Patients with pelvic fracture: what factors are associated with mortality?

Background

Pelvic fracture is one of the major injuries that lead to death in patients who sustain high-impact injuries such as road traffic accidents and falls from height.

Aims

This study aims to look at the epidemiology and the significant predictors of mortality in victims with pelvic fracture presenting to the emergency department (ED) of an urban Asian city.

Methods

This was a retrospective data analysis of all trauma patients with pelvic fracture who were treated at the ED of an urban adult hospital in Singapore from April 2001 to December 2004. Student’s t-test and χ² test were used in statistical analysis where appropriate.

Results

The study included 179 consecutive patients. Sixty-four percent of patients were males, and 71% of patients were in the 20–49-year-old age group. Road traffic accidents and falls from height were the two most common mechanisms of injury. Mortality rate was 37%. Pelvic fracture severity, shock and coma at presentation, and the presence of concurrent head and chest injuries were associated with increased mortality. Gender, other mechanisms of injury and other concomitant injuries were not associated with increased mortality.

Conclusions

The mortality rate of trauma patients with pelvic fracture continues to be high. In such patients, predictors of mortality are the severity of the pelvic fracture, the presence of coma, shock, and head and chest injuries.     

Preparedness of emergency departments in northwest England for managing chemical incidents: a structured interview survey

Background

Ocular injuries are common in survivors of terror incidents that involve the use of explosive materials. These explosives are commonly of a High Explosive type (HE) and may be fashioned into improvised explosive devices (IED) that incorporate additional materials to maximise trauma and injuries. Serial IED explosions have occurred in commuter trains in several cities including London and Madrid but data on ocular injuries is limited. We report the ocular injuries of the survivors of a series of IED explosions in crowded commuter trains.

Methods

28 patients (56 eyes, 28 male, ages ranging from 22 to 52 years (mean 35.27 years) were screened in the triage area or the Intensive Care Unit (ICU). Testing included bedside visual acuity testing, torchlight examination of the anterior segment and dilated (or if necessary, undilated) fundus examination. Selected patients underwent B-scan examination, magnetic resonance imaging of the brain, orbits and the optic nerves or visual evoked potential assessment. The injuries, investigations and procedures were entered into the patient's case sheet as well as into a standardised format suggested by the Indian eye injury registry (IER).

Results

16 of 28 patients (57.1%) had ocular injuries whereas 12 (42.8%) were found to be normal. Injuries were seen unilaterally in 10 patients and bilaterally in six yielding a total of 22 injured eyes. The common injuries were periorbital haemorrhages (09 eyes, 40%); first or second degree burns to the upper or lower lids (seen in 07 eyes, 31.8 %) and corneal injuries (seen in 08 eyes, 36.3%). Open globe injuries were seen in two eyes of two patients (09%). One patient (4.5%) had a traumatic optic neuropathy.

Conclusion

Ophthalmologists and traumatologists should be aware of these patterns of ocular injuries. Protocols need to include the screening of large numbers of patients in a short time, diagnostic tests (B scan, visual evoked potential (VEP) etc) and early surgery preferably at the initial triage itself as most of the serious injuries in our studies had been missed or not treated at an initial assessment.     

Epidemiology of injuries presenting to the national hospital in Kampala, Uganda: implications for research and policy

Background

Despite the growing burden of injuries in LMICs, there are still limited primary epidemiologic data to guide health policy and health system development. Understanding the epidemiology of injury in developing countries can help identify risk factors for injury and target interventions for prevention and treatment to decrease disability and mortality.

Aim

To estimate the epidemiology of the injury seen in patients presenting to the government hospital in Kampala, the capital city of Uganda.

Methods

A secondary analysis of a prospectively collected database collected by the Injury Control Centre-Uganda at the Mulago National Referral Hospital, Kampala, Uganda, 2004-2005.

Results

From 1 August 2004 to 12 August 2005, a total of 3,750 injury-related visits were recorded; a final sample of 3,481 records were analyzed. The majority of patients (62%) were treated in the casualty department and then discharged; 38% were admitted. Road traffic injuries (RTIs) were the most common causes of injury for all age groups in this sample, except for those under 5 years old, and accounted for 49% of total injuries. RTIs were also the most common cause of mortality in trauma patients. Within traffic injuries, more passengers (44%) and pedestrians (30%) were injured than drivers (27%). Other causes of trauma included blunt/penetrating injuries (25% of injuries) and falls (10%). Less than 5% of all patients arriving to the emergency department for injuries arrived by ambulance.

