伴直肠肛管损伤的开放性骨盆骨折的早期急救处理策略及死亡危险因素分析

目的 探讨伴有直肠、肛管损伤的开放性骨盆骨折的早期急救处理策略及死亡危险因素.方法 回顾性分析2001年4月至2010年4月两家医院救治的25例伴有直肠、肛管损伤的开放性骨盆骨折患者,男23例,女2例;年龄16～56岁,平均(30.1±10.9)岁.采用Fisher精确概率法及多因素Logistic回归分析法对可能的死亡危险因素进行统计学分析.结果 19例存活,6例死亡,死亡率为24%.经Fisher精确概率法分析显示:骨盆骨折Tile分型、创伤严重程度评分(injury severity score,ISS)、格拉斯哥昏迷评分(glasgow coma score,GCS)及改良创伤评分(revised trauma score,RTS)是此类损伤的死亡危险因素.当Tile分型为C型、ISS≥25分、GCS≤8分或RTS≤8分时,患者的死亡概率较大.对此4个危险因素进行多因素Logistic回归分析后发现,RTS≤8分是此类损伤的独立危险因素.结论 积极稳定血流动力学,创口彻底清创引流,早期结肠造瘘以及骨盆固定是此类损伤早期急救处理的关键.RTS是否≤8分可作为判断患者死亡概率的可靠指标.     

Reamed versus unreamed nail in the treatment of tibia shaft fractures

Purpose

The aim of the prospective randomized study was to compare the results of the treatment of tibia shaft fractures (TSF) by reamed or unreamed intramedullar nail.

Methods

There were 103 patients with 104 TSF enrolled in the study within the period from December 2005 to June 2010. Seven patients were excluded from the study. Factors of injury severity, course of surgery and hospitalization, and incidence of early and delayed complications were recorded. X-ray was performed every 4 weeks until the fracture was healed. Functional results were evaluated at least 1 year after the surgery. Closed fractures were classified according to Tscherne classification and the open ones according to Gustilo classification.

Results

Forty-eight patients with 49 TSF were treated by unreamed tibial nail. There were 15 women and 33 men in this group. Injury severity score (ISS) ranged from 4 to 25 (ø 6.63). There were 45 closed fractures (0 16; I 22; II 7) and four open fractures (I 2; II 1; IIIA 1). In the reamed nail group there were 48 TSF. ISS ranged from 4 to 18 (ø 6.13). There were 35 closed (0 17; I 13; II 5) and 13 open (I 5; II 5; IIIA 3) fractures in this group. The time of operation was on average 15 min shorter in the unreamed nail group. X-ray healing was the same in both groups (18.12 versus 17.92 weeks). We had four patients in the unreamed nail group and six patients in the reamed nail group with delayed healing (28–44 weeks). We recorded no infection, loss of reduction or re-operation in both groups. Follow-up of functional results was 90 %.

Conclusions

There was no statistically significant difference in clinical and functional results between the groups. We suggest that both methods are comparable.     

Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures

Background

Open pelvic fractures are life-threatening injuries. Preperitoneal pelvic packing (PPP) has been suggested to be ineffective for hemorrhage control in open pelvic fractures. We hypothesize that PPP is effective at hemorrhage control in patients with open pelvic fractures and reduces mortality.

Paediatric pelvic ring fractures and associated injuries

Introduction

Paediatric pelvic fractures have been infrequently reviewed. The study was performed to highlight the unique features of pelvic fractures in children.

Patients and methods

A 14-year retrospective study was undertaken of all patients treated for a pelvic fracture at our institute.

Results

Thirty-nine children were included. The mean Injury Severity Score (ISS) was 17.1 (range 4–75). Simple ring fractures were the most common type (46%), dominated by pedestrian versus motor vehicle trauma (58.9%). A pelvic fracture was evident on the initial plain radiographs of all 39 children. Further radiographic investigations (12 CTs and 1 MRI) were undertaken in 13 (33%) of the children. Additional posterior ring fractures were identified in 9. A total of 32 children (82%) sustained one or more associated injuries. Head injuries accounted for 25% and orthopaedic/skeletal injuries for 33% of all associated injuries. Fourteen children required a total of 24 acute surgical procedures. Mean out-pateint clinical follow-up was for 27 months (range 3–85). There was one mortality in this series. Eight children (20%) suffered long term sequale.

