Fatal road accidents in Birmingham: Times to death and their causes

The intervals between injury and death in the 254 fatalities after road traffic accidents in Birmingham during 1969 and 1970 were analysed and correlated with other data. Sixty-three per cent were pedestrians and 23 per cent were passengers and drivers of vehicles. In round figures, about a third of the series died within half an hour, a half by 2 hours, two-thirds by 24 hours, and three-quarters by 2–4 days. The patterns of survival-time could be divided into three phases. There was an early steep decline, with 36 per cent dying during the first half-hour and 44 per cent within 1 hour of the accidents. This was followed by a longer stage during which the rate of dying decreased progressively in logarithmic fashion. The cumulative tolls were 51 per cent by 2 hours, 58 per cent by 4 hours, 68 per cent by 24 hours, and 83 per cent by 7 days. The curve then flattened into a prolonged tail. Between 7 and 28 days another 10 per cent died, making 93 per cent by 28 days. The remaining 7 per cent succumbed during the subsequent weeks and months, 3 patients surviving longer than a year.

Fifty-six per cent of vehicle occupants and 40 per cent of pedestrians died within an hour of injury, and the excess of rapid deaths among vehicle occupants was mainly due to a higher proportion of rupture of the aorta. All the ruptured aortae in vehicle occupants occurred after accidents at night or the early hours of the morning. Many of the affected drivers and passengers had consumed alcohol and their injuries were more rapidly lethal than after accidents at other times. Serious cerebral trauma dominated all groups of road users and multiple injuries were common. Included among the fatality tail was a group of subjects, mainly pedestrians, with relatively modest injuries who might have survived had they not developed pulmonary embolism, respiratory infection, or other complications.     

Self-inflicted rotation osteotomy of the tibia

A case is described in which two accidental injuries were instrumental in correcting bilateral club feet. The role of rotation osteotomy in the correction of deformity of the foot is discussed.     

Multiple fractures of the pelvis with an unusually wide disruption of the symphysis pubis sustained in an accident shortly after childbirth: a case report,

A case of multiple fractures of the pelvis with wide separation of the pubic bones associated with other extensive injuries is reported. The diastasis of the symphysis pubis was reduced with surprising ease at operation. A pink discharge from the vagina was seen at the operation, but its significance was only clear after 3 days when the patient revealed that she had given birth to a child on the day before the accident. The soft relaxed pelvic and sacro-iliac ligaments associated with pregnancy prevented damage to the sacro-iliac joints and made it easy to reduce the disrupted symphysis.     

Blast injuries to the lungs: clinical presentation,management and course

Five patients with blast injuries to the lungs after bomb explosions are reported. In each patient radiological changes were apparent on the initial chest film taken within 4 hours of the explosions. Arterial hypoxaemia was also present. Four patients were actively treated with continuous positive-pressure ventilation, which was adjudged effective therapy. Two patients died, one owing to bilateral pneumothorax which occurred during anaesthesia, and the other owing to overwhelming infection. Hypoxaemia persisted for 4 months in one of the survivors. Lung function tests which were performed on the same patient 10 months after the blast injuries, however, were normal.     

Mechanical factors in the prediction of integrity of the gastrojejunal anastomosis in ex-vivo RYGB models

