Cranial injuries secondary to assault with a machete

Background

Assaults with a machete cause compound skull fractures which present as a neurosurgical emergency. We aimed to profile cranial injuries caused by a machete over a 10 year period in a single neurosurgical unit.

Materials and methods

Retrospective data analysis of cranial injuries following assault with a machete, admitted to the neurosurgery ward, from January 2003 to December 2012 was performed. Medical records were analyzed for demographics, clinical presentation, CT scan findings, surgical treatment and Glasgow Outcome Scale (GOS) at discharge. Management involved wound debridement with antibiotic cover.

Results

Of 185 patients treated 172 (93%) were male. Mean age was 31 ± 11.4 years. Mean GCS on admission was 13 ± 2. Presenting features were focal neurological deficit (48%), brain matter oozing from wounds (20%), and post traumatic seizures (12%). Depressed skull fractures were found in 162 (88%) patients. Findings on CT brain scan were intra-cranial haematoma (88%), pneumocephalus (39%) and features of raised intra-cranial pressure (37%). Thirty-one patients (17%) presented with septic head wounds. One hundred and fifty seven patients (85%) were treated surgically. The median hospital stay was 8 days (range 1–145). The median GOS at discharge was 5 (range 1–5). Twelve patients died within the same admission (6.5%).

Conclusion

Machetes cause complex cranial injuries with associated neurological deficit and should be treated as neurosurgical emergency. Timeous intervention and good surgical principles are advocated to prevent secondary infection and further neurological deterioration.     

Enquête française sur la prise en charge de la circulation extracorporelle et la formation des perfusionnistes en 2008

Introduction

Cardiopulmonary bypass (CPB) is a medical act that can be performed by nurses as long as they are constantly supervised by a physician. No initial formalized training course is required. The personal responsibilities of nurses and physicians about CPB have not been defined.

Objectives

The purpose of this study was: to list perfusionists; to evaluate the training of perfusionists; to determine which physicians are considered as in charge during actions performed by paramedics, as well as their qualification; to point out the changes since 1997.

Type of study

Professional practice assessment.

Methods

A questionnaire was sent to all perfusionists in activity in France.

Results

There were 71% of replies. We found an aging of perfusionists (median 49 years vs. 40 years in 1997), a fall in the proportion of trained physicians (13% of perfusionists had a training course in adequacy with professional guidelines, 25% of perfusionists said they worked with a physician who could intervene at all time, and 61% declared only one physician was in charge). There is no CPB referent in 26% of perfusion units.

Conclusion

An urgent need appears to define the respective responsibilities of medical and paramedical perfusion staff, especially as this technique spreads out of the conventional cardiac surgery operating theatres.     

Necessity of monitoring after negative head CT in acute head injury

Objective

The main objective of this study was to evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT).

Materials and methods

This retrospective study included 3023 consecutive patients who underwent head CT due to an acute HI at the Emergency Department (ED) of Tampere University Hospital (August 2010–July 2012). Regardless of clinical injury severity, the patients with a normal head CT were selected (n = 2444, 80.9%). The medical records of these patients were reviewed to identify the individuals with a serious clinically significant complication related to the primary HI. The time window considered was the following 72 h after the primary head CT. A repeated head CT in the hospital ward, death, or return to the ED were indicative of a possible complication.

Results

The majority (n = 1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n = 27) of these patients returned to ED within 72 h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72 h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%.

Conclusion

In the present study, which includes head injuries of all severity, the probability of delayed life-threatening complications was negligible when the primary CT scan revealed no acute traumatic lesions.     

A second look at the utility of serial routine repeat computed tomographic scans in patients with traumatic brain injury

Background

The practice of a routine repeat head computed tomographic scans in patients with traumatic brain injury (TBI) is under question. The aim of our study was to evaluate the utility of a more than 1 repeat head computed tomography (M1CT) scans in patients with TBI.

Methods

We performed a 3-year analysis of a prospectively collected database of all TBI patients presenting to our level I trauma center. Patients who received M1CT scans were included. Findings and reason (without neurologic decline vs after neurologic decline) for M1CT were recorded. Primary outcome measure was neurosurgical intervention.

