Post-traumatic stress disorder following critical illness

Critical illness requiring ICU admission can be a distressing experience for patients and this was highlighted by two pieces of research published last week. This article describes the findings of the research papers and discusses their implications for practice.     

严重急性呼吸系统综合征创伤后应激障碍的评价量表

目的：分析美国创伤后应激障碍研究中心制定的创伤后应激障碍检查量表平时版在中国使用的可行性。方法：于2003-12/2004-01采取整群抽样的方法抽取2003年春辽宁省的SARS确诊患者和医护人员以及在校的医学院校学生为观察对象，包括5组，SARS患者组（辽宁省健在的SARS患者4名，其中大连3名，葫芦岛1名），一线医护人员组（直接为SARS患者治疗和护理的医护人员60名），二线医护人员组（参与SARS排查并在发热门诊和发热病房从事医疗和护理的医护人员50名），普通医护人员组（在普通病房工作的医护人员30名），大学生组（SARS封校期间在校的医学院校学生30名）。采用的问卷和测量工具包括创伤后应激障碍检查量表平时版、美国为临床医生使用的DSM-Ⅳ创伤后应激量表以及自行设计的基本情况问卷，对所有人员进行面对面访谈、心理测量和记录。对所得数据资料进行整理、编码，建立SPSS 10．0数据库，用秩和检验、Speaman相关分析等分析方法进行数据处理。结果：共获得162份有效问卷，将其进行结果分析。在创伤后应激障碍检查量表平时版与创伤后应激量表的相关性分析中，创伤后应激障碍检查量表平时版与创伤后应激量表分为创伤后应激障碍组与非创伤后应激障碍组进行描述可见，创伤后应激障碍检查量表平时版与创伤后应激量表均呈正偏态分布，采用Speaman相关分析，创伤后应激障碍检查量表平时版与创伤后应激量表呈高度正相关。创伤后应激障碍检查量表平时版的90％范围是17～42，总的诊断符合率为91.3％。结论：创伤后应激障碍检查量表平时版可成为国内筛查创伤后应激障碍的临床应用工具，其临床医学参考范围是17-42。     

严重急性呼吸系统综合征创伤后应激障碍的评价量表

目的:分析美国创伤后应激障碍研究中心制定的创伤后应激障碍检查量表平时版在中国使用的可行性。方法:于2003-12/2004-01采取整群抽样的方法抽取2003年春辽宁省的SARS确诊患者和医护人员以及在校的医学院校学生为观察对象,包括5组,SARS患者组(辽宁省健在的SARS患者4名,其中大连3名,葫芦岛1名),一线医护人员组(直接为SARS患者治疗和护理的医护人员60名),二线医护人员组(参与SARS排查并在发热门诊和发热病房从事医疗和护理的医护人员50名),普通医护人员组(在普通病房工作的医护人员30名),大学生组(SARS封校期间在校的医学院校学生30名)。采用的问卷和测量工具包括创伤后应激障碍检查量表平时版、美国为临床医生使用的DSM-Ⅳ创伤后应激量表以及自行设计的基本情况问卷,对所有人员进行面对面访谈、心理测量和记录。对所得数据资料进行整理、编码,建立SPSS10.0数据库,用秩和检验、Spearman相关分析等分析方法进行数据处理。结果:共获得162份有效问卷,将其进行结果分析。在创伤后应激障碍检查量表平时版与创伤后应激量表的相关性分析中,创伤后应激障碍检查量表平时版与创伤后应激量表分为创伤后应激障碍组与非创伤后应激障碍组进行描述可见,创伤后应激障碍检查量表平时版与创伤后应激量表均呈正偏态分布,采用Spearman相关分析,创伤后应激障碍检查量表平时版与创伤后应激量表呈高度正相关。创伤后应激障碍检查量表平时版的90%范围是17～42,总的诊断符合率为91.3%。结论:创伤后应激障碍检查量表平时版可成为国内筛查创伤后应激障碍的临床应用工具,其临床医学参考范围是17～42。     

