Changing patterns of severe craniomaxillofacial trauma in Auckland over eight years

BACKGROUND: This study was performed to review the changing pattern of incidence of severe craniomaxillofacial (CMF) trauma in Auckland over 8 years (1989-1997) and to audit the involvement of the regional plastic surgery service. METHODS: A review of prospectively collected admission data of patients admitted to the Auckland Hospital Department of Critical Care Medicine (DCCM) with severe CMF trauma during 1997. A comparison is made with similar data from 1989. Injury severity was defined using the Injury Severity Score (ISS). RESULTS: Twenty-six patients with severe CMF trauma were admitted to Auckland Hospital DCCM in 1997. Their average ISS was 35. Eighty per cent had a significant head injury. Sixty-two per cent had injuries due to road traffic accidents (RTA) and 42% had positive blood alcohol levels, including 37% of the RTA victims. Twenty-three per cent had their surgical care provided by the regional plastic surgery service. In 1989, 55 patients were admitted to DCCM with severe CMF trauma. The average ISS was 36. Ninety-five per cent had a significant head injury. Seventy-three per cent had injuries due to RTA and 55% had positive blood alcohol, including 60% of the RTA group. CONCLUSIONS: Patients with severe CMF trauma make up a significant proportion of trauma admissions to DCCM and have a high incidence of life-threatening injuries. A multidisciplinary approach is essential. The nature and severity of these injuries has not changed over the last decade. There has been a clear decrease in the incidence of these injuries. This seems to be due to a profound decrease in the rate of RTA associated with alcohol intoxication.     

Pilot study of injured patients seen in the University of Port Harcourt Teaching Hospital, Nigeria

A 12-month pilot study of injured patients seen in the Emergency Department of the University of Port Harcourt Teaching Hospital was carried out. Trauma (28.8 per cent) was the main reason for emergency visits; 82.1 per cent of the patients were under 31 years of age. Domestic accidents were the commonest cause of trauma (42.5 per cent), followed by criminally motivated injuries (30.4 per cent), road traffic accidents (26.0 per cent), industrial (0.5 per cent) and other accidents (0.6 per cent). The overall mortality rate due to trauma was 5.4 per cent and within the period of study, trauma was the most common cause of deaths in hospital (10.1 per cent). Road traffic accidents were responsible for 67.9 per cent of these deaths, followed by criminally motivated injuries (16.1 per cent). Domestic, industrial and boat accidents caused 7.6 per cent, 5.4 per cent and 3.1 per cent deaths, respectively. Injury Severity Scores (ISS) among 419 patients showed a 100 per cent mortality for those with scores above 35. There were 48 prehospital, 19 emergency room and 14 in-hospital deaths among patients with an ISS below 35. The deaths resulted largely from delayed transportation of victims to the hospital and partly from inadequate emergency medical services. To reduce the current high rate of preventable deaths from injury, we recommend (i) ambulance services for early transportation of victims to the hospital and (ii) improved emergency medical care.     

Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries

This is a retrospective review of 731 patients sustaining diaphragmatic trauma over a 22 year period (1980-2002) at an urban level I trauma center. Patients had an average injury severity score (ISS) of 22 +/- 12. The mortality rate (MR) was 23 per cent (168/731). There were a total of 460 left-sided diaphragmatic injuries (L-TDR), 263 right-sided diaphragmatic injuries (R-TDR), and 8 bilateral diaphragmatic injuries (B-TDR). There were no significant differences in mortality with L-TDR versus R-TDR. Shotgun wounds had the highest MR (42%) (P = 0.0028). Emergency thoracotomies were performed in 31 per cent (225) with a 62 per cent (140) MR. Bilateral thoracotomies had a significantly higher MR of 85 per cent (33/39) compared to the 58 per cent (107/186) for unilateral thoracotomies (P = 0.0028). Multivariate analysis revealed the most significant independent predictors of mortality to be the revised trauma score, transfusion of pRBCs > 10 units, and need for thoracotomy (P < 0.0001). The infection rate was 41 per cent. Multivariate analysis revealed blunt trauma, blood transfusions, ISS, and pancreatic injury as the most significant independent predictors of infection (P < 0.001). The initial physiologic presentation of the patient and the severity of hemorrhagic shock are the primary determinants for survival. Prompt identification of associated injuries with rapid control of bleeding is paramount to survival.     

Auditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care

BACKGROUND: To determine the role of pelvic fractures in auditing mortality resulting from trauma. STUDY DESIGN: This retrospective case-control study based on autopsy-evaluated circumstances of the deaths of patients with pelvic fractures. RESULTS: Of 2,583 patients injured in motor-vehicle collisions, 655 (25.4%) constituted the pelvic fracture (PFx) group, and 1,928 (74.6%) constituted the control group. One-third of the PFx group's fatalities had an Injury Severity Score (ISS) of 75 and were not preventable. The PFx group had a substantially higher median ISS than the control group (50 versus 34; p < 0.0001). Four hundred fifty-four patients (69.3%) in the PFx group with ISS 16 to 74 had substantially higher rates of associated injuries. Nearly half of the PFx group patients with ISS 相似文献   

Severe trauma caused by stabbing and firearms in metropolitan Sydney, New South Wales, Australia

BACKGROUND: Stabbing and firearm trauma causing severe injuries (injury severity score (ISS) >15) and death is uncommon in Australia. The present study describes the experience with stabbings and firearm trauma causing severe injuries at a major Australian urban trauma centre. METHODS: Data from a prospectively generated trauma registry regarding all patients presenting to Royal Prince Alfred Hospital (RPAH), Sydney, Australia with penetrating trauma causing severe injuries from July 1991 to June 2001 was retrospectively analysed. RESULTS: Of all patients presenting to RPAH with stabbing and firearms wounds over the 11 year study period, 28% received an ISS >15. One hundred and forty patients were identified. 94% were male. The mean age was 34 years (15-82 years). The number of cases/year has not shown an increasing trend. Thirty per cent of patients sustained firearm related injuries, with the remainder mainly caused by knives or machetes. Fifteen per cent of injuries were self inflicted. The most common location of injury was on a public street. Fifty-two per cent of patients were injured in more than one anatomical region, with the abdomen being the most common site of injury (53%). On hundred and seventy-four operations were performed - laparotomies (43%), thoracotomies (26%), craniotomies (5%) and orthopaedic, vascular, wound explorations and other procedures (26%). Twenty-eight per cent of patients suffered at least one complication during their admission, with coagulopathy being the most common complication (20%). Mean length of stay was 10.4 days (1-107 days). The total mortality rate for the severely injured patients was 21%, with gun-related injuries having a higher mortality rate than stabbing injury (36%vs 15%). Sixty per cent of deaths were related to exsanguination. CONCLUSIONS: Stabbings and firearm trauma are associated with significant morbidity, mortality and utilization of hospital resources in metropolitan Sydney. Overall mortality rates are similar to institutions with higher volumes of penetrating trauma.     

Dangerous toys

Background: Motorcycles are sources of significant injury for children. There is limited data describing New Zealand's experience. The study's aim was to quantify the burden of motorcycle trauma presenting to Starship Children's Hospital by assessing the annual admission rates, severity and pattern of injuries, and patient mortality, and to compare injury patterns of those riding all‐terrain vehicles (ATV) and two‐wheeled motorbikes (MB). Methods: Retrospective chart review of all motorcycle trauma admissions to Starship Children's Hospital between November 1999 and December 2008. Patients were identified using the Starship Trauma Registry. Results: One hundred forty‐six admissions (123 MBs, 23 ATVs). Admissions have increased threefold in 9 years. Mean age was 10.5 years (range 2–14 years). ATV riders were significantly younger than MB riders (median 9 and 12 years, P = 0.001). Eighty‐five per cent of patients were male and New Zealand European. There were two deaths in the study. Median length of stay was 2 days (1–80 days); 7.4% required intensive care admission. The median injury severity score (ISS) was 4 (1–35). Twenty‐six per cent of ATV riders had an ISS >12, and 8.9% of MB riders had and ISS >12, P = 0.03. Eighty‐five per cent of patients with an ISS >12 were under 12 years. Sixty per cent of patients required an operative procedure. No difference in pattern of injuries between in ATVs and motorbikes. Conclusions: Motorcycle trauma admissions are increasing. ATV riders are more severely injured and younger than MB riders. Children <12 years are more likely to be severely injured in comparison to those >12 years.     