Results

A total of 296 patients that underwent M1CT were included. Of those, 291 patients (98.6%) had M1CT without a neurologic decline, and neurosurgical intervention was performed in 1 patient (.3%) who was inexaminable (Glasgow coma scale score = 6). The remaining (n = 5) had M1CT due to a neurologic decline; 4 patients (80%) of the 5 had worsening of ICH; and neurosurgical intervention was performed in 3 (75%) of the 4 patients.

Conclusions

The practice of multiple repeat head computed tomographic scans should be limited to inexaminable patients or patients with neurological deterioration.     

Radiation exposure during paediatric emergency CT: Time we took notice?

Introduction

Concerns exist about radiation exposure during medical imaging. Comprehensive computerised tomography (CT) dose standards exist for adults, but are incomplete for children. We investigated paediatric CT radiation doses at a NHS Trust in order to define the extent of the risk.

Methods

CT dose indicators (CTDI) were recorded for all scans on paediatric patients from January – December 2011 and benchmarked against American College of Radiologists reference levels (75 mGy for adult head, 25 mGy for adult abdomen, and 20 mGy for paediatric (5-year-old) abdomen). Size-specific dose estimates (SSDE) were calculated based on effective patient diameter as recommended by the American Association of Physicists in Medicine. Student t-test was used to compare CTDI and SSDE values for each anatomical region.

Results

Of 53,648 paediatric emergency presentations, CT was requested in 211 (0.39%). One hundred fifty-four patients underwent 169 scans, with the rest being cancelled for clinical improvement or senior overrule. Indication for CT was trauma in 130/154 (90%), of which 55% were after falls, 19% following road traffic collisions, 12% after sporting injury, and 12% after alleged assault. CTDI values were available for 96/169 (57%) scans, with the rest lacking sufficient data. There was no significant difference between CTDI and derived SSDE values. 3% of head scans exceeded the adult head reference level.

Conclusion

There is wide variation in radiation exposure during paediatric trauma CT, with some scans delivering doses in excess of recommended adult values. There is an urgent need to define standards for radiation dose in paediatric CT for all ages and anatomical regions.     

The anatomic suitability of the C2 vertebra for intralaminar and pedicular fixation: a computed tomography study

Background context

Several methods have been used to stabilize the atlantoaxial joint, including the use of C2 pedicle and laminar screws. No report has used computed tomography (CT) angiograms to compare the risk to the vertebral artery or assess the suitability for each fixation technique.

Purpose

To compare the suitability of C2 pedicle versus laminar screws using CT angiograms.

Study design

We retrospectively evaluated the anatomic dimensions of the C2 lamina and pedicle in 50 patients using CT angiograms.

Methods

We retrospectively reviewed the last 50 patients admitted who underwent CT angiograms of the head and neck. Data recorded included the pedicle length and width and the laminar length and width. Vertebral artery anatomy was also assessed to determine if an aberrant location would preclude pedicle fixation.

Results

Mean pedicle length and width were 15.5±3.5 and 4.7±1.7 mm, respectively, with 24% of patients having anatomy that would preclude 3.5-mm pedicle screw fixation. The mean lamina length and width were 25.2±3.6 and 5.5±1.4 mm, and more than 90% of patients could tolerate a 3.5-mm C2 laminar screw.

Conclusion

Preoperative CT angiography or noncontrast CT is an excellent method to delineate the anatomy at C2 to determine the suitability for pedicle or intralaminar fixation. In cases where vertebral artery anatomy precludes C2 pedicle fixation, more than 90% of patients may be a candidate for C2 intralaminar fixation.     

Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center?

Purpose

To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging.

Methods

A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry.

Results

A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score < 14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%).

Conclusion

The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging.     

Patient preferences and acceptable risk for computed tomography in trauma

Background

Rising use of computed tomography (CT) to evaluate patients with trauma has increased both patient costs and risk of cancer from ionizing radiation, without demonstrable improvements in outcome. Patient-centred care mandates disclosure of the potential risks, costs and benefits of diagnostic testing whenever possible.

Objective

We sought to determine (1) patient preferences regarding emergency department (ED) real-time discussions of risks and costs of CT during their trauma evaluations; and (2) whether varying levels of odds of detection of life-threatening injury (LTI) were associated with changes in patient preferences for CT.

