Evaluating mechanism and severity of injuries among trauma patients admitted to Sina Hospital, the National Trauma Registry of Iran

Purpose: Injuries are one of the leading causes of death and lead to a high social and financial burden. Injury patterns can vary significantly among different age groups and body regions. This study aimed to evaluate the relationship between mechanism of injury, patient comorbidities and severity of injuries. Methods: The study included trauma patients from July 2016 to June 2018, who were admitted to Sina Hospital, Tehran, Iran. The inclusion criteria were all injured patients who had at least one of the following: hospital length of stay more than 24 h, death in hospital, and transfer from the intensive care unit of another hospital. Data collection was performed using the National Trauma Registry of Iran minimum dataset. Results: The most common injury mechanism was road traffic injuries (49.0%), followed by falls (25.5%). The mean age of those who fell was significantly higher in comparison with other mechanisms (p < 0.001). Severe extremity injuries occurred more often in the fall group than in the vehicle collision group (69.0% vs. 43.5%, p < 0.001). Moreover, cases of severe multiple trauma were higher amongst vehicle collisions than injuries caused by falls (27.8% vs. 12.9%, p = 0.003). Conclusion: Comparing falls with motor vehicle collisions, patients who fell were older and sustained more extremity injuries. Patients injured by motor vehicle collision were more likely to have sustained multiple trauma than those presenting with falls. Recognition of the relationship between mechanisms and consequences of injuries may lead to more effective interventions.     

Injuries from the 2002 North Carolina ice storm, and strategies for prevention

CONTEXT: In 2002, an ice storm interrupted power to 1.3 million households in North Carolina, USA. Previous reports described storm injuries in regions with frequent winter weather. [Blindauer KM, Rubin C, Morse DL, McGeehin M. The 1996 New York blizzard: impact on noninjury visits. Am J Emerg Med 1999;17(1):23-7; Centers for Disease Control and Prevention. Community needs assessment and morbidity surveillance following an ice storm--Maine, January 1998. MMRW 1998;47(17):351-5; Daley WR, Smith A, Paz-Argandona E, Malilay J, McGeehin M. An outbreak of carbon monoxide poisoning after a major ice storm in Maine. J Emerg Med 2000;18(1):87-93; Hamilton J. Quebec's ice storm'98: "all cards wild, all rules broken" in Quebec's shell-shocked hospitals. Can Med Assoc J 1998;158(4):520-4; Hartling L, Brison RJ, Pickett W. Cluster of unintentional carbon monoxide poisonings presenting to the emergency departments in Kingston, Ontario during 'Ice Storm 98'. Can J Public Health 1998;89(6):388-90; Hartling L, Pickett W, Brison RJ. The injury experience observed in two emergency departments in Kingston, Ontario during 'ice storm 98'. Can J Public Health 1999;90(2):95-8; Houck, PM, Hampson NB. Epidemic carbon monoxide poisoning following a winter storm. J Emerg Med 1997;15(4):469-73; Lewis LM, Lasater LC. Frequency, distribution, and management of injuries due to an ice storm in a large metropolitan area. South Med J 1994;87(2):174-8; Smith RW, Nelson DR. Fractures and other injuries from falls after an ice storm. Am J Emerg Med 1998;16(1):52-5]. We postulated that injuries might differ in a region where ice storms are less common. OBJECTIVE: Identify storm-related injuries. DESIGN: Emergency department (ED) charts from the storm period (defined as onset of precipitation until 99% power restoration) were retrospectively reviewed. Included injuries were: falls on ice; injuries due to darkness; cold exposure; injuries from storm-related damage; burns; or carbon monoxide/smoke exposure. SETTING: Tertiary care ED, central North Carolina. PATIENTS: All ED patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Mechanism of injury. RESULTS: One hundred thirty incidents occurred, most resulting from storm damage and carbon monoxide. Seven were life threatening: four spinal fractures and two intracranial hemorrhages from falling tree limbs and one hypothermia. Carbon monoxide poisoning affected one pregnant woman and all children in our series. Twenty three percent of patients were Hispanic, although Hispanics comprise only 11% of the study ED population. CONCLUSIONS: Injuries from storm-related damage and carbon monoxide exposure predominated. Available hyperbaric chambers were quickly filled to capacity. Hispanics experienced a disproportionate number of injuries.     