Mortality burden from motor vehicle accidents in Taiwan

OBJECTIVE: To examine the risk factors contributing to the mortality burden due to road traffic accidents (RTA) in Taiwan. DESIGN: We compared RTA years of life lost (YLL) rates of Taiwan with those of the surrounding region. We also investigated the risk factors described by the police in a Linked Database combined from police-reported accident data and vital registration data. SAMPLE: RTA deaths (3,234 males/1,160 females) in vital registration data and the deaths (2,918 males/1,063 females) in the Linked Database were used. MEASUREMENT: YLL and YLL rate. RESULTS: (1) YLL rates for 15-29 year olds were the highest for Taiwan and the surrounding region. (2) The YLL rate was remarkably high in the first 2 years of the legal motorcycle licensing age for males riding motorcycles. (3) The YLL rates were usually higher during the day, but were higher for young males at night. (4) Overall, the YLL rates were higher when multiple vehicles were involved and for motorcycles with large engines; however, the rate was higher for motorcycles with small engines for the older female group. CONCLUSIONS: The burden due to premature mortality in RTA showed gender disparities and varied by age among personal, environment, and structure factors.     

Facial trauma in motor vehicle accidents: Etiological factors

The effects of seat belts and the use of alcohol and drugs have been studied as etiological factors in facial trauma to occupants of motor vehicle accidents (MVAs). During a 15-month period, 461 patients were admitted to a regional trauma center as a result of injuries sustained in MVAs. Two hundred thirty-seven (51%) of these patients had facial trauma. Facial trauma was the single most common injury in these patients. One hundred eighty-five patients (78%) had major soft tissue injury, and 52 patients (22%) had facial bone fractures. Forty-two of 237 patients (18%) with facial trauma were wearing seat belts compared with 74 of 224 patients (33%) without facial trauma who were wearing seat belts at the time of the accident. Large numbers of patients who were wearing seat belts at the time of the accident had minor injuries and were never admitted to the hospital. Sixty-five of 224 patients (24%) without facial trauma and 121 of 237 patients (51%) with facial trauma tested positive for alcohol or drugs. The majority of the patients who tested positive for alcohol had blood alcohol levels of more than 100 mg/dL. Head injuries and blunt chest trauma were most commonly associated injuries in these patients. This study suggests that use of alcohol and drugs in occupants of the motor vehicle had a major effect on the etiology of facial trauma. Also it supports the data that suggests that the use of seat belts prevents a wide range of injuries including facial trauma in MVAs.     

Extrication of entrapped victims from motor vehicle accidents: the crew concept.

During the extrication process the trauma victim is at high risk for additional injuries or aggravation of existing lesions. Improper handling during extrication with poor concern and knowledge of the ongoing resuscitation process may increase the time spent at the scene and expose the patient to unnecessary risks. Earlier studies report a significant number of neurological injuries that appear to be a result of the extrication process, or of inadequate immobilization during transport. Recent work also underlines the need for appropriate and situation adapted Advanced Life Support (ALS) procedures to improve outcome after prehospital trauma resuscitation. In this paper we present a method for training advanced extrication of trauma victims and the results obtained after five consecutive courses. The training focuses on enhanced liaison between medical and technical team members to optimize synchronization of operations. The course consists of both theoretical lectures and practical training in different crash scenarios. The complexity of the scenarios increases throughout the course and different extrication techniques and strategies are practised. Both the times to extrication and on-scene times were reduced during the 3-day course. Therapeutic interventions and handling of the patient were also improved, in terms of early recognition of medical and technical risks and reduction of the time of no therapy.     

Pneumopericardium in blunt chest trauma after high-speed motor vehicle accidents

Pneumopericardium is the presence of air in the pericardial space. In adults, it may be seen in the context with severe blunt chest trauma, pneumothorax, pneumoperitoneum, or other causes of pneumomediastinum. The diagnosis is made by computed tomography scan of the thorax and abdomen that allows the additional detection of concomitant injuries. Possible causes of the pneumopericardium such as tracheobronchial or oesophageal tears have to be excluded by bronchoscopy or esophagogastroduodenoscopy. Usually, pneumopericardium is self-limiting requiring no specific therapy. However, a continuous monitoring of the electrocardiography and the blood pressure is necessary at an intermediate care unit. Tension pneumopericardium causing a life-threatening cardiac tamponade requires an immediate pericardial aspiration, the subsequent pericardial drainage via a pericardial window or emergent open subxyphoid approach to the pericardium.     

Pacemaker ventricular lead microdislodgement following a motor vehicle accident.