Methods

Excluding patients already receiving CT and patients with altered mental status, we surveyed adult, English-speaking patients at four Level I verified trauma centres. After informing subjects of cancer risks associated with chest CT, we used hypothetical scenarios with varying LTIs to assess patients’ preferences regarding CT.

Results

Of 941 patients enrolled, 50% were male and their mean age was 42 years. Most patients stated they would prefer to discuss CT radiation risks (73.5%, 95% CI [66.1–80.8]) and costs (53.2%, 95% CI [46.1–60.4]) with physicians. As the odds of detecting LTI decreased, preferences for receiving CT decreased accordingly: LTI 25% (desire 91.2%, 95% CI [89.4–93.1]), LTI 10% (desire 79.3%, 95% CI [76.7–81.9]), LTI 5% (desire 69.1%, 95% CI [66.1–72.1]) and LTI <2% (desire 53.8%, 95% CI [50.6–57.0]). If the LTI was <2% and subjects were required to pay $1000 out-of-pocket, only 34.5% (95% CI 31.4–37.5) would opt for CT.

Conclusion

Most non-critically injured patients prefer to discuss radiation risks and costs of CT prior to receiving imaging. As the odds of detecting LTI decrease, fewer patients prefer to have CT; at an LTI threshold of 2%, approximately half of patients would prefer to forego CT. Adding out-of-pocket costs reduced this proportion to one-third of patients.     

The UK military experience of thoracic injury in the wars in Iraq and Afghanistan

Introduction

Thoracic injury during warfare is associated with a high incidence of morbidity and mortality. This study examines the pattern and mortality of thoracic wounding in the counter-insurgency conflicts of Iraq and Afghanistan, and outlines the operative and decision making skills required by the modern military surgeon in the deployed hospital setting to manage these injuries.

Methods

The UK Joint Theatre Trauma Registry was searched between 2003 and 2011 to identify all patients who sustained battle-related thoracic injuries admitted to a UK Field Hospital (Role 3). All UK soldiers, coalition forces and local civilians were included.

Results

During the study period 7856 patients were admitted because of trauma, 826 (10.5%) of whom had thoracic injury. Thoracic injury-related mortality was 118/826 (14.3%). There were no differences in gender, age, coalition status and mechanism of injury between survivors and non-survivors. Survivors had a significantly higher GCS, Revised Trauma Score and systolic blood pressure on admission to a Role 3 facility. Multivariable regression analysis identified admission systolic blood pressure less than 90, severe head or abdominal injury and cardiac arrest as independent predictors of mortality.

Conclusions

Blast is the main mechanism of thoracic wounding in the recent conflicts in Iraq and Afghanistan. Thoracic trauma in association with severe head or abdominal injuries are predictors of mortality, rather than thoracic injury alone. Deploying surgeons require training in thoracic surgery in order to be able to manage patients appropriately at Role 3.     

Gonadotropin-releasing Hormone Agonists and Acute Kidney Injury in Patients with Prostate Cancer

Background

Androgen deprivation therapy (ADT) might increase the risk of acute kidney injury (AKI) in patients with prostate cancer (PCa).

Objective

To examine the impact of ADT on AKI in a large contemporary cohort of patients with nonmetastatic PCa representing the US population.

Design, setting, and participants

Overall, 69 292 patients diagnosed with nonmetastatic PCa between 1995 and 2009 were abstracted from the Surveillance Epidemiology and End Results–Medicare database.

Outcomes measurements and statistical analyses

Patient in both treatment arms (ADT vs no ADT) were matched using propensity-score methodology. Ten-year AKI rates were estimated. Competing-risks regression analyses tested the association between ADT and AKI, after adjusting for the risk of death during follow-up.

Results and limitations

Overall, the 10-yr AKI rates were 24.9% versus 30.7% for ADT-naive patients versus those treated with ADT, respectively (p < 0.001). When patients were stratified according to the type of ADT, the 10-yr AKI rates were 31.1% versus 26.0% for men treated with gonadotropin-releasing hormone (GnRH) agonists and bilateral orchiectomy, respectively (p < 0.001). In multivariable analyses, the administration of GnRH agonists (hazard ratio [HR]: 1.24; 95% confidence interval [CI], 1.18–1.31; p < 0.001), but not bilateral orchiectomy (HR: 1.11; 95% CI, 0.96–1.29; p = 0.1), was associated with the risk of experiencing AKI. Our study is limited by its retrospective design.