Recent trends in the management of combined pancreatoduodenal injuries

In an effort to better characterize the natural history of pancreatoduodenal injuries, we present a review of clinical experiences in the treatment of combined traumatic pancreatoduodenal injuries, focusing on patients in extremis. Records of patients with abdominal trauma admitted to a level 1 trauma center from 1997 to 2001 were reviewed. Of 240 patients who sustained a pancreatic or duodenal injury, 33 had combined pancreatoduodenal injuries. Eighty-two per cent of the patients (27/33) in this series had penetrating injuries, 72 per cent (24) sustained gunshot wounds (GSW). Thirty-one patients were male, and the mean age was 33 years (range, 7-74). These patients presented with an average Injury Severity Score (ISS) of 22 +/- 12 and an average Glasgow Coma Score of 14 +/- 2. Overall length of stay was 39 +/- 59 days (range, 0-351 days). These 33 patients underwent a total of 57 laparotomies with an average of 1.7 operations per patient (range, 1 to 5 operations). Eighty-four per cent of the patients had an associated gastrointestinal injury and 45 per cent had a major vascular injury. Thirteen of the 33 (39%) patients presented in extremis, all 13 underwent an abbreviated laparotomy. The complication rate was 36 per cent, including fistula, abscess, pancreatitis, and organ dysfunction. There were 6 hospital deaths for a mortality rate of 18 per cent. Pancreatoduodenal injuries are associated with a variety of other serious injuries, which add to the overall complexity of these patients. Abbreviated laparotomy may be helpful when managing combined pancreatoduodenal injuries in patients who are in extremis.     

Trauma in cirrhotics: survival and hospital sequelae in patients requiring abdominal exploration

Hepatic cirrhosis significantly increases the mortality and morbidity of elective surgery; therefore we hypothesized that cirrhosis would adversely impact outcome after abdominal trauma. We used the trauma registry to identify 17 patients with cirrhosis who sustained trauma injuries requiring emergent exploratory laparotomy. Patients were characterized with respect to age, sex, hospital days, intensive care unit days, and trauma scores. A control group (n = 73) was constructed from the registry by matching age, sex, Injury Severity Score (ISS) and Abbreviated Injury score. Mortality rates were compared by Fisher's exact test and age, ISS, Revised Trauma Score 2, and hospital and intensive care unit days were compared by Student's t test. Despite similar ISS between cirrhotic patients and controls, patients with cirrhosis had a fourfold increase in mortality (mortality odds ratio = 7.2; 95% confidence interval = 2.2-24.0). Cirrhotic trauma patients had a complication rate of 71 per cent and a mortality of 44 per cent. We conclude that cirrhosis is a major independent risk factor for mortality in trauma patients with injuries that require emergent abdominal surgery.     

The value of laparoscopy in management of abdominal trauma

The role of laparoscopy (LS) in abdominal trauma is controversial. Concerns remain regarding missed injuries and safety. Our objective for this study was to determine the safety and better define the role of LS in abdominal trauma victims. We performed a retrospective review of all patients who sustained abdominal trauma and underwent LS in a level I trauma center. The main outcome measures were age, gender, mechanism of injury (MOI), indication for laparoscopy, presence of intra-abdominal injury (IA), therapeutic laparoscopy (TxLS), need for laparotomy, length of hospital stay (LOS), missed injuries, complications, and deaths. Forty-eight patients underwent LS (62 per cent male; average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8). At laparoscopy, 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation. There was one complication: a pneumothorax. There were no deaths. LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. LS can serve as a useful adjunct for the evaluation of blunt trauma. In a level I trauma center with LS readily available, the procedure is associated with a low rate of complications and missed injury.     