Conclusions

Road traffic injuries are by far the largest cause of both morbidity and mortality in Kampala. They are the most common cause of injury for all ages, except those younger than 5, and school-aged children comprise a large proportion of victims from these incidents. The integration of injury control programs with ongoing health initiatives is an urgent priority for health and development.     

The epidemiology of childhood injury in Maputo, Mozambique

Background

Injury remains a major cause of death and disability worldwide.

Aims

This study describes the characteristics of childhood injury at three hospitals in Maputo, Mozambique.

Methods

An observational, prospective convenience study was conducted in June and July 2007. We prospectively collected data on 335 children (0–14 years) who presented to three hospitals in Maputo during the study period.

Results

The prevalence of trauma-related complaints on presentation to the hospital in this study was 12%, with higher rates in boys (59%) and in those between the ages of 5–9 years (34.9%). Falls were the most common mechanism of injury (40.6%), followed by burns (19.1%) and road traffic injuries (RTI) (14.3%). The majority of falls occurred in the home (61.8%) and were unintentional. (94.1%) Burns were predominantly due to hot liquids (82.8%) and less frequently due to fire (17.2%). The majority of burns involved the patient alone (62.5%). The majority of RTIs were pedestrians struck by vehicles (81.2%). A substantial number of patients presented more than 24 h after injury (23.3%). Children from households living with a lower family income in general suffered trauma more often regardless of the mechanism.

Conclusions

Childhood injury accounts for a substantial burden of disease in Maputo, Mozambique. This study highlights the fact that many of these injuries are consistent with the injury patterns seen in children in other low and middle income countries, and are amenable to prevention, access, and emergency care programs targeted at children and their families, schools, and the local and national community.     

Motocross-associated head and spine injuries in adult patients evaluated in an emergency department

Background

Motor vehicle–related injuries (including off-road) are the leading cause of traumatic brain injury (TBI) and acute traumatic spinal cord injury in the United States.

Admission hypo- or hyperthermia and survival after trauma in civilian and military environments

Background

In the care of patients with traumatic injuries, focus is placed on hypothermia secondary to its deleterious impact on the coagulation cascade. However, there is scant information on the mortality effect of hyperthermia.

Study objectives

We hypothesized that both hypothermia and hyperthermia are associated with decreased survival in patients with traumatic injuries. Furthermore, we hypothesized that in the military setting, the incidence of hyperthermia would be greater compared to the civilian environment and thus contributing to an increase in mortality.

Methods

Registries compared were the National Trauma Data Bank (NTDB), three civilian Level I trauma centers, and military combat support hospitals. The NTDB was used as a reference to define hypothermia and hyperthermia based upon survival. Admission temperature and outcome were known for 4,093 civilian and 4,394 military records.

Results

Hypothermia was defined as < 36°C and hyperthermia > 38°C as mortality increased outside this range. The overall mortality rates were 3.5% for civilians and 2.5% for military (p < 0.05). Of civilians, 9.3% (382) were hypothermic and 2.2% (92) hyperthermic. The incidence of hypothermia in the military patients was 6.0% (263) and for hyperthermia the incidence was 7.4% (327). Irrespective of group, patients with hypothermia or hyperthermia had an increased mortality compared to those with normal temperatures, ([for civilian:military ] hypothermia 12%:11%; normal 2%:2%; hyperthermia 14%:4%).

Conclusion

Care of the victim with traumatic injuries emphasizes avoidance of hypothermia; however, hyperthermia is also detrimental. The presence of hypothermia or hyperthermia should be considered in the initial treatment of the patient with traumatic injuries.

     

One year ago not business as usual: Wound management, infection and psychoemotional control during tertiary medical care following the 2004 Tsunami disaster in southeast Asia

Introduction

Following the 2004 tsunami disaster in southeast Asia severely injured tourists were repatriated via airlift to Germany. One cohort was triaged to the Cologne-Merheim Medical Center (Germany) for further medical care. We report on the tertiary medical care provided to this cohort of patients.