Conclusions

ADT is associated with an increased risk of AKI in patients with nonmetastatic PCa. In particular, the administration of GnRH agonists, but not surgical castration, may substantially increase the risk of experiencing AKI. These observations should help provide physicians with better patient selection to reduce the risk of AKI.

Patient summary

The administration of gonadotropin-releasing hormone agonists, but not bilateral orchiectomy, increases the risk of acute kidney injury (AKI) in patients with prostate cancer (PCa). These observations should help provide physicians with better patient selection to reduce the risk of AKI in PCa patients.     

Head injury and unclear mechanism of injury: Initial hematocrit less than 30 is predictive of abusive head trauma in young children

Purpose

Head injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT.

Methods

A retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002–2011.

Results

A total of 1129 patients (mean age 1.7 ± 1.7 years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤ 30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤ 30% was predictive of AHT as the cause of injury (P < .0001), as was a platelet count of greater than 400,000 (P < .0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤ 30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P < .05).

Conclusions

In the setting of head injury and unclear history of trauma, a hematocrit of ≤ 30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5 years.     

Low-dose aspirin therapy is not a reason for repeating head computed tomographic scans in traumatic brain injury: a prospective study

Background

Most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate the utility of repeat head computed tomography (RHCT) and outcomes in patients on low-dose aspirin (acetylsalicylic acid; ASA) therapy.

Methods

Patients with traumatic brain injury with intracranial hemorrhage on initial head computed tomography (CT) were prospectively enrolled. Patients on prehospital low-dose (81 mg) aspirin therapy were matched with patients exclusive of antiplatelet and anticoagulation therapy using propensity score matching in a 1:1 ratio for age, Glasgow Coma Scale, head Abbreviated Injury Scale score, Injury Severity Score, and neurological examination. Outcome measures were progression on RHCT and subsequent neurosurgical intervention.

Results

A total of 144 patients who had intracranial hemorrhage on initial CT scan (ASA group: 72; No-ASA group: 72) were enrolled. The mean age was 72.8 ± 11.7 years, 59.7% were male, and median head Abbreviated Injury Scale was 3 (2–3). There was no difference in progression on RHCT (25% in ASA versus 16.6% in no-ASA), change in management as a result of RHCT (1.4% versus 1.4%), RHCT as a result of neurological decline (0 versus 1.4%), discharge Glasgow Coma Scale (15 [14–15] versus 15 [14–15]), and mortality (0 versus 1.4%) between the two groups.

Conclusions

Low-dose aspirin therapy is not associated with progression of initial insult on RHCT or clinical deterioration. Prehospital low-dose aspirin therapy as a sole criterion should not warrant a routine repeat head CT in traumatic brain injury.     

Enquête nationale sur la prise en charge de l’intubation difficile en médecine d’urgence préhospitalière

Objectives

Difficult intubation rate is higher in the prehospital setting than in the operating room.Goal of this survey was to assess compliance of the French prehospital mobile emergency unit (Smur) to the recent French guidelines for the difficult airway management.

Study design

National phone survey.

Methods

A phone questionnaire was proposed to one senior emergency physician of all 380 French Smur. Seven questions were asked about intubation devices used, availability of a written difficult intubation algorithm and intubation training of the Smur's physicians.

Results

Guidelines of the recent French consensus conference on difficult intubation are only partly followed by the Smur. Only 60% of the Smur perform systematic rapid intubation sequence, plastic laryngoscope blades are used by more than 50% of the Smur and less than 50% of the Smur have a written difficult intubation management algorithm available. The Gum elastic Bougie is available in 58% of the Smur and the intubating laryngeal mask airway in 71%, whereas initial formation for difficult intubation devices used is provided to the emergency physicians in only 58% of the Smur.

Conclusion

This survey shows that the French guidelines for the difficult airway management are only partially followed by the French Smur. An effort should be made for a larger diffusion of these guidelines towards the emergency physicians working in the Smur.     