Beneficial effect of helicopter emergency medical services on survival of severely injured patients

BACKGROUND: In Rotterdam, the Netherlands, a helicopter-transported medical team (HMT), staffed with a trauma physician, provides additional therapeutic options at the scene of injury. This study evaluated the influence of the HMT on the chance of survival of severely injured trauma victims. METHODS: This was a 2-year prospective observational study of consecutive adults who suffered multiple trauma (Injury Severity Score (ISS) 16 or more) and presented to the Erasmus Medical Centre emergency ward. The effect of the HMT was quantified by an odds ratio (OR), adjusted for confounding variables in logistic regression models. RESULTS: Complete data for a total of 346 patients were available for analysis. Two hundred and thirty-nine patients were treated by ambulance personnel alone and 107 received additional HMT assistance. Patients in the HMT group had significantly lower Glasgow Coma Scale scores (mean 8.9 versus 10.6; P = 0.001) and a higher ISS (mean 30.9 versus 25.3; P < 0.001). The unadjusted OR for death was 1.7 in favour of the group treated by ambulance staff only (OR for survival 0.61 (95 per cent confidence interval (c.i.) 0.37 to 1.0, P = 0.048)). After adjustment, however, patients in the HMT group had an approximately twofold better chance of survival (all injuries: OR 2.2 (95 per cent c.i. 0.92 to 5.9), P = 0.076; blunt injuries: OR 2.8 (95 per cent c.i. 1.07 to 7.52), P = 0.036). CONCLUSION: The presence of the HMT may increase chances of survival for patients suffering multiple trauma, especially for those with blunt trauma.     

Delayed Diagnosis of Injury in survivors of the February 2009 crash of flight TK 1951

IntroductionOn 25th February 2009, a Boeing 737 crashed nearby Amsterdam, leaving 126 victims. In trauma patients, some injuries initially escape detection. The aim of this study was to evaluate the incidence of Delayed Diagnosis of Injury (DDI) and the tertiary survey on the victims of a plane crash, and the effect of ATLS^® implementation on DDI incidence.Patients and methodsData from all victims were analysed with respect to hospitalisation, DDI, tertiary survey, ISS, Glasgow Coma Score (GCS), injuries (number and type) and emergency intervention. Clinically significant injuries were separated from non-clinically significant injuries. The data were compared to a plane crash in the UK (1989), which occurred before ATLS^® became widely practiced.ResultsAll 126 victims of the Dutch crash were evaluated in a hospital; 66 were hospitalised with a total of 171 clinically significant injuries. Twelve (7%) clinically significant DDIs were found in 8 patients (12%). In 65% of all patients, a tertiary survey was documented.The incidence of DDI in patients with an ISS ≥16 (n = 13) was 23%, vs. 9% in patients with ISS <16. Patients with >5 injuries had a DDI incidence of 25%, vs. 12% in patients with ≤5 injuries. Head injury patients had a DDI incidence of 19%, patients without head injury 10%. Fifty percent of patients who needed an emergency intervention (n = 4) had a DDI; 3% of patients who did not need emergency intervention.Eighty-one survivors of the UK crash had a total of 332 injuries. DDIs were found in 30.9% of the patients. Of all injuries 9.6% was a DDI. The incidence of DDI in patients with >5 injuries was 5%, vs. 8% in those with ≤5 injuries.ConclusionDDI in trauma still happen. In this study the incidence was 7% of the injuries in 12% of the population. In one third of the patients no tertiary survey was documented. A high ISS, head injury, more than 5 injuries and an emergency intervention were associated with DDI. The DDI incidence in our study was lower than in victims of a previous plane crash prior to ATLS implementation.     

Cirrhosis and trauma: a deadly duo

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and X2 were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantly greater in the trauma patients with cirrhosis. Fifty-five per cent of deaths in the cirrhosis group was due to sepsis, and, as the Child's class increases, so does the mortality (Child's A, 15%; B, 37%; and C, 63%). In 64 per cent of cirrhotics without an emergent abdominal operation, mortality was 21 per cent. In the 36 per cent of cirrhotics who had emergent abdominal operation, mortality was 55 per cent. Hepatic cirrhosis in trauma patients, regardless of severity of injury or the need for an abdominal intervention, is a poor prognostic indicator. The necessity of an abdominal operative intervention further amplifies this effect. Trauma and cirrhosis is, in fact, a deadly duo.     