Methods

This study is an observational report on complex wound management, infection and psychoemotional control associated with the 2004 Tsunami disaster. The setting was an adult intensive care unit (ICU) of a level I trauma center and subjects included severely injured tsunami victims repatriated from the disaster area (19 to 68 years old; 10 females and 7 males with unknown co-morbidities).

Results

Multiple large flap lacerations (2 × 3 to 60 × 60 cm) at various body sites were characteristic. Lower extremities were mostly affected (88%), followed by upper extremities (29%), and head (18%). Two-thirds of patients presented with combined injuries to the thorax or fractures. Near-drowning involved the aspiration of immersion fluids, marine and soil debris into the respiratory tract and all patients displayed signs of pneumonitis and pneumonia upon arrival. Three patients presented with severe sinusitis. Microbiology identified a variety of common but also uncommon isolates that were often multi-resistant. Wound management included aggressive debridement together with vacuum-assisted closure in the interim between initial wound surgery and secondary closure. All patients received empiric anti-infective therapy using quinolones and clindamycin, later adapted to incoming results from microbiology and resistance patterns. This approach was effective in all but one patient who died due to severe fungal sepsis. All patients displayed severe signs of post-traumatic stress response.

Conclusion

Individuals evacuated to our facility sustained traumatic injuries to head, chest, and limbs that were often contaminated with highly resistant bacteria. Transferred patients from disaster areas should be isolated until their microbial flora is identified as they may introduce new pathogens into an ICU. Successful wound management, including aggressive debridement combined with vacuum-assisted closure was effective. Initial anti-infective therapy using quinolones combined with clindamycin was a good first-line choice. Psychoemotional intervention alleviated severe post-traumatic stress response. For optimum treatment and care a multidisciplinary approach is mandatory.     

Fireworks type,injury pattern,and permanent impairment following severe fireworks-related injuries

Background

There is a paucity of clinical data on severe fireworks-related injuries, and the relationship between firework types, injury patterns, and magnitude of impairment is not well understood. Our objective was to describe the relationship between fireworks type, injury patterns, and impairment.

The possibility of application of spiral brain computed tomography to traumatic brain injury

Objectives

The spiral computed tomography (CT) with the advantage of low radiation dose, shorter test time required, and its multidimensional reconstruction is accepted as an essential diagnostic method for evaluating the degree of injury in severe trauma patients and establishment of therapeutic plans. However, conventional sequential CT is preferred for the evaluation of traumatic brain injury (TBI) over spiral CT due to image noise and artifact. We aimed to compare the diagnostic power of spiral facial CT for TBI to that of conventional sequential brain CT.

Methods

We evaluated retrospectively the images of 315 traumatized patients who underwent both brain CT and facial CT simultaneously. The hemorrhagic traumatic brain injuries such as epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and contusional hemorrhage were evaluated in both images. Statistics were performed using Cohen's κ to compare the agreement between 2 imaging modalities and sensitivity, specificity, positive predictive value, and negative predictive value of spiral facial CT to conventional sequential brain CT.

Results

Almost perfect agreement was noted regarding hemorrhagic traumatic brain injuries between spiral facial CT and conventional sequential brain CT (Cohen's κ coefficient, 0.912). To conventional sequential brain CT, sensitivity, specificity, positive predictive value, and negative predictive value of spiral facial CT were 92.2%, 98.1%, 95.9%, and 96.3%, respectively.

Conclusion

In TBI, the diagnostic power of spiral facial CT was equal to that of conventional sequential brain CT. Therefore, expanded spiral facial CT covering whole frontal lobe can be applied to evaluate TBI in the future.     

Uncovering the burden of intentional injuries among children and adolescents in the emergency department

Introduction

In low- and middle-income countries, injuries are a leading cause of mortality in children. Much work has been done in the context of unintentional injuries but there is limited knowledge about intentional injuries among children. The objective of this paper was to understand the characteristics of children with intentional injuries presenting to emergency departments in Pakistan.