BackgroundSurgical staplers represent one of the important instruments in modern surgery. Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric procedures. Various techniques have been described for performing gastrojejunal (GJ) anastomosis, including linear stapled anastomosis (LSA), circular stapled anastomosis (CSA) and hand-sewn anastomosis (HSA).ObjectivesAn ex-vivo porcine-based experiment was designed to compare the mechanical integrity of the GJ anastomosis among the 3 different techniques by measuring burst pressure (BP).SettingLaboratory-based study conducted at the clinical skills laboratory at Birmingham Heartlands Hospitals, Birmingham, United Kingdom.MethodsPorcine stomachs and small bowels were used to create a GJ model. Four GJ anastomosis models each were created using circular stapler (CSA group) and hand-sewn techniques (HSA group). Stomach and small bowel thickness were recorded. BP was measured by sequential injections of methylene-blue diluted saline until a leak was detected. Total volume until leak is recorded. Compliance (C) was calculated using the formula C = ΔP/ΔV.ResultsResults from our previous experiment for the LSA group are included. One model was excluded from the CSA and the HSA groups due to technical errors. Results were presented as mean ± standard deviation. Total volume in LSA, CSA, and HSA groups was 60 ± 4.08 mL, 73.67 ± 3.22 mL, and 51.67 ± 20.21 mL, respectively. BP in LSA, CSA, and HSA groups was 18 ± 4.69 mm Hg, 20.33 ± 5.77 mm Hg, and 9.67 ± 3.79 mm Hg, respectively. There was a statistically significant difference in BP among the 3 groups (P = .033; Kruskal-Wallis test). C in LSA, CSA, and HSA were 3.50 ± .88 mm Hg/mL, 3.78 ± .85 mm Hg/mL, and 5.39 ± 1.34 mm Hg/mL, respectively (P = .064).ConclusionBP was higher in CSA and LSA groups compared with the HSA group, suggesting a mechanically stronger anastomosis. Despite the lack of statistical significance, higher BP recorded in the CSA group than in the LSA group suggests better anastomotic integrity.     

ChitoHeal gel use on the nasal site for prevention of N95 masks caused pressure injuries: A randomised clinical trial

Prolonged use of personal protective equipment can cause pressure injuries on the skin. The current study was conducted with the aim of investigating the effect of ChitoHeal gel on the nasal site on the prevention of N 95 masks that caused pressure injuries in nurses working in intensive care units. This is a randomised controlled clinical trial that was conducted in 2022. The study sample consisted of 92 nurses working in the intensive care units. A randomised block method was used to allocate the nurses to two equal groups of intervention and control. However, in the intervention group, ChitoHeal gel was applied on nurses' nose bridge. To perform this, the researcher referred to the department during the morning and evening shifts and applied the gel on nurses' nose bridge at the beginning of each shift. Then, the N95 mask was installed on the face by the nurse. Before and at the end of each work shift, the skin in both groups was assessed for any signs of pressure injuries. No significant differences were observed between the two intervention and control groups in terms of demographic variables. The frequency distribution of mask-caused pressure injuries on nurses' nose bridge in the two groups was analysed using the Chi-square test (Fisher's exact test). The results showed that after the intervention, it was 0 in the intervention group. However, 4 nurses (8.6%) in the control group developed pressure injuries, and this difference between the two groups was statistically significant (P > .05). The result of the current study showed that the use of ChitoHeal gel is effective in preventing N95 mask-related pressure injuries. Considering the cheapness and rational global availability of this gel, it seems that its use is an effective strategy in order to prevent N95 mask-related pressure injuries. Given the lack of studies in this regard, similar studies are strongly recommended to be conducted.     

The effect of pentoxifylline in treatment of skin degloving injuries: an experimental study

BACKGROUND: Management of skin degloving injuries is still a problematic issue and the avulsed part of the skin may become necrotic. In this pilot study, we attempted to develop an experimental model for degloving injuries and investigated the efficacy of pentoxifylline, a well-known potent agent in enhancement of erythrocyte flexibility and tissue vascularization, in treatment of this injury model. METHODS: Degloving injuries were created in 15 rats' tails by circular puncturing of the skin at the middle of the tail and then applying moderate force to avulse the skin from the underlying tissue. Then, the skin was repaired back to its original position. No treatment was given in the first group (n=6). In the second group (n=3), 0.4cm(3) physiological serum was administered intraperitoneally for 10 days. In the third group (n=6), intraperitoneal 25mg/kg pentoxifylline was administered for 10 days. Tails were observed daily for 21 days and then examined histopathologically. RESULTS: At the end of the study, the avulsed segment of the skin became cyanotic and ulcerated in the first and the second group, and in the third group, the skin was intact. In histopathological examination, loss of superficial ephitelium and dense infiltration of inflammatory cells were seen in groups 1 and 2, and the skin layers were normal in the group 3. CONCLUSION: Pentoxifylline improved tissue preservation and was proved to be highly beneficial in treatment of skin degloving injuries.     

Effect of trospium chloride on urodynamic parameters in patients with detrusor hyperreflexia due to spinal cord injuries. A multicentre placebo-controlled double-blind trial.