An appraisal of trauma in the elderly

To review the trends of trauma in the elderly experienced at our trauma center compared with other Level I trauma centers. This was a retrospective trauma registry analysis (1996-2003) of 2783 blunt trauma in elderly (BTE) and 4568 adult (BTA) patients in a Level 1 trauma center. Falls and motor vehicular crashes were the most common mechanisms noted in 47 per cent and 31 per cent (84% and 13% in BTE, 25% and 42% in BTA). BTE were sicker, with higher Injury Severity Scores (ISS), lengths of stay, and mortality (5% vs 2%, P value < 0.05). ISS was 5.2-fold higher in nonsurvivors to survivors in BTA and 2.4-fold in BTE. Elevation in ISS resulted in higher linear increase in mortality in BTE (vs BTA) at any ISS level. Mortality in patients with ISS > or = 25 was 43.5 per cent vs 23.8 per cent. ISS > or = 50 had 31 per cent adult survivors but no elderly survivors. Among isolated injuries, head trauma in the elderly carried the highest mortality, at 12 per cent (19% in patients with an Abbreviated Injury Score > or = 3). Abdominal injuries were the most lethal (18.3% and 41.2% in patients with an Abbreviated Injury Score > or = 3) in multiple trauma victims (41% vs 18% in isolated trauma). There was 4.4-fold increased mortality in the presence of thoracic trauma. Combined head, chest, and abdominal trauma carried the worst prognosis. Thirty-four per cent of BTE and 88 per cent of BTA patients were discharged home. Elderly patients need more aggressive therapy, as they are sicker with higher mortality.     

Low falls: an underappreciated mechanism of injury

OBJECTIVE: This is a retrospective study designed to evaluate the pattern and severity of injuries that result from low falls, defined as falls from less than 20 ft, subsequent mortality, and requirements of hospital resources. Our hypothesis is that many of these injuries, even without cardiopulmonary instability, are worthy of trauma center care. METHODS: The records of all patients entered into the hospital trauma registry at an urban Level I trauma center during the years 1991 through 1997 who suffered low falls and who either died after admission or were hospitalized for at least 3 days were reviewed. Patients suffering isolated hip fractures were excluded. One hundred seventy-six patients constituted the study population. This group accounts for about 2% of all admissions for falls at our institution. Patterns of injury were examined. Age, mechanism of injury, Injury Severity Score (ISS), and cardiopulmonary or neurologic instability on admission were documented. Mortality, length of intensive care unit and hospital stays, as well as billed hospital charges, were reviewed. RESULTS: The majority of patients (62%) were younger than 50 years. Sixty patients had ISS >15 and 116 patients had ISS >9. Sixty patients had multisystem injuries requiring specialty care. Head injuries were found in 81 patients (35%), and vertebral fractures or spinal cord injuries were found in 49 patients (22%), including 9 quadriplegics and 5 paraplegics. There were seven patients with intra-abdominal injuries (five spleen and two bowel injuries). There was one patient with a rupture of the thoracic aorta. Seventeen patients had deteriorating neurologic or pulmonary function on arrival, but the majority (90%) were stable. Of the 159 "stable" patients, 48 suffered head injuries, 7 were quadriplegic, and 3 were paraplegic. All intra-abdominal injuries were in this group. Overall, 14 of 176 patients (8%) died. Seven deaths were in patients older than 60 years, and seven deaths were in younger patients (p = 0.04). The majority of deaths (9 of 14) were from head trauma. Care in the intensive care unit was required in 92 of 176 patients. Nine patients had billed charges exceeding $100,000. CONCLUSION: Low falls can cause significant injuries, most commonly to the head and spine. Based on mechanism of injury alone, patients injured in low falls might not be taken to trauma centers. We have found, however, that many of these patients sustain serious multisystem injuries, even though they are stable initially. Although these patients represent only a fraction of those who fall, our study would support adjustment of triage guidelines to recommend transport of such patients, particularly elderly patients, to trauma centers.     

Blunt liver injury in children and adults: is there really a difference?