Geriatric falls: injury severity is high and disproportionate to mechanism

OBJECTIVE: Falls are a well-known source of morbidity and mortality in the elderly. Fall-related injury severity in this group, however, is less clear, particularly as it relates to type of fall. Our purpose is to explore the relationship between mechanism of fall and both pattern and severity of injury in geriatric patients as compared with a younger cohort. METHODS: Our trauma registry was queried for all patients evaluated by the trauma service over a 412-year period (1994-1998). Two cohorts were formed on the basis of age greater than 65 or less than or equal to 65 years and compared as to mechanism, Injury Severity Score (ISS), Abbreviated Injury Scale score, and mortality. RESULTS: Over the study period, 1,512 patients were evaluated, 333 greater than 65 years and 1,179 less than or equal to 65 years of age. Falls were the injury mechanism in 48% of the older group and 7% of the younger group (p < 0.05). Falls in the older group constituted 65% of patients with ISS >15, with 32% of all falls resulting in serious injury (ISS >15). In contrast, falls in the younger group constituted only 11% of ISS >15 patients, with falls causing serious injury only 15% of the time (both p < 0.05). Notably, same-level falls resulted in serious injury 30% of the time in the older group versus 4% in the younger group (p < 0.05), and were responsible for an ISS >15 30-fold more in the older group (31% vs. <1%; p < 0.05). Abbreviated Injury Scale evaluation revealed more frequent head/neck (47% vs. 22%), chest (23% vs. 9%), and pelvic/extremity (27% vs. 15%) injuries in the older group for all falls (all p < 0.05). The mean ISS for same-level falls in the older group was twice that for the younger group (9.28 vs. 4.64, p < 0.05), whereas there was no difference in mean ISS between multilevel and same-level falls within the older group itself (10.12 vs. 9.28, p > 0.05). The fall-related death rate was higher in the older group (7% vs. 4%), with falls seven times more likely to be the cause of death compared with the younger group (55% vs. 7.5%) (both p < 0.05). Same-level falls as a cause of death was 10 times more common in the elderly (25% vs. 2.5%, p < 0.05). CONCLUSION: Falls among the elderly, including same-level falls, are a common source of both high injury severity and mortality, much more so than in younger patients. A different pattern of injury between older and younger fall patients also exists.     

Pediatric Hand and Upper Extremity Injuries Presenting to Emergency Departments in the United States: Epidemiology and Health Care–Associated Costs

Background: Upper extremity injuries represent one of the most common pediatric conditions presenting to emergency departments (EDs) in the United States. We aim to describe the epidemiology, trends, and costs of pediatric patients who present to US EDs with upper extremity injuries. Methods: Using the National Emergency Department Sample, we identified all ED encounters by patients aged <18 years associated with a primary diagnosis involving the upper extremity from 2008 to 2012. Patients were divided into 4 groups by age (≤5 years, 6-9 years, 10-13 years, and 14-17 years) and a trauma subgroup. Primary outcomes were prevalence, etiology, and associated charges. Results: In total, 11.7 million ED encounters were identified, and 89.8% had a primary diagnosis involving the upper extremity. Fracture was the most common injury type (28.2%). Dislocations were common in the youngest group (17.7%) but rare in the other 3 (range = 0.8%-1.6%). There were 73.2% of trauma-related visits, most commonly due to falls (29.9%); 96.9% of trauma patients were discharged home from the ED. There were bimodal peaks of incidence in the spring and fall and a nadir in the winter. Emergency department charges of $21.2 billion were generated during the 4 years studied. While volume of visits decreased during the study, associated charges rose by 1.21%. Conclusions: Pediatric upper extremity injuries place burden on the economy of the US health care system. Types of injuries and anticipated payers vary among age groups, and while total yearly visits have decreased over the study period, the average cost of visits has risen.     