Methods

The data was from the Pakistan National Emergency Departments Surveillance (Pak-NEDS), conducted from November 2010 to March 2011 in seven major emergency departments of Pakistan. Data on 30,937 children under 18 years of age was collected. This paper reports frequency of intentional injuries and compares patient demographics, nature of injury, and discharge outcome for two categories of intentional injuries: assault and self-inflicted injuries.

Results

Intentional injuries presenting to the emergency departments (EDs) accounted for 8.2% (2551/30,937) amongst all other causes for under 18 years. The boy to girl ratio was 1:0.35. Intentional injuries included assault (n = 1679, 65.8%) and self-inflicted injuries (n = 872, 34.2%). Soft tissue injuries were most commonly seen in assault injuries in boys and girls but fractures were more common in self-inflicted injuries in both genders.

Conclusion

Intentional injury is one of the reasons for seeking emergency treatment amongst children and a contributor to morbidity in EDs of Pakistan. Moreover, such injuries may be underestimated due to lack of reporting and investigative resources. Early identification may be the first step leading to prevention.

     

Efficacy and compliance of a prehospital spinal immobilization guideline

Background

Prehospital spinal immobilization criteria are useful in identifying those at risk for spinal fractures, while reducing the number of patients unnecessarily immobilized. The use of immobilization criteria, without regard to mechanism of injury, has been shown to accomplish this task.

Aims

The study’s purpose is to examine efficacy of a prehospital spinal clearance guideline and triage/management of these injuries.

Methods

This was a retrospective study of traumatically injured patients based on a clinical clearance spinal immobilization guideline between January 2006 and January 2007. Two gold standards were used in the analysis (radiographic findings and physician clearance without radiographs). This project was approved by the Mayo Clinic Institutional Review Board.

Results

The study included 942 patients documented to have a traumatic injury. Of these, 43 (4.6%) had an acute spinal fracture. The guideline allowed 558 (59.2%) patients to be cleared, and 1.3% (7/558) had fractures. The remaining 384 did not meet clearance criteria and accounted for 36 (9.4%, 36/384) fractures. The guideline correctly predicted 36 of 43 fractures. The median age of the 7 fractures not immobilized was 82 years and of the 36 patients with fractures that were immobilized was 48 years. When immobilization was indicated, caregivers were 77.6% (298/384) compliant. Of the noncompliant 22.4% (86/384) there were 9 fractures.

Conclusions

This spinal guideline demonstrates efficacy in identifying those at risk for spinal fractures. An age extreme criteria may enhance this already effective guideline. Further analysis of compliance failures may improve the guideline’s ability for fracture prediction.     

Mortality in patients with loss of consciousness at the scene of trauma

Background and aim:

The aim of this study was to evaluate if loss of consciousness at the scene of an accident in patients with thoracic trauma classified by the Abbreviated Injury Scale (AIS) as thorax >2 has a different outcome in respect to immediate hospital discharge, hospitalization, death and type of accident.

Methods:

A prospective study was performed in the Regional Trauma Center of São José do Rio Preto. All patients with scores related to thoracic injury ≥2 were included in this study. Thus, 134 patients with penetrating and 231 with blunt thoracic injuries were evaluated. The chi-square, Fisher's exact and relative risk tests were utilized for statistical analysis with an alpha error greater than 5% (p?Results: A significantly higher number of patients who lost consciousness (35–33.9%) died compared to those who did not lose consciousness (9–3.5%, Fisher's exact test: p?Conclusion: The loss of consciousness at the time of trauma is a warning sign in patients with thoracic injuries whether associated with other types of injuries or not.     

Topical Yunnan Baiyao administration as an adjunctive therapy for bleeding complications in adolescents with advanced cancer

Purpose

Yunnan Baiyao (White Medicine from Yunnan, YNB) is a Chinese herbal medicinal powder used to stop bleeding and improve circulation in traumatic injuries. We describe the use of YNB in adolescents with cancer as an adjunct to uncontrolled bleeding in the palliative care setting.

Methods

Through a retrospective chart review of all patients receiving integrative medicine consultations at the Integrative Therapies Program at Columbia University from January 1, 2007 to January 31, 2012, we describe the outcome of patients treated with YNB for management of uncontrolled bleeding.