In a multicentre placebo-controlled double-blind study 61 patients with spinal cord injuries and detrusor hyperreflexia were treated: 20 mg trospium chloride was given twice daily over a period of 3 weeks. Pre- and posttreatment urodynamic measurements demonstrated large improvements in maximum cystometric capacity (mean = 138.1 ml), decreased maximum detrusor pressure (mean = -37.8 cm H2O) and an increase in compliance (mean = 12.1 ml/cm H2O) in the treatment group. Urodynamic parameters in the placebo group remained substantially unchanged. Comparisons between the two groups revealed highly significant differences for these parameters (all, p less than 0.001). No effect on maximum flow rate and residual urine was detected in either group. The incidence of spontaneously reported side-effects was extremely low and comparable for both groups.     

An analysis of the post-mortem findings in the 21 victims of the Birmingham pub bombings.

On the evening of 21 November, 1974 explosions occurred almost simultaneously in two crowded public houses in the centre of Birmingham. Of the 21 people who died, 18 were killed outright and 3 died later in hospital. All 21 cases showed the terrible multiple injuries associated with close proximity to a powerful explosion within a confined space. Although all the victims suffered one or more injuries which alone would have been fatal, certain patterns of injury were noted which, if appreciated early in any future similar incident, may help to save the lives of those who are futher removed from the centre of the explosion or exposed to one of lesser force.     

Capsulectomy of the metacarpophalangeal and proximal interphalangeal joints.

From July 1975, through March, 1978, 105 metacarpophalangeal joint capsulectomies in 37 patients, 47 dorsal proximal interphalangeal (PIP) capsulectomies in 26 patients, and 65 volar PIP capsulectomies in 41 patients were performed. The procedures were done after conservative methods had failed, and the results were tabulated in each area by diagnostic category. In the major group in which stiffness resulted from fracture and crushing injuries, average gains of 13 degrees to 18 degrees of active motion were achieved, with a change in arc of motion, while nerve paralysis patients did substantially better. The study should clarify expectations from the procedure; functional gains may still be significant.     

Renal trauma: re-evaluation of the indications for radiographic assessment

We studied prospectively 359 consecutive patients with blunt (306) or penetrating (53) renal trauma to refine the indications for radiographic evaluation. Various factors, including the degree of hematuria, presence of shock and associated injuries easily assessable at the time of initial evaluation, were correlated with the severity of renal injury to determine whether any combination of parameters will separate patients with renal contusions from those with significant renal injuries (minor and major lacerations, and vascular injuries). We identified 3 groups: group 1-85 patients with gross hematuria or microscopic hematuria and shock after blunt trauma (including all 23 with significant renal injuries), group 2-221 patients with microscopic hematuria but no shock after blunt trauma (all with renal contusions) and group 3-53 patients with penetrating trauma. No combination of parameters was able to predict a severe injury in group 3. Our data support radiographic evaluation in groups 1 and 3. However, because all patients in group 2 had renal contusions and experienced no complications from nonoperative management we believe that excretory urography, which is time-consuming and costly, can be avoided in patients with microscopic hematuria but no shock after blunt renal trauma.     

Mechanical circulatory support decreases neurologic complications in the treatment of traumatic injuries of the thoracic aorta.

The surgical treatment of traumatic injuries of the thoracic aorta is controversial because a number of technical approaches have been recommended. Despite the technique employed, spinal cord ischemia continues to be a persistent problem. Nineteen patients with confirmed aortic injuries secondary to blunt trauma were treated at the Yale-New Haven (Conn) Medical Center from 1984 to 1991. The patients were analyzed in two groups: group 1 (n = 10) underwent repair using mechanical circulatory support and group 2 (n = 9) underwent repair without mechanical circulatory support. Sixteen patients survived. Three patients died of complications of multiple trauma. The groups were comparable with respect to aortic cross-clamp time, preoperative systolic blood pressure, and Injury Severity Score. Three patients in the nonmechanical support group developed neurologic complications (P less than .05). No patient in the mechanical support group had a neurologic complication. We believe that mechanical circulatory support reduces the incidence of neurologic complications following traumatic injuries of the thoracic aorta and should be used whenever clinically feasible.     