Conclusion

Paediatric pelvic fractures differ from their adult counterpart in aetiology, fracture type, and associated injury pattern. They represent a reliable marker for severe trauma. Prospective studies are required to define optimal treatment guidelines, particularly in older children.     

Pelvic injuries in childhood and adolescence: Retrospective analysis of 5-year data from a national trauma centre

Background

Pelvic fractures are uncommon injuries in paediatric trauma patients because of specific anatomical features. Due to the low incidence there is no standardized therapeutic algorithm.

Material and methods

This retrospective review evaluates paediatric pelvic fractures of a Level I Trauma Centre over 5 years. In addition, we compared the data with adult pelvic fractures and reviewed the literature. A total of 37 pelvic fractures (??16 years) were documented, with an incidence of 9.9% in the child with multiple injuries. The most common injury mechanisms were traffic accidents, followed by falls from heights.

Results

Type A injuries occurred in 50% (type B: 16%, type C: 27%, acetabular injuries: 11%). Osteosynthesis was performed in nine cases. Therapeutic intervention was necessary in three cases of haemodynamically relevant bleeding; 97% of all children had associated injuries (mean ISS: 38).

Conclusion

Our data showed some differences to the literature. Pelvic fractures are predictors for high injury severity. Despite similar fracture pattern, in contrast to adults most injuries could be treated non-operatively. In unstable or dislocated fractures open reduction and stabilization must be performed.     

Pelvic ring fractures: has mortality improved following the implementation of damage control resuscitation?

Background

Over the last 10 years, the paradigm of damage control resuscitation (DCR) has been associated with improved patient outcomes. This study investigates the outcomes of both closed and open pelvic ring fractures at a single institution before and after the formal implementation of DCR principles.

Methods

A retrospective chart review was performed in an urban level I trauma center of all patients who sustained open or closed pelvic ring fractures between 2002 and 2012.

Results

Two thousand two hundred forty-seven patients presented with pelvic fractures between 2002 and 2012. Overall mortality was 10% (n = 212). Only 8% of all patients with closed fractures required DCR compared with 28% of patients with open fractures. There was no difference in mortality when comparing DCR and pre-DCR cohorts for either open or closed pelvic fractures.

Conclusions

Interestingly, although DCR seems to lead to more efficient initial resuscitations, further improvements in patient mortality were not realized with formal implementation of DCR principles.     

Bladder injuries after external trauma: 20 years experience report in a population-based cross-sectional view

Objectives

Report 20 years experience of bladder injuries after external trauma.

Methods

Gender, age, mechanism/location of damage, associated injuries, systolic blood pressure (SBP), Revised Trauma Score (RTS), Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), complications, and length of stay (LOS) were analyzed in a prospective collected bladder injuries AAST-OIS grade ≥II database (American Association for the Surgery of Trauma Organ Injury Scaling) from 1990 to 2009 in a trauma reference center.

Results

Among 2,575 patients experiencing laparotomy for trauma, 111 (4.3 %) presented bladder ruptures grade ≥II, being 83.8 % (n = 93) males, mean age 31.5 years old (±11.2). Blunt mechanism accounted for 50.5 % (n = 56)–motor vehicle crashes 47.3 % (n = 26), pedestrians hit by a car (29.1 %). Gunshot wounds represented 87.3 % of penetrating mechanism. The most frequent injury was grade IV (51 patients, 46 %). The mean ISS was 23.8 (±11.2), TRISS 0.90 (±0.24), and RTS 7.26 (±1.48). Severity (AAST-OIS), mechanism (blunt/penetrating), localization of the bladder injury (intra/extraperitoneal, associated), and neither concomitant rectum lesion were related to complications, LOS, or death. Mortality rate was 10.8 %. ISS > 25 (p = 0.0001), SBP <90 mmHg (p = 0.0001), RTS <7.84 (p = 0.0001), and pelvic fracture (p = 0.0011) were highly associated with grim prognosis and death with hazard ratios of 5.46, 2.70, 2.22, and 2.06, respectively.

Conclusions

Trauma scores and pelvic fractures impact survival in bladder trauma. The mortality rate has remained stable for the last two decades.     

Pelvic trauma: What are the predictors of mortality and cardiac,venous thrombo-embolic and infectious complications following injury?

