon, but associated with significant overall morbidity and mortality. A vast majority of these adverse outcomes can be attributed to the presences of associated injuries. Among those patients who survive the initial injury, however, the subsequent development of pancreas-related complications represents a significant source of adverse outcomes.

Methods and results

A total of 257 patients admitted from January 1996 to April 2007 were identified from the trauma registry database at our institution. One hundred and eighty-three patients surviving more than 48 h after admission were selected for analysis. These patients were grouped according to the surgical management utilised to address their pancreatic injuries: either resection or operative drainage. After exclusion of patients with associated vascular injuries, those undergoing drainage had lower rate of associated hollow viscus injuries (51.9% vs. 69.9%; p = 0.016) and lower rates of associated solid organ injuries (44.2% vs. 70.9%; p ≤ 0.001). Patients undergoing drainage were noted to have a higher incidence of pseudocyst formation (19.5% vs. 9.0%; OR: 2.47, 95% CI, 0.92-6.67; p = 0.068), but lower hospital lengths of stay (18.7 ± 18.5 vs. 33.8 ± 63.5; p = 0.001). No difference in mortality was noted between the two populations (5.7% vs. 3.0%; p = 0.700). After multivariate analysis pseudocyst formation was the only complication that proved different between the two management groups, with patients undergoing operative drainage more commonly developing this adverse sequela (OR: 2.93, 95% CI, 1.02-8.36; p = 0.041).

Conclusions

In the absence of vascular injury, the choice of surgical management did not affect adjusted mortality or the overall occurrence of pancreas-related complications. Individuals treated with operative drainage alone, however, were significantly more likely to develop a post-operative pseudocyst than their resectional counterparts.     

Screening cervical spine MRI after normal cervical spine CT scans in patients in whom cervical spine injury cannot be excluded by physical examination

Background

Cervical spine injuries can occur in as many as 10% of patients with blunt trauma with mental status changes from closed head injuries. Despite normal results on cervical spine computed tomography (CT), magnetic resonance imaging (MRI) is often recommended to exclude ligamentous or soft tissue injury.

Methods

A retrospective review was conducted of trauma patients admitted to a level I trauma center from 2002 to 2006, in whom cervical spine injuries could not be excluded by physical examination. All patients with normal results on cervical spine CT followed by cervical spine MRI were included in the analysis.

Results

One hundred twenty patients underwent MRI to examine their cervical spines. Seven patients had abnormal MRI findings suggestive of acute traumatic injury. No MRI studies led to operative intervention. Screening MRI increased from 1% of comatose patients in 2002 to 18% in 2006.

Conclusions

The use of MRI in patients with normal results on cervical spine CT does not appear to alter treatment.