Traumatic ruptures of the aorta: a clinico-pathological study

Thirty-seven subjects with traumatic ruptures of the aorta coming to necropsy between 1958 and 1975 were analysed. All had been involved in road accidents and most had suffered multiple injuries. Most had survived to be admitted to hospital, and 25 lived for up to 13 days. The ruptures can be divided into those in (a) the ascending aorta (7 cases), (b) the proximal descending aorta (25 cases) and (c) the distal descending thoracic aorta (5 cases). Ruptures of the distal thoracic aorta were confined to pedestrians and motor cyclists with local hyperextension dislocations of the spine. Occupants of vehicles suffered ruptures of the proximal descending aorta (15 cases) or the ascending part (2 cases).All tears were transverse and internal, involving intima and media. The adventitia was intact though usually haemorrhagic. Ruptures of the ascending aorta (2 drivers, 5 pedestrians) were supravalvar and 6 were on the posterior wall. With one exception, these ruptures were associated with severe chest trauma from direct impact.Ruptures of the proximal descending aorta were located 1–3 cm beyond the left subclavian artery. The tears were major in 22 subjects, some of which were circumferential, whilst others affected part of the wall. False aneurysms contained by intact adventitia had formed in those surviving more than a day. In most cases haemorrhage had tracked into the mediastinum, finally rupturing into the pleural cavities, usually the left. However, two immediate survivors died later from complications of other injuries. In 3 subjects, only small subclinical tears were present and similar small ones were found near several major ruptures. Most major and minor ruptures are above the ligamentum arteriosum and on the anterior aortic wall, indicating a mechanism involving cranially directed tension on the aorta. Thoracic injury was also common in these, but was absent in 7 cases (including 3 motor cyclists and 2 pedestrians). This suggested that at least some ruptures result from indirect forces such as body deceleration. One rupture seemed due to a blow directed upwards against the lower chest. Analysis of all road traffic deaths in Birmingham over a 2-year period showed that aortic rupture is a major cause of rapid death among vehicle occupants, and that this is related to accidents at night and alcohol consumption.     

Dislocation of the scaphoid and lunate bones without fracture: a case report

A patient with a dislocation of both lunate and scaphoid bones is described. The position of the hand at the moment of injury seems to have been dorsiflexion and radial deviation. A mechanism for this injury is proposed. Internal fixation in severe carpal injuries is advised.     

Factors influencing mortality and morbidity from injuries to tha abdominal aorta and inferior vena cava.

Fifty patients having undergone operation for injury to the abdominal aorta and/or vena cava at the University of Alabama Hospital are reviewed. Factors influencing mortality include mechanism and location of injury, presence of shock, associated vascular and visceral organ injuries, and delay in treatment. Rapid restoration of blood volume and control of hemorrhage are the primary goals of resuscitative measures. Only with a preconceived and coordinated plan can the surgeon fully employ the necessary skills in the management of these serious injuries.     

The problem of the closed abdominal injury in polytrauma patients]

The histories of 66 patients with blunt abdominal trauma requiring surgery in the period from 1985 to 1989 were analysed. The patients were divided into three groups on the basis of the other injuries present. Group I, isolated blunt abdominal trauma and blunt abdominal trauma with slight concomitant injuries (18 patients, ISS 17.17 +/- 1.40); group II, blunt abdominal trauma with severe concomitant injuries but without craniocerebral trauma (23 patients, ISS 29.34 +/- 1.45); and group III, blunt abdominal trauma with severe concomitant injuries and an additional craniocerebral trauma (25 patients, ISS 31.08 +/- 1.27, GCS: 10.04 +/- 0.88). Initially, the diagnosis was made in 23 cases by means of diagnostic peritoneal lavage and in 43 cases by means of sonography. The subsequent laparotomy revealed the ultrasound findings to have been false-positive in 3 cases. No false-negative ultrasound findings were demonstrated at all. Peritoneal lavage, on the other hand, was found to have yielded false-negative and false-positive findings in 2 cases each. Counting from the time of admission, the time up to diagnosis of the intra-abdominal injury was 85 +/- 14.3 min in group I, 82 +/- 9.9 min in group II, and 86 +/- 12.9 min in group III. Thus, the presence of severe additional injuries did not lead to any significant delay in the diagnosis of blunt abdominal injury requiring surgery. The total mortality rate was 18.18% (group I, 11.1%; group II, 21.7%; group III, 20.0%). Six patients died in the acute phase and a further six patients during their stay on the intensive care ward.     