Introduction

This study sought to determine risk factors that influence mortality, cardiac events, venous thrombo-embolic disease (VTED), and infection following fractures of the pelvis and/or acetabulum.

Methods

The 2008 National Sample Program (NSP) of the National Trauma Databank was queried to identify all patients who sustained pelvic and acetabular fractures. Demographic data, injury-specific and surgical characteristics, and medical co-morbidities were abstracted. The occurrence of in-hospital mortality, cardiac events, VTED and infections were documented. Univariate testing, weighted logistic regression, and sensitivity analyses were performed to identify significant independent predictors of mortality and the complications under study.

Results

The NSP contained 41,297 cases of pelvic trauma. In-hospital mortality was documented in 3055 (7%) and one or more complications occurred in 6932 (17%). Cardiac events transpired in 2% of patients, VTED in 4% and infections in 3%. Increasing age, shock, time to procedure, ISS, and GCS were predictive of mortality. Cardiac events were found to be influenced by obesity, diabetes, ISS, GCS, age, and trauma mechanism. VTED was impacted by obesity, history of respiratory disease, male sex, ISS, GCS, medical co-morbidities, and time to procedure. Injuries caused by mechanisms other than blunt trauma, shock, age, ISS, GCS, medical co-morbidities, and time to procedure were associated with infection.

Conclusions

Several important predictors were identified for specific complications and mortality following pelvic trauma. The design of this study may render it more generalisable to American patients with pelvic injuries.

Level of evidence

II – Prognostic retrospective study of a prospective dataset.     

Survival trends and predictors of mortality in severe pelvic trauma: estimates from the German Pelvic Trauma Registry Initiative

Study objective

To determine longitudinal trends in mortality, and the contribution of specific injury characteristics and treatment modalities to the risk of a fatal outcome after severe and complex pelvic trauma.

Methods

We studied 5048 patients with pelvic ring fractures enrolled in the German Pelvic Trauma Registry Initiative between 1991 and 1993, 1998 and 2000, and 2004 and 2006. Complete datasets were available for 5014 cases, including 508 complex injuries, defined as unstable fractures with severe peri-pelvic soft tissue and organ laceration. Multivariable mixed-effects logistic regression analysis was employed to evaluate the impact of demographic, injury- and treatment-associated variables on all-cause in-hospital mortality.

Results

All-cause in-hospital mortality declined from 8% (39/466) in 1991 to 5% (33/638) in 2006. Controlling for age, Injury Severity Score, pelvic vessel injury, the need for emergency laparotomy, and application of a pelvic clamp, the odds ratio (OR) per annum was 0.94 (95% confidence interval [CI] 0.91–0.96). However, the risk of death did not decrease significantly in patients with complex injuries (OR 0.98, 95% CI 0.93–1.03). Raw mortality associated with this type of injury was 18% (95% CI 9–32%) in 2006.

Conclusion

In contrast to an overall decline in trauma mortality, complex pelvic ring injuries remain associated with a significant risk of death. Awareness of this potentially life-threatening condition should be increased amongst trauma care professionals, and early management protocols need to be implemented to improve the survival prognosis.     

Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: A multivariate analysis of factors affecting deep infection and fracture healing

Background:

The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis.

Materials and Methods:

We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (≤6 h or >6 h), method of soft-tissue management, skin closure time (≤1 week or >1 week), existence of polytrauma (ISS< 18 or ISS≥18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection.

Results:

Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion (P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r² = 0.263, P = 0.0001).

Conclusion:

Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.     

Fall from heights: does height really matter?

Introduction

Fall from heights is high energy injuries and constitutes a fraction of all fall-related trauma evaluations while bearing an increase in morbidity and mortality. We hypothesize that despite advancements in trauma care, the overall survivability has not improved in this subset of trauma patients.

Methods

All adult trauma patients treated after sustaining a fall from heights during a 40-month period were retrospectively reviewed. Admission demographics, clinical data, fall height (ft), injury patterns, ISS, GCS, length of stay, and mortality were reviewed.