Results

Four patients were identified who received topical YNB for uncontrolled bleeding; patients included two males and two females with diagnoses of solid tumors (n?=?3) and Burkitt’s lymphoma (n?=?1). Mean age was 15.5?years (range 15–17). Fifty percent had life-threatening bleeding from the tumor site and 50?% experienced uncontrollable epistaxis. All patients received preceding therapy with packed red blood cells and platelet transfusions, topical thrombin, and oral aminocaproic acid. Two patients used YNB in the inpatient setting, and all four patients used YNB as outpatients. In all patients, bleeding control improved with the addition of YNB to conventional hemostatic interventions. Two patients using YNB in their home reported control of bleeding episodes. There were no adverse events reported.

Conclusions

YNB may be an efficacious agent for uncontrolled bleeding in conjunction with conventional hemostatic agents in adolescents with advanced cancer. It is well accepted by patients. YNB may be especially valuable in the outpatient setting to prevent the recurrence of hemorrhage.     

Analysis of traumatic injuries presenting to a referral hospital emergency department in Moshi, Tanzania

Background

Injuries represent a significant and growing public health concern in the developing world, yet their impact on patients and the emergency health-care system in the countries of East Africa has received limited attention. This study evaluates the magnitude and scope of injury related disorders in the population presenting to a referral hospital emergency department in northern Tanzania.

Methods

A retrospective chart review of patients presenting to the emergency department at Kilimanjaro Christian Medical Centre was performed. A standardized data collection form was used for data abstraction from the emergency department logbook and the complete medical record for all injured patients. Patient demographics, mechanism of injury, location, type and outcomes were recorded.

Results

Ten thousand six hundred twenty-two patients presented to the emergency department for evaluation and treatment during the 7-month study period. One thousand two hundred twenty-four patients (11.5%) had injuries. Males and individuals aged 15 to 44?years were most frequently injured, representing 73.4% and 57.8%, respectively. Road traffic injuries were the most common mechanism of injury, representing 43.9% of injuries. Head injuries (36.5%) and extremity injuries (59.5%) were the most common location of injury. The majority of injured patients, 59.3%, were admitted from the emergency department to the hospital wards, and 5.6%, required admission to an intensive care unit. Death occurred in 5.4% of injured patients.

Conclusions

These data give a detailed and more robust picture of the patient demographics, mechanisms of injury, types of injury and patient outcomes from similar resource-limited settings.     

Identification of distinct subgroups of breast cancer patients based on self-reported changes in sleep disturbance

Purpose

The purposes of this study were to identify distinct subgroups of patients based on self-reported sleep disturbance prior to through 6 months after breast cancer surgery and evaluate for differences in demographic, clinical, and symptom characteristics among these latent classes.

Methods

Women (n?=?398) who underwent unilateral breast cancer surgery were enrolled prior to surgery. Patients completed measures of functional status, sleep disturbance (i.e., General Sleep Disturbance Scale (GSDS); higher scores indicate higher levels of sleep disturbance), fatigue, attentional fatigue, depressive symptoms, and anxiety prior to surgery and monthly for 6 months.

Results

Three distinct classes of sleep disturbance trajectories were identified using growth mixture modeling. The high sustained class (55.0%) had high and the low sustained class (39.7%) had low GSDS scores prior to surgery that persisted for 6 months. The decreasing class (5.3%) had high GSDS score prior to surgery that decreased over time. Women in the high sustained class were significantly younger, had more comorbidity and poorer function, and were more likely to report hot flashes compared to the low sustained class. More women who underwent mastectomy or breast reconstruction were in the decreasing class. Decreasing and high sustained classes reported higher levels of physical fatigue, attentional fatigue, depressive symptoms, and anxiety compared to the low sustained class.

Conclusions

A high percentage of women has significant sleep disturbance prior to surgery that persists during subsequent treatments (i.e., radiation therapy and chemotherapy). Clinicians need to perform routine assessments and initiate appropriate interventions to improve sleep prior to and following surgery.     

Concomitant injuries and its influence on functional outcome after traumatic brain injury

Abstract

Purpose: This study aims to describe the presence and severity of extracranial concomitant injuries in traumatic brain injury (TBI) patients and to ascertain their effect on long-term functional outcome.