Gender differences in etiology and outcome of open globe injuries

PURPOSE: Patterns of injury and outcomes after multi-system trauma differ between men and women. Few data exist regarding the epidemiology of gender differences in severe eye trauma. We hypothesized that the incidence and patterns of open globe injuries might differ between men and women. METHODS: Charts of 220 patients with open globe injuries presenting to the Massachusetts Eye and Ear Infirmary during a three-year period were retrospectively reviewed. The data were analyzed with respect to gender, type of open globe injury (penetrating, perforating, or rupture), and mechanism of globe injury (projectile, non-projectile, assault, fall, sports, motor vehicle crash). RESULTS: The majority (78.6%) of patients were men. Women with open globe injuries were older (median age 73 years) than men (median age 36 years). Men were more likely to suffer from penetrating injuries (69.9%) while women were more likely to experience blunt globe rupture (68.1%). Projectile objects accounted for the majority of open globe injuries in men (54.9%) and were an infrequent cause in women (4.3%). Nearly one-third (31.8%) of the projectile injuries in men were work-related, and 19.7% occurred during home improvement projects. Compared with men, falls were more frequently responsible for globe injuries in women (55.3% versus 8.1%). Injuries limited to the cornea were more common in men than women (46.2% versus 23.4%), while more posterior globe injuries were more common among women (46.8% versus 28.3% men). Women were more likely than men to have poor visual acuity at 3 months after injury. CONCLUSIONS: The causes and patterns of open globe injuries differ between men and women. In this series, the majority of injuries to men were caused by projectile objects related to work or home improvement projects. Open globe injuries in women were most often resulted from fall, and were more likely to cause rupture posterior to the limbus.     

Falls from flat-roofed houses: a surgical experience of 1643 patients

PURPOSE: High falls from flat-roofed houses are a common cause of death and disability in the south-east part of Turkey; the aim of this study was to describe our experience of such falls seen over a 4-year period in Diyarbakir. METHODS: One thousand six hundred and forty-three patients (570 females and 1073 males) who sustained injuries after an accidental fall from a flat-roofed house were entered into the study. RESULTS: The mean age was 18 (1-95) years; 49.4% of patients were under 10 years old; 81.5% were under 30 years old. The mean fall height was 4.5m (1-20 m). The mortality rate was 5.8% (96 patients). The mean fall height in children under the age of 15 years who died from the fall was 4m (67 patients) and in patients over the age of 15 years, 9m (29 patients). The most common injuries were to the head (45.1%) and 93.75% of those (n = 90) who died had a head injury. One hundred patients (6%) were followed because of abdominal bleeding: one of these had fallen from 2m, the reminder from 4 to 9 m; 12 were operated on and 88 treated conservatively. CONCLUSION: Craniocerebral trauma is the most common injury in fatal falls from flat roofs and blunt abdominal trauma is an uncommon injury after falling from less than 4m.     

Spinal injuries after falls from hunting tree stands.

BACKGROUND CONTEXT: Spinal injuries are common sequelae of falls from hunting tree stands. Significant neurological injury is not uncommon and can result in significant morbidity as well as enormous expenditure of health care dollars. Recent literature on the subject is limited. PURPOSE: The purpose of this study was to identify precipitating causes, characterize the spectrum of spinal injury, and determine potential interventional safety and prevention recommendations. STUDY DESIGN: A retrospective study. METHODS: Medical record review of 22 patients admitted either directly or via referral to a level I spinal cord injury referral center over a 10-year period (1995-2005) after a fall from a hunting tree stand. RESULTS: All patients were men with a mean age of 46 years (range, 27-80 years). Initial acute care hospitalization averaged 10 days (range, 2-28 days). The average height of fall was 18 feet (range, 10-30 feet). Four of 19 falls (21%) occurred during the morning hours, 2 of 19 falls occurred during the afternoon, and 13 of 19 falls (68%) occurred during the evening hours. Time lapse from injury to presentation to an emergency department ranged from 30 minutes to 14 hours. Alcohol use was a factor in 2 of 20 falls (10%). Hypothermia complicated 3 of 21 cases (14%). Associated injuries were present in 12 of 21 patients (57%) and included fractures to the axial and appendicular skeleton, pneumothoraces, a retroperitoneal bleed, and a brachial plexopathy. Eight of 22 patients (37%) sustained injury to the cervical spine. Five of these 8 patients (63%) had neurological deficits (3 complete and 2 incomplete spinal cord injuries). Thirteen of 22 (59%) patients sustained injury to the thoracic or lumbar spine. Ten of these 13 (77%) had neurologic deficits (3 complete and 7 incomplete). Nine of 22 (41%) patients were treated nonoperatively; the remaining 13 (59%) underwent operative intervention. CONCLUSIONS: Falls from hunting tree stands remain a significant cause of spinal injury and subsequent disability. The best intervention for these injuries is prevention. There is a continued need for hunter safety education to reduce the incidence of these injuries with emphasis on safety harness usage, proper installation and annual inspection of tree stands, hunting in groups with periodic contact, the use of communication devices, and abstinence from alcohol consumption while hunting.     