Epidemiology of paediatric minor head injury: Comparison of injury characteristics with Indices of Multiple Deprivation

Background

Head injury (HI) is a common presentation to Child Emergency Departments (CEDs), but the actual number of children attending with minor HI is unclear. Most research has focussed on admitted patients, often relying on hospital-coded admission data. We studied the incidence of minor HI presenting to the CED of a major teaching hospital in Coventry and Warwickshire. HI attendances were compared with population data to identify injury patterns relating to deprivation.

Methods

All CED admissions were screened by the research team, and data on minor head injuries (GCS 13–15) collected prospectively from 1st January until 31st August 2011. Information was collected on demographics, ethnicity, cause and severity of injury, injury location (in or outside the home), other injuries and mode of arrival. Deprivation data were obtained by cross-referencing postcodes with English Indices of Multiple Deprivation (IMD 2010). For comparison, the hospital audit department provided figures for coded head injuries during the same period.

Results

During the 8 month period, hand-searching identified 1747 children with minor HI, aged between 0 and 16 years. Of these 99% had minimal HI (GCS 15 or ‘alert’). In the same period, hospital-coded minor HIs numbered only 1081. HIs formed 9% of all CED attendances. Thirteen children returned to the CED with worrying symptoms after discharge home. Approximately 3.4% of the local paediatric population attend the CED with HI per year (3419/100,000 population). Falls accounted for 62% of HIs overall, rising to 77% in children aged 0–5. Most in-home head injuries (81%) were the result of falls (p < 0.0001). Significantly more injuries took place inside the home for 0–5 year olds (58%) than for older children (20%) (p < 0.0001). Children living in the most deprived areas were more likely to attend the CED with HI (RR: 1.19; CI: 1.06–1.35, p = 0.004), and arrive using emergency services (OR: 1.77; CI: 1.30–2.40, p < 0.001). There were no significant differences between the deprived and non-deprived groups for location or cause of injury.

Conclusions

Young children are particularly at risk of HI and parents should be offered information on injury prevention. More children from deprived areas attended with HI and these families may benefit most from targeted interventions.     

On and off the horse: Mechanisms and patterns of injury in mounted and unmounted equestrians

Introduction

The purpose of this study is to determine whether discrepant patterns of horse-related trauma exist in mounted vs. unmounted equestrians from a single Level I trauma center to guide awareness of injury prevention.

Methods

Retrospective data were collected from the University of Kentucky Trauma Registry for patients admitted with horse-related injuries between January 2003 and December 2007 (n = 284). Injuries incurred while mounted were compared with those incurred while unmounted.

Results

Of 284 patients, 145 (51%) subjects were male with an average age of 37.2 years (S.D. 17.2). Most injuries occurred due to falling off while riding (54%) or kick (22%), resulting in extremity fracture (33%) and head injury (27%). Mounted equestrians more commonly incurred injury to the chest and lower extremity while unmounted equestrians incurred injury to the face and abdomen. Head trauma frequency was equal between mounted and unmounted equestrians. There were 3 deaths, 2 of which were due to severe head injury from a kick. Helmet use was confirmed in only 12 cases (6%).

Conclusion

This evaluation of trauma in mounted vs. unmounted equestrians indicates different patterns of injury, contributing to the growing body of literature in this field. We find interaction with horses to be dangerous to both mounted and unmounted equestrians. Intervention with increased safety equipment practice should include helmet usage while on and off the horse.     

Enquête VENTILOP. Enquête sur la ventilation mécanique peropératoire

Introduction

Mechanical ventilation can initiate ventilator-associated lung injury and postoperative pulmonary complications. The aim of this study was to evaluate (1) how mechanical ventilation was comprehended by anaesthetists (physician and nurses) and (2) the need for educational programs.

Methods

A computing questionnary was sent by electronic-mail to the entire anaesthetist from Alsace region in France (297 physicians), and to a pool of 99 nurse anaesthetists. Mechanical ventilation during anaesthesia was considered as optimized when low tidal volume (6–8 mL) of ideal body weight was associated with positive end expiratory pressure, FiO₂ less than 50%, I/E adjustment and recruitment maneuvers.