Pacemaker lead dislodgement can be defined as any lead position change, whether the functionality of the pacemaker is affected or not. Only dislodgements that provoke a malfunction in the pacing system, however, are clinically relevant. Lead dislodgement can be categorized as 'macro' or 'micro' dislodgement depending upon the presence of radiographic evidence. This case illustrates a case of lead microdislodgement after a low-impact motor vehicle accident. The lead tip was minimally displaced; enough to produce an increase in capture threshold and eventually loss of capture while keeping near normal lead impedance values. Review of the literature shows that ventricular lead dislodgement after a motor vehicle accident is a rare incidence and cause of pacemaker malfunction.     

Return visits to the emergency room after minor trauma from motor vehicle accidents.

Most patients with minor trauma following motor vehicle accidents (MVAs) are discharged from the emergency room (ER) of a trauma centre after evaluation and observation. Some return with similar or additional symptoms. This study aimed to determine which patients returned, if any injuries had been missed, and what should be the policy of medical management. We reviewed the records of 8836 patients with minor trauma following MVAs who were examined in an inner city trauma centre during 1997. When the group of patients who returned to the emergency room (n = 160) was compared with the whole post-MVA minor trauma group, the former was found to have more males (75.6% vs. 55.9%), younger age (36.31 years vs. 39.72 years), more motorcyclists than drivers, passengers and pedestrians ( p < 0.002, for the three variables), and had more multi-site injures. During the return visits the patients stayed longer in the emergency room, were examined by more consultants and had repeated radiological evaluations and tests, compared with the initial visit. However, in none of the patients was the initial diagnosis revised nor were additional injuries found and consequently the initial management was not changed in any of them. It is concluded that the initial thorough evaluation by the primary traumatologist is adequate for MVA patients with minor trauma. These patients do not require any follow up in specialized clinics, and are best managed in the community by their general practitioners.     

Alcohol intoxication increases morbidity in drivers involved in motor vehicle accidents

We prospectively examined the correlation of alcohol intoxication with injury severity, morbidity, and mortality in drivers involved in motor vehicle accidents in a prospective cohort study. The study enrolled 923 injured patients, of whom 421 were legally intoxicated (blood alcohol concentration [BAC] > or = 50 mg/dL) and 502 were not intoxicated (BAC < 50 mg/dL). The intoxicated drivers had a significantly higher injury severity score (ISS), lower Glasgow Coma Score, lower systolic blood pressure; higher rate in old age, male sex, greater rate of habitual drinking, greater lack of use of safety gear, and greater accident-related morbidity. After logistic regression analysis, alcohol intoxication was not associated with severe injury (ISS > or = 9); however, alcohol intoxication analyzed either as a preinjury or postinjury risk factor, was one of the predictors for morbidity. Severe head injury was the only predictor of mortality. In conclusion, although alcohol intoxication is not associated with an increased incidence of severe injury or mortality in drivers involved in motor vehicle crashes, it is one of the significant predictors for morbidity after injury.     

Cervical spine fracture following a motor vehicle accident

We present the case of a 50-year-old man who visited our emergency department 12 h after an alcohol-related motor vehicle accident complaining of shoulder pain and neck stiffness. Cervical spine radiographs were obtained and interpreted as normal, and the patient was discharged. Subsequent review by a radiologist raised the question of a second cervical vertebra (C-2) abnormality, and the patient was recalled. Cervical computed tomography (CT) scan revealed an unstable oblique fracture of C-2 and a congenital nonfusion of the arch of C-1. The patient was placed in halo traction, and subsequent radiographs revealed a fracture of the transverse process of C-7. The patient made an uneventful recovery. The limitations of routine cervical radiographs are well-documented, but no feasible alternative exists as a screening procedure. Thus, a certain level of uncertainty must be accepted. Both physician and patient must recognize the limitations inherent in all medical practice and that follow-up examination and treatment are essential.     

Persistent shoulder pain following a motor vehicle accident

A 29-year-old woman had intermittent left shoulder pain during a 4-month period following a motor vehicle accident. Sudden development of a pleuritic component was noted. An elevated left hemidiaphragm of the chest radiograph prompted an ultrasound examination of the abdomen, which revealed a 15-cm complex mass in the left upper quadrant. At surgery, a tumor mass attached to the splenic artery, stomach, and diaphragm was removed. Pathologic studies revealed an encapsulated adrenal hematoma. This case represents an unusual cause of persistent shoulder pain due to diaphragmatic irritation by an adrenal hematoma.