Relations of osteoporosis and follow-up duration to recurrent falls in older men and women

Summary

There were differences in risk factors between men and women and between two follow-up time lengths. Osteoporosis was significantly associated with recurrent falls for women but not for men. The relationship of osteoporosis with falls in the past year decreased during follow-up, while those of sedatives and hypnotics remained.

Introduction

A prospective study to investigate relationships between osteoporosis and recurrent falls at two follow-up lengths of 6 and 12 months in older men and women.

Methods

In total, 204 men and 447 women who visited an emergency department due to a fall were recruited.

Results

For men, the risk of falling was not significantly associated with osteoporosis at 6 or 12 months. Men with a fall history were 127 and 100 %, respectively, more likely to have a fall at 6 and 12 months than those without. Men who did not use walking aids were 97 % more likely to have a fall at 12 months than those who did. Women with osteoporosis were 246 and 104 %, respectively, more likely to have a fall at 6 and 12 months than those without. Women with a fall history were 129 and 66 %, respectively, more likely to have a fall at 6 and 12 months than those without. Women taking sedatives and hypnotics were 75 and 102 %, respectively, more likely to have a fall at 6 and 12 months than their counterparts. Women with depression were 138 % more likely to have a fall at 6 months and those using walking aids were 59 % more likely to have a fall at 12 months, compared to their counterparts.

Conclusions

Osteoporosis is association with falls for older women but not for older men. Identifying risk factors for recurrent falls in older people may be affected by the follow-up length, as their associations are reduced over time.     

Injuries in infants and small children resulting from witnessed and corroborated free falls

The height of a free fall necessary to cause injury to infants and small children is a confusing and controversial issue among health care, law enforcement, and legal professionals responsible for evaluating cases of possible child abuse. To resolve this confusion, the circumstances of falls were recorded prospectively for 398 consecutive victims of falls seen at Children's Hospital, Oakland, California. From these cases, 106 were selected for further analysis where the falls were witnessed by a second person other than the caretaker and the circumstances of the fall were documented. No injuries occurred in 15 patients, including seven falling more than 10 feet. Mild bruises, abrasions, or simple fractures occurred in 77 patients, including 43 falling more than 10 feet. Severe injuries, including intracranial hemorrhages, cerebral edema, depressed skull fractures, and compound or comminuted fractures occurred in 14 patients falling between 5 and 40 feet. However, no life-threatening injuries occurred in the 3 patients who fell less than 10 feet. These three had small, depressed skull fractures without loss of consciousness, from falling against an edged surface. Only one death occurred in this series, resulting from a fall of 70 feet. In conclusion, infants and small children are relatively resistant to injuries from free falls, and falls of less than 10 feet are unlikely to produce serious or life-threatening injury.     

Incidence and characteristics of falls leading to hip fracture in Iranian population

An estimated one in three adults aged 65 years or older falls each year, making falls a major health concern. Hip fractures are the most serious consequences of falls in elderly people. Identifying the characteristics of falls leading to hip fracture may provide information about high risk individuals, environment, and activities useful for the development of intervention strategies. Little is known, however, about the incidence and characteristics of falls leading to hip fracture in Middle Eastern countries. Therefore, the authors presented data from the Iranian Multicenter Study on Accidental Injuries, a prospective population-based study conducted in 9 provinces of Iran in 2003. All the hospitals serving about 9.5 million people in the study area were prospectively surveyed for any incident injury resulting from accidental events. A total of 2,186 patients (1,372 male, 814 female) were admitted due to any injurious fall events, where 572 (26.2%) of them suffered a hip fracture. Annual incidence rates of injurious fall events and related hip fractures were 116.3 and 30.4 per 100,000 person-years, respectively. These figures were 237.1 and 93.6 per 100,000 person-years for people over the age of 50 years, respectively. 71% of fall injuries and 76% of hip fractures occurred indoors. Among 450 patients with hip fractures >or=50 years of age, 61.8% arose from a fall from standing height or less. Only 1 in these 450 hip fractures occurred at the time of recreational activity. In multivariate logistic regression analysis, no factor was an independent predictor of hip fractures comparing to other fall-related injuries among younger participants (>or=20 and <50 years). For older patients, falls from standing height or loss (odds ratio (OR) = 2.67), falls during walking (OR = 1.71), and falls on stairs (OR = 1.73) were detected as risk factors of hip fracture. Married persons and those falling from a ladder or other elevations were less likely to fracture their hip in this age group. Our data suggest that modification of the factors external to the homes is less likely to prevent more than a small proportion of fall-related hip fractures in Iran. Further studies on this topic have potential applications for developing preventive strategies.     