Results

The participation rate was 50.5% (172 professionals). Only 2.3% of professionals used the five parameters for optimized ventilation. Majority of professionals considered that mechanical ventilation adjustment influenced the patients’ postoperative outcome. Majority of the professionals asked for a specific educational program in the field of mechanical ventilation.

Discussion

Only 2.3% of professionals optimized mechanical ventilation during anaesthesia. Guidelines and specific educational programs in the field of mechanical ventilation are widely expected.     

Reliability of injury grading systems for patients with blunt splenic trauma

Objectives

The most widely used grading system for blunt splenic injury is the American Association for the Surgery of Trauma (AAST) organ injury scale. In 2007 a new grading system was developed. This ‘Baltimore CT grading system’ is superior to the AAST classification system in predicting the need for angiography and embolization or surgery. The objective of this study was to assess inter- and intraobserver reliability between radiologists in classifying splenic injury according to both grading systems.

Methods

CT scans of 83 patients with blunt splenic injury admitted between 1998 and 2008 to an academic Level 1 trauma centre were retrospectively reviewed. Inter and intrarater reliability were expressed in Cohen's or weighted Kappa values.

Results

Overall weighted interobserver Kappa coefficients for the AAST and ‘Baltimore CT grading system’ were respectively substantial (kappa = 0.80) and almost perfect (kappa = 0.85). Average weighted intraobserver Kappa's values were in the ‘almost perfect’ range (AAST: kappa = 0.91, ‘Baltimore CT grading system’: kappa = 0.81).

Conclusion

The present study shows that overall the inter- and intraobserver reliability for grading splenic injury according to the AAST grading system and ‘Baltimore CT grading system’ are equally high. Because of the integration of vascular injury, the ‘Baltimore CT grading system’ supports clinical decision making. We therefore recommend use of this system in the classification of splenic injury.     

Conditions de prise de décision d’admission ou de non admission en réanimation chirurgicale

Objectives

To describe the condition of the decision-making of admission and non-admission in intensive care unit.

Study design

Non-interventional observational cohort.

Patients and methods

Retrospective analysis of declarative terms of decision-making of patients admitted or denied in a surgical intensive care unit. The decision-making in the two admitted or not admitted troops was compared.

Results

That it is during a non-admission (149 decisions) or of an admission (149 decisions), the decision-making process was not very different. The instruction of the files was regarded as collegial in nearly 80% of the cases by the intensivist in load. The dialogue precedent the decision utilized generally several speakers but who could be residents. The participation of the patient and/or his close relations, as that of the ancillary medical personnel was rare. No person of confidence or anticipated directive was quoted. More than 50% of the decisions were taken within a time lower than 30 minutes. The decisions of non-admission were considered to be more difficult than the decisions of admission. Traceability was not automatically given.

Conclusion

Thus, this study shows that in its current form the intensivists of the service estimate that in the majority of the cases the instruction of the files was collegial. However, the conditions of seniorisation of the decision, the collection of opinion of the patient and/or his close relations and the traceability are tracks of improvement to be implemented in certain circumstances of admission or non-admission.     

Severity of head computed tomography scan findings fail to explain racial differences in mortality following child abuse

Introduction

Differences in head injury severity may not be fully appreciated in child abuse victims. The purpose of this study was to determine if differential findings on initial head computed tomography (CT) scan could explain observed differential outcome by race.

Methods

We identified 164 abuse patients from our trauma registry with an Injury Severity Score (ISS) ≥ 15. Their initial head CT scan was graded from 1 to 4 (normal to severe). Statistical analysis was performed to asses the correlation between race, head CT grade, Glascow Coma Scale (GCS) score, and mortality.

Results

Overall mortality was 17%: 11% for white children, 32% for African-American children (P < .05). In review of the head CT scans there was no difference by race in types of injuries or head CT grade. Using a multivariate regression model, African-American race remained an independent risk factor for mortality with an odd ratio of 4.3 (95% confidence interval [CI] 1.6-11.5).

Conclusion

African-American children had a significantly higher mortality rate despite similar findings on initial head CT scans. Factors other than injury severity may explain these disparate outcomes.