Method: A retrospective cohort study was performed in a single-center recruiting patients with first episode of TBI. The types and severity of extracranial concomitant injuries were documented for patients who fulfilled the inclusion criteria. Injuries with Abbreviated Injury Scale (AIS) grade 3–6 were considered to be high grade. A cross-sectional functional assessment was conducted at 18 months post-injury using Glasgow Outcome Scale.

Results: A total of 100 patients were included in the analysis. Extracranial concomitant injuries were seen in 78% of the patients. Three commonest injuries were facial (44%), lower extremity (20%) and upper extremity (12%) injuries. Among the AIS grade?≥?3, injury involving the chest was most common (41%). Presence of extracranial concomitant injuries AIS grade?≥?3 was significantly associated with disability in TBI patients at 18 months (OR 12.74, 95% CI 2.39–67.95, p?=?0.003).

Conclusion: Presence of extracranial concomitant injuries was high. In TBI survivors, extracranial concomitant injuries AIS grade?≥?3 influenced the long-term functional outcome at 18 months, causing moderate and severe disabilities.

• Implications for Rehabilitation

• Concomitant injuries should be suspected in patients with traumatic brain injury, especially in a high-speed trauma mechanisms as the incidence can be as high as 78% as in this study and may interfere with the long term rehabilitation and outcome.

• This study shows that severe extra cranial concomitant injuries are associated with a poor long term functional outcome even in the mild traumatic brain injury patients and therefore need to be addressed early in the rehabilitation of this group of patients.

• Early diagnosis and management of severe concomitant injuries is warranted and may improve the functional gains in the long term after traumatic brain injury.

     

Zervikogene Kopfschmerzen können eine akute Sinusitis imitieren

Background

For many patients with head- and facial pain and no other symptoms the referral diagnosis of untreatable sinus headache could not be confirmed and cervicogenic head and neck pain was diagnosed by osteopathy. The present study attempts to clarify some aspects regarding cervicogenic complaints.

Study design

A prospective observational study was carried out on adults referred to an ENT practice in 2006.

Patients and methods

A total of 57 patients referred with head and facial pain without any additional sinusitis symptoms were investigated. These included 48 females with an average age of 46 years (range 18–72 years) and 9 males with an average age of 43 years (range 36–70 years). One quarter of the patients had already been treated with up to 3 different antibiotics. The diagnosis included previous medical history, ENT and manual therapeutic status, x-ray and possibly computed tomography imaging of the paranasal sinuses as well as basic neurological and/or orthopedic examinations.

Results

Of the 57 patients with isolated head and facial pain 17% (n=10) had acute sinusitis based on x-ray findings and in general the duration was less than 2 weeks. The remaining 83% (n=47) had cervicogenic headache with a duration of up to 16 weeks (median 4 weeks) and 87% of those were female. In 70% of the patients with cervicogenic complaints, a clear improvement of the pain could be achieved by self-administered isometric and stretching exercises.

Conclusion

Although the present study is small, it could be demonstrated that cervicogenic headache is frequent in women. Most of the patients showed an improvement in symptoms by carrying out self-administered stretching exercises.     

Kraniosakrales System und Funktionsstörungen der oberen HWS bei Säuglingen

Background

It was the aim of this study to find out if the manual -medical treatment of the head joints of KTSS- children with kinematic imbalances due to suboccipital strain (KISS) can cause a change/modificoation of their facial dissymmetry and thus-by this— of the faulty position and function of the bones.

Material and methods

In the surgery 30 infants/babies with functional. disturbances of the head joints and a typical dissymmetry of the face, the skull, and the bearing were examined/treated by means of manual therapy and osteotherapy.

Results

In 20 cases there was a very great or great improvemenat of the facial dissymmetry. The status of 10 children remained unchanged. The dissymmetry of the eyes improved in 23 cases whereas there was no change infor seven 7 children. The cranial dissymmetry became better in 2’1 cases, but remained unchanged in 9 cases.

Conclusion

The effects of manual therapy on infants/Bbabies can be partially understood and explained by eliminating theseas secondary adaptive reactions of the cranio-sacral system in the forim of a torsional lesion of the SBS.