The use of ultrasound in the diagnosis of injuries of the ulnar collateral ligament of the thumb

We describe the use of a specialist referral clinic and ultrasound assessment for all injuries to the ulnar collateral ligament of the metacarpophalangeal joint of the thumb presenting to an Accident and Emergency (A&E) department. Senior House Officers in the A&E department were able to correctly diagnose only 45% of the ruptures of the ulnar collateral ligament. The overall agreement between specialist clinic examination and ultrasound for injury to the ulnar collateral ligament was 85% (kappa 0.647). When compared with the operative finding ultrasound had a positive predictive value for rupture of 94%. An algorithm is presented for the assessment of injuries to the ulnar collateral ligament in A&E departments.     

Pediatric falls: is height a predictor of injury and outcome?

Falls account for a significant proportion of pediatric injuries and deaths. A retrospective review of pediatric patients (age 0-14 years) was performed to determine whether patterns of injuries and outcomes could be predicted on the basis of the height of the fall. In addition we evaluated the triage criterion "fall greater than 15 feet" for transport of patients to a trauma center. Patients were stratified by the height of the fall: greater than or less than 15 feet. The end points for analysis were the associated injuries and survival. Patients who fell less than 15 feet had a higher incidence of intracranial injuries (and fewer extremity fractures than patients who fell more than 15 feet). Skull fractures were the most frequent injury and were associated with an increase in intracranial injuries in both subgroups. In conclusion low-level falls are associated with significant intracranial injuries. The evaluation of patients sustaining low-level falls should not be limited on the basis of the height of the fall. Using falls of greater than 15 feet as a triage criterion for transport to a trauma center needs to be prospectively evaluated to ensure that critically injured patients are triaged appropriately.     

Nonoperative management of splenic injuries: improved results with angioembolization

BACKGROUND: Nonoperative management (NOM) of patients with severe splenic injuries carries a significant risk of failure. We hypothesized that adding angiographic embolization (AE) to the NOM protocol would decrease the laparotomy rate, and increase the success rate of NOM and splenic salvage rate. METHODS: A protocol introducing AE in the treatment of splenic injuries was implemented. AE was performed in OIS splenic injury grades 3 to 5 and in all cases where signs of ongoing bleeding were encountered regardless of injury grade. Patients included in a prospective study during a 24-month period were compared with a historic control group. RESULTS: Group 1 (before AE) consisted of 69 patients with a mean Injury Severity Score (ISS) of 31, and group 2 (after introducing AE) included 64 patients with a mean ISS of 30. In group 1, 30 patients underwent immediate laparotomy (43%), and the NOM success rate was 79%. After introducing AE, 17 patients underwent immediate laparotomy (27%; p = 0.04), with a NOM success rate of 96% (p = 0.02). Overall splenic salvage rate increased from 57% to 75% (p = 0.02). Angiography was performed in 31 patients in group 2. Embolization was performed in 27 of these patients. AE failure rate was 4%. NOM was successful in 14 of 15 patients with OIS injury grades 4 and 5 after the introduction of AE (93%). CONCLUSION: A formal protocol adding mandatory AE to NOM for severe splenic injuries increased the percentage of patients in whom NOM was attempted, the NOM success rate, and the splenic salvage rate.     