Hepatic injuries are increasingly managed nonoperatively with the availability of adjunctive procedures such as angiography, ERCP, and percutaneous drainage. Although extensively discussed in the adult population, little has been reported on outcomes and management of pediatric liver injury. Retrospective review of all patients with blunt liver injuries admitted to an adult Level I trauma center and pediatric trauma center within the same community was performed from 2004 to 2006. The necessity for operation, adjuncts to nonoperative management, and outcome were collected and compared for the pediatric (PED) (<18 years of age) versus the adult (> or = 18 years of age) injured patients. There were 389 liver injuries identified (PED = 90, adult = 299); 25 per cent of adult injuries were greater than or equal to grade III, while 23 per cent of PED injuries were high-grade injuries. Each group of patients had similar rates of primary operative intervention: adult patients (18%) versus PED patients (16%). Adjunctive therapies were rarely used in the PED patients with only one patient requiring a percutaneous drain and one patient undergoing ERCP twice. Conversely, the adult patient group required eight percutaneous drains, 15 angiograms, 6 ERCPs and 14 laparoscopic abdominal washout procedures. ICU and hospital LOS were 25 per cent and 33 per cent lower in the adult population for high-grade injuries. The overall mortality rates were similar at 7 per cent (PED) and 9 per cent (adult). Liver-related mortality was 50 per cent (3/6 deaths) in the PED group with no liver-related deaths in the adult group (27 deaths). Adult patients with blunt liver injury were no more likely to sustain high grade liver injuries than PED patients. Furthermore, adult and PED patients underwent similar rates of operative intervention and primary liver procedures. Adult patients used adjunctive measures as part of their nonoperative management more frequently, but both subsets had similar length of hospital stays and low overall mortality. A higher rate of liver-related mortality was seen in the PED population. Overall, PED patients seemed to sustain fewer liver related complications necessitating invasive procedures despite similar injury patterns.     

Perils of rib fractures

Rib fractures (RF) are noted in 4 to 12 per cent of trauma admissions. To define RF risks at a Level 1 trauma center, investigators conducted a 10-year (1995-2004) retrospective analysis of all trauma patients. Blunt chest trauma was seen in 13 per cent (1,475/11,533) of patients and RF in 808 patients (55% blunt chest trauma, 7% blunt trauma). RF were observed in 26 per cent of children (< 18 years), 56 per cent of adults (18-64 years), and 65 per cent of elderly patients (> or = 65 years). RF were caused by motorcycle crashes (16%, 57/347), motor vehicle crashes (12%, 411/3493), pedestrian-auto collisions (8%, 31/404), and falls (5%, 227/5018). Mortality was 12 per cent (97/808; children 17%, 8/46; adults 9%, 46/522; elderly 18%, 43/240) and was linearly associated with a higher number of RF (5% 1-2 RF, 15% 3-5 RF, 34% > or = 6 RF). Elderly patients had the highest mortality in each RF category. Patients with an injury severity score > or = 15 had 20 per cent mortality versus 2.7 per cent with ISS < 15 (P < 0.0001). Increasing age and number of RF were inversely related to the percentage of patients discharged home. ISS, age, number of RF, and injury mechanism determine patients' course and outcome. Patients with associated injuries, extremes of age, and > or = 3 RF should be admitted for close observation.     

Analyses of preventable deaths by mechanism of injury among 13,500 trauma admissions.

Preventable deaths (PD) were evaluated by mechanism of injury for 13,500 trauma admissions to eight hospitals over 2 years. There were 42 (3.3%) hospital deaths. Preventable deaths were analyzed by time of death, anatomic site of injury, and mechanism; penetrating (PEN) and blunt with low fall (LF) injuries were considered separately. Preventability of death for patients with probability of survival of less than 0.5, "unexpected deaths," after penetrating and blunt injuries, was determined by consensus of three trauma surgeons. Twelve per cent of deaths were found to be possibly preventable. The incidence of preventable deaths did not differ significantly across groups. Factors in preventable deaths varied by injury cause; delays in operation, PEN (50%), and blunt injury patients (48%); management errors, blunt (52%) and LF (84%); and technical errors, PEN (37.5%). Median times to death were significantly different by cause of injury: PEN, 3 hours; blunt, 13 hours; and LF, 3975 hours. Problems were identified in the hospital care of patients, especially those with LF, leading to sepsis and multiple organ failure.     