Results

116 patients sustained a fall from heights, 90.4% accidental. A mean age of 37± 14.7 years, 86% male, and a fall height of 19 ± 10 ft were encountered. Admission GCS was 13 ± 2 with ISS 10 ± 11. Overall LOS was 6.6 ± 14.9 days and an ICU LOS of 2.8 ± 8.9 days. Falls ≥ 25 ft.(16%) had lower GCS 10.4 ± 5.8, increased ISS 22.6 ± 13.8, a fall height 37.9 ± 13.1 ft and associated increased mortality (p < 0.001). Mortality was 5.2%, a mean distance fallen of 39 ± 22 ft. and an ISS of 31.5 ±16.5. Brain injury was the leading cause of death, 50% with open skull fractures.

Conclusion

Level of height fallen is a good predictor of overall outcome and survival. Despite advances in trauma care, death rates remain unchanged. Safety awareness and injury prevention programs are needed to reduce the risk of high-level falls.

     

Management of open fractures of the tibial shaft in multiple trauma

Background:

The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients.

Materials and Methods:

The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8–10 days after the trauma.

Results:

The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation.

Conclusion:

Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8–10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture.     

Blunt aortic injury: risk factors and impact of surgical approaches

Purpose

This study reviews our 17-year experience of managing blunt traumatic aortic injury (BTAI).

Methods

We analyzed information collected retrospectively from a tertiary trauma center.

Results

Between October 1995 and June 2012, 88 patients (74 male and 14 female) with a mean age of 39.9 ± 17.9 years (range 15–79 years) with proven BTAI were enrolled in this study. Their GCS, ISS, and RTS scores were 12.9 ± 3.7, 29.2 ± 9.8, and 6.9 ± 1.4, respectively. Twenty-one (23.8 %) patients were managed non-operatively, 49 (55.7 %) with open surgical repair, and 18 (20.5 %) with endovascular repair. The in-hospital mortality rate was 17.1 % (15/81) and there were no deaths in the endovascular repair group. The mean follow-up period was 39.9 ± 44.2 months. The survivors of blunt aortic injury had lower ISS, RTS, TRISS, and serum creatinine level and lower rate of massive blood transfusion, shock, and intubation than the patients who died, despite higher rates of endovascular repair, hemoglobin, and GCS on presentation. The degree of aortic injury, different therapeutic options, GCS, shock presentation, and intubation on arrival all had significant impacts on outcome.

Conclusions

Shock, aortic injury severity, coexisting trauma severity, and different surgical approaches impact survival. Endovascular repair achieves a superior mid-term result and is a reasonable option for treating BTAI.

     

Adrenal Injuries: Historical Facts and Modern Truths

Background

Prior to the advent of whole body computed tomography, injuries of the adrenal gland were almost exclusively identified on postmortem examinations and were associated with severe injury. Recent literature has continued to identify an association between adrenal injuries and high ISS. The purpose of this study was to assess the influence of adrenal trauma on ISS and mortality while controlling for potential confounding factors.

Methods

A 15-year retrospective review for all adrenal gland injuries from a Level 1 Trauma Center’s Trauma Registry was performed. Based on the characteristics of that patient population, the same Trauma Registry was then queried for case-matched patients, and the two groups compared to assess the influence of adrenal gland injuries on mortality.

Results

Seventy-two patients with adrenal injuries were identified and compared to 1026 case-matched patients. The adrenal gland injury was not a contributing factor in any of the study group mortalities. The mean ISS for the adrenal gland injured group was higher than the overall Registry ISS (18.7 vs 10.6) but almost identical to the ISS of patients case matched for abdominal injuries.

Conclusion

Case-matched analysis based on multiple clinical variables demonstrates that the ISS of patients with adrenal gland injuries were similar to the ISS of patients with other injuries to the abdominal region and were in fact associated with a 0.02% decrease in mortality.

     

Pelvic fractures in the Netherlands: epidemiology,characteristics and risk factors for in-hospital mortality in the older and younger population

Purpose

To examine nationwide epidemiology of pelvic fractures in the Netherlands and to compare characteristics and outcome of older versus younger patients as well as predictors for in-hospital mortality.

Methods

Retrospective review of pelvic fracture patients admitted to all Dutch hospitals (2008–2012) utilizing National Trauma Registry. Average annual incidence of (minor and major) pelvic fractures was calculated for the population. Older (≥ 65 years) and younger (< 65 years) patients were compared. Multivariate regression analysis was performed to identify independent predictors for in-hospital mortality.