A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries

BACKGROUND: Angiographic embolization (AE) is used with increasing frequency as an alternative to surgery for control of intraperitoneal and retroperitoneal bleeding. There are no prospective studies on its efficacy, safety, and indications. PATIENTS: From April 1999 to June 2001, patients with abdominal visceral organ injuries or major pelvic fractures sent for AE were prospectively studied. Patients were transported to the angiography suite either because they were hemodynamically unstable ("emergent" angiography) or hemodynamically stable but had injuries likely to bleed ("preemptive" angiography). The efficacy of AE was derived from its ability to control bleeding radiographically and clinically; the safety of AE was determined by the complications related to transport, vascular access, catheter insertion, contrast administration, and tissue necrosis after interruption of blood supply to organs. Predictors of bleeding were identified by comparing patients who showed contrast extravasation on angiography with those who did not by univariate and multivariate analysis. RESULTS: Of 100 consecutive patients evaluated by angiography for bleeding from major pelvic fractures (n = 65) or solid visceral organ injuries (n = 35), 57 were found to have active contrast extravasation and were embolized, 23 were found to have indirect signs of vascular injury or ongoing hemodynamic instability and were embolized, and 20 had no signs of bleeding and were not embolized. AE was effective and safe in 95% and 94%, respectively, of 80 patients who were embolized. Four patients had recurrent bleeding after AE and five developed AE-related complications. In three of the four patients, bleeding was controlled by repeat AE. In all five patients, the complications were managed with no further sequelae. Three independent factors were predictive of bleeding identified on angiography: age older than 55 years, absence of long-bone fractures, and emergent angiography. The presence of all three independent predictors was associated with a 95% probability of bleeding; however, the probability of bleeding was still 18% when all three independent predictors were absent. CONCLUSION: AE is highly effective in controlling bleeding caused by abdominal and pelvic injuries and difficult to manage by surgery. Older age, the absence of long-bone fractures, and emergent angiography increase the likelihood of finding active bleeding angiographically. However, there are no clinical characteristics to exclude reliably all patients who are not actively bleeding internally. Because of this and its reasonable safety profile, AE should be offered liberally in patients with selected injuries of the pelvis and abdominal visceral organs.     

Les traumatismes fermés du rein: Notre expérience dans la prise en charge thérapeutique

ObjectiveTo study the results of our therapeutic approach over a period of 5 years to major kidney blunt trauma, and to compare our results to the different series in the literature.Patients and methodsThis is a retrospective study of 44 cases, collected at the urology department at the Ibn Rochd University Hospital of Casablanca, managed over a period between 2005 and 2010.ResultsMean age was 26 years. The sex ratio (M/F) was 10:1. The causes were dominated by highway accidents (21 cases) and falls (9 cases). Four patients presented in shock and received and emergency operation. The radiological assessment allowed the classification of injuries according to the AAST (American Association for the Surgery of Trauma): 25% of grade I, 9% of grade II, 38.6% of grade III, 22.7% grade IV, and 4.5% for grade V. Non-operative management was successful in 33 cases, and required the use of a double J stent in 5 patients for persistent urinary extravasation. Surgical treatment was necessary in 11 cases, 4 in immediate emergency and 7 in delayed emergency after an initial conservative trial.ConclusionOur favorable findings in patients with non-operative management and considering the results of the literature, we believe that in the absence of associated intra-abdominal injuries or hemodynamic instability, expectant management alone remains the therapeutic method of choice.     

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 splenic injury: operation versus angiographic embolization

BACKGROUND: Splenic injuries, like other blunt traumatic injuries, are increasingly treated with non-operative management. Angiographic embolization (AE) has emerged as an alternative modality for treatment of splenic injuries. We hypothesized that splenic embolization would lead to equivalent, if not improved, outcomes in terms of mortality, total costs, complications, and duration of stay. METHODS: A retrospective review of a prospective data set was performed for all adult splenic injuries admitted to our level I trauma center from 2000 through 2003. Demographics, number of red cell units, emergency department hemodynamics, costs, and outcomes were examined. The operative group included those who underwent computed tomography (CT) first then went to the operating room (OR) (CT+OR) or those who went directly to the OR. RESULTS: There were 25 CT+OR and 24 AE patients of 164 blunt splenic injuries. After univariate analysis, higher injury severity score (ISS), lower systolic blood pressure, lower pH, and higher packed red blood cell transfusions were associated with increased mortality and duration of stay. The splenic Abbreviated Injury Scale (AIS; mean +/- SD) was the same for AE compared to CT+OR patients (3.8 +/- 0.4 vs 3.5 +/- 0.9). Although the AE group was older (50 +/- 20 vs 36 +/- 13 years, P < .01), Glasgow Comma Score (13 +/- 4 vs 11 +/- 5), age, highest heart rate (109 +/- 24 vs 120 +/- 43), and splenic AIS were not predictive of the need for an operation. Abdominal complications were lower in the AE group compared to the CT+OR (13% vs 29%), but mortality was not different (8% vs 4%). Total costs were similar for both groups after adjustment for ISS, GCS, pH, pretreatment transfusions, and spleen AIS (AE, $49,300 +/- $40,460 vs CT+OR, $54,590 +/- $34,760). The non-operative failure rate in this study was 2%. CONCLUSIONS: AE of splenic injuries is safe and associated with fewer complications. The spleen AIS, heart rate, age, and GCS did not correlate with the need for an operation. Higher ISS, lower blood pressure, lower pH, and increased number of packed red blood cell transfusions were better indicators of the need for an operation versus embolization.     