Predictors of fetal outcome in pregnant trauma patients: a five-year institutional review

Injury Severity Score (ISS) and lactate are controversial in predicting fetal outcome. A retrospective review was conducted to determine whether ISS and lactate are valuable in predicting fetal survival in injured pregnant patients. Injured pregnant women were identified by ICD-9 codes from our Trauma Registry, Emergency Department Registry, and hospital medical records. Records were reviewed for demographic data, mechanism of injury, ISS, Glascow Coma Scale, lactate, vital signs, and maternal/fetal outcome. To determine statistical analysis, chi2 and t test analysis was performed. From 2001 to 2005, 294 women reported injuries. Most patients (51.7%) were discharged from the Emergency Department, yet 18 per cent were admitted to Trauma Surgery. The average maternal and gestational age was 23.4 years and 19.6 weeks, respectively. Seventy-two (33.3%) patients were in the first trimester. The majority of patients (88.1%) were involved in blunt trauma, and 10 (3.9%) had poor fetal outcome (nine fetal deaths and one hydrops fetalis). There were no maternal deaths. Maternal age, first trimester, elevated lactate, and high ISS were significant risk factors for poor fetal outcome (P = 0.044, P = 0.0173, P = 0.0001, and P = 0.0001, respectively). Specific parameters (ISS, lactate, maternal age, and gestational age) may be helpful in predicting poor fetal outcome and directing patient management.     

IS PENETRATING INJURY ON THE INCREASE IN SOUTH-WESTERN SYDNEY?

Background: Few Australian studies describe the epidemiology of penetrating trauma. This study describes the incidence and demographic features of penetrating injuries with emphasis on trends and severity analysis. Methods: Case analysis was performed utilizing data from the Liverpool Hospital Trauma Registry (1989–94). NSW Department of Health Hospital Separations (1991–93), and the NSW Bureau of Crime Statistics (1991–93) with reference to the Liverpool and Fairfield Local Government Areas (LGA). Results: The Trauma Registry revealed 251 of penetrating trauma. The median age was 26 years (interquartile range 21–33). Ninety-one per cent of the victims were male. Fourteen per cent of patients had an Injury Severity Score (ISS) > 15. Sixty-five per cent of cases were stab injuries and 20% gunshot injuries with the abdomen being the most commonly injured site. Twenty-one per cent of patients underwent laparotomy, 1.6% thoracotomy and 1.2% thoracotomy and laparatomy. There were 10 (4%) deaths. Trends in incidence of penetrating trauma and violent crime involving weapons were analysed. Static trends were observed for the annual incidence of penetrating trauma from the Liverpool Hospital Trauma Registry. Separations for penetrating trauma from Liverpool and Fairfield hospitals showed a slightly increasing trend. Violent crimes involving weapons in the Liverpool and Fairfield LGA showed a static trend. Nevertheless, separations for penetrating trauma and rates of violent crimes involving weapons were higher in south-western Sydney than metropolitan Sydney or NSW. Eight per cent of the LGA population are Vietnamese but this study identified 16% of victims as being Vietnamese. Conclusions: This study found no significant increase in penetrating trauma or violent crime predisposing to penetrating injury in south-western Sydney.     

Trauma in nonagenarians and centenarians: review of 137 consecutive patients

The purpose of this study was to examine the hospital course and outcomes of elderly trauma patients. We accomplished a retrospective review of all consecutive trauma patients admitted to a level II trauma center from January 2000 to April 2002. Gender, Injury Severity Score (ISS), length of stay (LOS), operative procedure, morbidity, and mortality of patients > or = 90 years of age were compared with younger patients. Of 2645 trauma admissions, 137 patients (5%) were > or = 90 years (range, 90 to 108 years; mean, 93.1 years); 5 patients were > or = 100 years. One hundred eleven (81%) patients were female; 26 (19%) male. Average ISS for patients > or = 90 was 8.75 and was 7.78 for younger patients. One hundred sixteen elderly patients (85%) had ISS < 15. Falls were the most common mechanism of injury (93%), usually ground-level falls (64%). Two hundred ninety-two injuries included 133 fractures and 102 soft tissue injuries. Thirty-four elderly patients (25%) and 733 younger patients (29%) required surgery. Complications developed in 8 per cent of older and 6 per cent of younger patients. Hospital LOS averaged 4.36 days for older and 3.51 days for younger patients. Six older (4.4%) and 63 younger (2.5%) patients died. ISS scores and LOS were slightly higher in elderly patients, but morbidity and mortality were comparable in both groups.