Results

Of 11,879 pelvic fracture patients (61.8%, ≥ 65 years), annual incidence of pelvic fractures in older versus younger population was 57.9 versus 6.4 per 100,000 persons. Older patients had lower ISS (7.1 (SD 6.9) vs 15.4 (SD 13.4)) and less frequently had severe associated injuries (15.6 vs 43.5%), an admission systolic blood pressure (SBP) ≤ 90 mmHg (1.6 vs 4.1%) or Glasgow Coma Score (GCS) ≤ 12 (2.0 vs 13.3%) (all, p < 0.01). In-hospital mortality was equal in older and younger patients (5.3 vs 4.8%: p = 0.28). In both subgroups, greatest independent predictors for in-hospital mortality were GCS ≤ 12, ISS ≥ 16, and SBP ≤ 90 mmHg and in all patients age ≥ 65 (OR 6.59 (5.12–8.48): p < 0.01).

Conclusion

The annual incidence of (both minor and major) pelvic fractures in the older population was substantially higher than in the younger population. Elderly patients had a disproportionately high in-hospital mortality rate considering they were less severely injured. Among other factors, age was the greatest independent predictor for in-hospital mortality in all pelvic fracture patients.

     

Pelvic fractures in polytrauma: which classification system better predicts hemodynamic instability?

Introduction and objectives

The correlation between pelvic fracture pattern and mortality has been previously investigated and demonstrated. However, the purpose of our investigation was to evaluate the relationship between hemodynamic instability and pelvic fracture pattern according to different classifications.

Materials and methods

A retrospective study of high-energy pelvic fractures was performed for consecutive patients admitted to our Level I trauma center between June 2007 and June 2010. A total of 759 polytrauma patients were attended, 100 of whom had a pelvic fracture and were included in our study. Demographic data, mechanism of injury, and associated injuries were recorded. The patients were classified as hemodynamic stable or unstable. The pelvic fracture patterns were divided into stable and unstable group according to the Young-Burgess and Tile classifications. Statistical analysis was performed to determine the relationship between fracture pattern and hemodynamic instability.

Results

High-energy pelvic fracture was more frequent in men (70 %), the mean age was 45.2 years, and the mortality rate was 24 %. The main mechanism of injury was motor vehicle injury (41 %). Pelvic fracture pattern (neither Tile classification nor Young-Burgess classification) showed no correlation with the hemodynamic condition of the patient in our study (p?>?0.05). Death could neither be predicted on the basis of pelvic fracture pattern (p?>?0.05). We found a statistical association between patients affected by high-energy pelvic fracture and head injury, and death (p?<?0.01).

Conclusion

Pelvic fracture pattern is not useful to predict hemodynamic instability in polytrauma, regardless of the classification system used. Pelvic fracture pattern is not useful to predict mortality risk; however, it contributes to increase mortality risk in cases of associated head injury.     

Treatment Outcomes of Open Pelvic Fractures Associated with Extensive Perineal Injuries

Background

The main causes of death in patients with open pelviperineal injuries are uncontrollable bleeding and pelvic sepsis. The aim of this study was to evaluate the management outcomes of open pelvic fractures associated with extensive perineal injuries.

Methods

We retrospectively studied 15 cases with open pelvic fractures associated with extensive perineal injuries (urethral and anal canal laceration) admitted between August 2006 and September 2010. Mechanism of injury, Injury Severity Score, associated injuries, hemodynamic status on arrival, resuscitation and transfusion requirements, operative techniques, intra- and postoperative complications, length of intensive care unit and hospital stay, and mortality were recorded in a computerised database for further evaluation and analysis.

Results

The male to female ratio was 12:3 with an average age of 38.6 years (ranged, 11 to 65 years). The average packed red blood cell units used were 8 units (ranged, 4 to 21 units). All patients were initially transferred to the operating room for colostomy, radical debridement and fixation of the pelvic fracture by an external fixator. One patient had acute renal failure, which improved with medical treatment and 2 patients (13.3%) died, one with type III anteroposterior compression fracture due to hemorrhagic shock and the other due to septicemia.

Conclusions

Open pelvic fractures with extensive perineal injuries are associated with high mortality rates. Early diagnosis and appropriate treatment, including reanimation, colostomy, cystostomy, vigorous and repeated irrigation and debridement, and fixation by an external fixator can improve the outcomes and reduce the mortality rate.     