The 5-question Geriatric Locomotive Function Scale predicts postoperative fall risk in patients undergoing surgery for degenerative cervical myelopathy

BackgroundFalling is one of the main reasons for which older adults require nursing care. Locomotive syndrome (LS) predicts the need for nursing care; however, the relationship between falling and LS remains unclarified. This study aimed to determine whether the 5-question Geriatric Locomotive Function Scale (GLFS-5) predicts postoperative fall risk in patients with degenerative cervical myelopathy (DCM).MethodsThis study is a post hoc analysis of the data from a prospective cohort of patients undergoing surgery for DCM. Participants recorded their falls in a fall diary from the time of study enrollment (baseline) to 1 year postoperatively. Functional assessments were conducted at baseline, hospital admission for surgery, and 1 year postoperatively. Outcome measures included the GLFS-5, Japanese Orthopaedic Association score, Neck Disability Index, EuroQol 5 Dimensions, and 12-Item Short Form Health Survey. Risk factors for falls were investigated, including previous falls, number of medications, and grip strength. Fallers were divided into two categories: all fallers (≥1 falls), and recurrent fallers (≥2 falls). Variables that were significant in univariate analyses were applied in multiple logistic regression models to adjust for confounders.ResultsFrom the initial group of 168 participants, 159 attended the 1-year follow-up, and 132 fall diaries were retrieved and analyzed. Of these 132 patients, 42 (32%) reported at least one fall, while 25 (19%) reported recurrent falls during the postoperative observation period. The GLFS-5 significantly increased from baseline to admission, and significantly decreased from admission to 1 year postoperatively. In multiple logistic regression analysis, the independent predictors of postoperative recurrent falls were previous falls and a higher baseline GLFS-5. The optimal cut-off value of GLFS-5 for predicting all falls/recurrent falls was 12.ConclusionsThe GLFS-5 reflected time-dependent functional changes in patients undergoing surgery for DCM. Previous falls and a higher baseline GLFS-5 were independent predictors of postoperative recurrent falls.     

Falls from heights among children: a retrospective review.

BACKGROUND: Falls are a major cause of emergency room visits and admissions in pediatric hospitals. METHODS: To better understand the epidemiology of falls from height and develop prevention strategies, the authors reviewed all admissions after a fall at a single institution from 1994 to 1997. Inclusion criteria are falls from a minimum height of 10 feet. RESULTS: Of 1,410 patients admitted after a fall, 64 patients including 45 boys and 19 girls with a mean age of 7.4 years (range, 1 to 18) are included in this study. Fifty (78%) children fell from 20 feet or less (two stories) and 14 (22%) from height greater than 20 feet. Patients mainly fell from balconies (n = 15), windows (n = 13), trees (n = 9), roofs (n = 6), stairs (n = 6), diving board (n = 3) and miscellaneous (n = 12). Over 60% of falls occurred in private houses and during the summer months. Fifty-five patients (86%) sustained only one system injury, two patients had no significant injury, and seven patients had multisystem injury. Major injuries included head trauma (39%), musculoskeletal (34%), abdominal (12%), maxillofacial (8%), and spine (6%). A surgical intervention was required for 43% of intracranial trauma, 39% of musculoskeletal injuries, 60% of facial trauma, and 50% of spine fractures. Mean length of stay in hospital varied according to the injured system. The overall survival rate is 98% with only one death after a fall greater than 50 feet. CONCLUSIONS: Although rarely mortal, falls from height carry a significant morbidity and are costly to the health care system. To decrease the occurrence of injuries caused by falls, strategies should include awareness campaigns, parent's education about the mechanisms of falls, increase parenteral supervision during playing activities, and legislative measures to ensure the safety of windows and balconies before the onset of summer.