Injury and pregnancy

This subject receives very little attention in textbooks and most of the articles in journals report small numbers of injuries of one kind or another. One general review suggests that between 5 and 10 per cent of pregnant women suffer injury, usually with no risk to the pregnancy: for example, the incidence of abortion ascribed to accidental injury is less than 1 in 10,000. Personal and reported experience can be summarized as follows. The baby may be injured during pregnancy or during birth, or may be harmed by the effects or complications of injury to the mother, e.g. Gram-negative septicaemia or hypoxic states. Injuries inflicted on the baby during pregnancy are most often fractures, which affect the skull almost as often as any other bone, and frequently accompany fractures of the mother's pelvis. Gunshot and other penetrating injuries of the child are rare and are not always fatal. Fractures of the maternal pelvis are the most frequent of the major injuries and are serious to viscera and other parts of the body. In some patients deformation of the pelvis can be corrected or prevented by operation, but it is usually best accepted. Rigid internal fixation of fractures of the lower limbs sustained in the later months of pregnancy can make labour much easier for the patient and her attendants. If the effect of injury on pregnancy is usually obvious, the effect of pregnancy on recovery from injury is usually not.     

CERVICAL SPINE INJURIES IN ROAD TRAFFIC CRASHES IN SOUTH AUSTRALIA, 1981–86

The records of all cases of injury to the cervical spine sustained in road crashes for the 6 year period (1 january 1981 to 31 december 1986) which were admitted to the spinal injuries unit of the royal adelaide hospital to the adelaide children's hospital, or were identified at post-mortem examination were examined and the relevant data extracted. There were 291 cases in the non-fatal group, and 161 in the fatal group. These represent a complete enumeration of all such patients in the state of south australia over the 6 year period, given that up to 50% of cervical injuries in fatal cases can be missed. Comparison of the two groups showed that the fatal group had a much higher proportion of pedestrians, and persons over 50 years of age. About one-half of the fatal group had injuries at the level of ci or the atlanto-occipital articulation. The most frequent level of injury in the non-fatal group was c2 (29.2%). About 30% of the non-fatal cases had some spinal cord damage. Case fatality rates were calculated, and ranged from 100% for injury at the atlanto-occipital articulation to 8% at c2. The fatality rate of pedestrians was about 4 times higher than that of vehicle occupants. About three-quarters of all cervical spine injuries occurred in vehicle occupants. There was an increase in the number of cases occurring in each year of the period studied. This rise was noted in non-fatal cases, in males, in vehicle occupants, and in crashes in the country.     

重型颅脑创伤早期使用自配匀浆膳肠内营养支持的临床研究

目的探讨自配匀浆膳在重型颅脑损伤后早期肠内营养支持中的作用。方法本研究是单中心、前瞻性、随机对照的临床研究。132例重型颅脑损伤患者随机分成自配匀浆膳组、商品营养液组和普通膳食组。在伤后早期（〈72h）给予肠内营养支持,比较各组在营养状态、血清蛋白水平、相关并发症及预后的差异。结果自配匀浆膳组与商品营养液组相比,在改善患者营养状态、血清生化指标及临床预后方面差异无显著性（P〉0.05）。自配匀浆膳组与普通膳食组比较．在改善临床预后及营养状态上有明显优势（P〈0.05）。结论重型颅脑损伤后早期应用自配匀浆膳肠内营养支持具有较好的耐受性,是一种简单、经济、有效的方法,有助于提高患者抗病能力并改善预后。     

Comparison of two percutaneous pinning methods for the treatment of the pediatric type III supracondylar humerus fractures

Fifty-nine surgically treated cases of type III supracondylar humeral fractures were retrospectively evaluated. Fracture fixation was performed by either crossed K-wires in 35 patients (group I) or lateral K-wires in 24 patients (group II). The reoperation rates and neural injury rates as major complications were similar in the two groups and all neural injuries except one had full recovery. At the last follow-up exam six patients in group I (17%) and four patients in the group II (16%) had apparent cosmetic deformities. No major differences were found between the results of each group. In order to reduce complications an experienced supervision is necessary during surgery of these seemingly benign fractures.