Thoracic trauma severity contributes to differences in intensive care therapy and mortality of severely injured patients: analysis based on the TraumaRegister DGU®

Background

Thoracic trauma is a relevant source of comorbidity throughout multiply-injured patient care. We aim to determine a measurable influence of chest trauma’s severity on early resuscitation, intensive care therapy, and mortality in severely injured patients.

Methods

Patients documented between 2002 and 2012 in the TraumaRegister DGU®, aged ≥?16 years, injury severity score (ISS) ≥ 16 are analyzed. Isolated brain injury and severe head injury led to exclusion. Subgroups are formed using the Abbreviated Injury Scale_Thorax.

Results

Twenty-two thousand five hundred sixty-five patients were predominantly male (74%) with mean age of 45.7 years (SD 19.3), blunt trauma (95%), mean ISS 25.6 (SD 9.6). Overall mean intubation period was 5.6 days (SD 10.7). Surviving patients were discharged from the ICU after a mean of about 5 days following extubation. Thoracic trauma severity (AIS_Thorax ≥ 4) and fractures to the thoracic cage significantly prolonged the ventilation period. Additionally, fractures extended the ICU stay significantly. Suffering from more than one thoracic injury was associated with a mean of 1–2 days longer intubation period and longer ICU stay. Highest rates of sepsis, respiratory, and multiple organ failure occurred in patients with critical compared to lesser thoracic trauma severity.

Conclusion

Thoracic trauma severity in multiply-injured patients has a measurable impact on rates of respiratory and multiple organ failure, sepsis, mortality, time of mechanical ventilation, and ICU stay.

     

Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery?

Purpose

Early operative control of hemorrhage is the key to saving the lives of severe trauma patients. We investigated whether emergency room (ER) stay time [time from the ER to the operating room (OR)] is associated with trauma severity and unexpected trauma death [Trauma and Injury Severity Score (TRISS) method-based probability of survival (Ps) ≥0.5 but died] of injured patients needing emergency trauma surgery.

Methods

We performed a retrospective review of all trauma patients requiring emergency surgery and all patients with pelvic fractures requiring transcatheter arterial embolization at our hospital from January 2002 to December 2012. We analyzed the relationships among injury severity on ER admission [Injury Severity Score (ISS); Revised Trauma Score (RTS); Ps; Shock Index (SI); American Society of Anesthesiologists Physical Status (ASA-PS)]; mortality rate; unexpected trauma death rate; and ER stay time.

Results

ER stay times were significantly shorter for patients with life-threatening conditions [RTS <6.0 (p < 0.01), Ps <0.5 (p < 0.001), SI ≥1.0 (p < 0.01), and ASA-PS ≥4E (p < 0.001)]. In particular, ER stay time was inversely related to injury severity up to 120 min. The risk of unexpected trauma death significantly increased as ER stay time increased over 90 min (p < 0.01).

Conclusions

Our results suggest that all medical staff should work together effectively on high-risk patients in the ER, bringing them immediately to the OR according to their level of risk. If injured patients need emergency trauma surgery, ER stay times should be kept as short as possible to reduce unexpected trauma death.     

The outcome of open pelvic fractures in the modern era

BACKGROUND: Recent series have reported that the mortality rate of open pelvic fractures has decreased to < 10%. These injuries are often associated with intra-abdominal visceral damage, although few series have documented the prognostic significance of this injury complex. METHODS: A retrospective review in an urban level I trauma center of all patients who sustained open pelvic fracture between 1995 and 2004. RESULTS: Forty-four patients were identified as having sustained open pelvic fracture. Average Injury Severity Score was 30, with 77% of patients having a score > or = 16. Overall mortality was 45% (n = 20): 11 early deaths and 9 late deaths at an average of 17 days. Vertical shear injuries, although rare, were universally fatal. Other risk factors for overall mortality included revised trauma score, Injury Severity Score, transfusion requirement, Faringer zones I or II injury, Gustilo grade III soft tissue injury, need for therapeutic angiography, and presence of intra-abdominal injury, the latter of which conferred 89% mortality. Risk factors for late deaths also included pelvic sepsis, which occurred in 5 patients and was fatal in 3 (60%). CONCLUSIONS: The morbidity of open pelvic fractures remains high. Associated intra-abdominal injury or active arterial bleeding requiring therapeutic angiography is associated with a grim prognosis. There is a continuing need for new therapeutic approaches to this injury complex.