Clinical and autopsy analysis of delayed diagnosis and missed injuries in trauma patients

Delayed diagnosis of injury (DDI) during hospitalization and missed injuries (MI) on autopsy in trauma deaths result in untoward outcomes. Autopsy is an effective educational tool for health care providers to evaluate trauma care. A retrospective study of trauma registry patients and coroner's records was categorized into groups 1 (alive patients) and 2 (trauma deaths) and analyzed. DDI incidence was similar in group 1 (1.8%) and group 2 (1.9%). Autopsy analysis (163 patients) yielded 139 MI in 94 patients (57.6%), <3 per cent of MI had negative impact on survival. Bony injuries comprised 68 per cent of DDI and 19 per cent of MI. Group 1 DDI patients were sicker with higher injury severity score (ISS: 16.07) than their cohorts (ISS 7.13, P value <0.05). These patients had higher Glasgow Coma Scale (14.41) and lower ISS (16.07) as compared with group 2 MI patients (ISS: 33.49, GCS: 6.45, P value < 0.05). Autopsy rate was 99.5 per cent in trauma deaths, 57 per cent for nontrauma deaths, and 79 per cent for all deaths. Less than 3 per cent of MI had negative impact on survival. Routine ongoing patient assessment with pertinent diagnostic workup is essential in reducing DDI. Trauma autopsies reveal MI, which aid performance improvement (PI).     

Prognostic determinants in duodenal injuries

A retrospective review of 222 consecutive patients with duodenal injuries admitted to an urban Level 1 Trauma Center who subsequently underwent laparotomy during the period July 1980 to April 2002 was performed in an effort to elucidate factors associated with mortality, infectious morbidity, and length of stay in these patients. Predictably, the patients were predominantly male (92.7%) and young (mean age, 31.6 years). The overall mortality rate was 22.5 per cent, with a mortality rate of 18 per cent seen in the first 48 hours. Penetrating trauma was suffered by 88.3 per cent of the patients. Multivariate analysis revealed the performance of a thoracotomy, initial emergency department (ED) systolic blood pressure (SBP) <90 mm Hg, final operating room (OR) core body temperature less than 35 degrees C, and presence of a splenic injury to be the most important predictors of mortality (all P < 0.05). Mortality in the patients undergoing a resuscitative thoracotomy was 88.9 per cent versus 13.3 per cent in those patients not requiring thoracotomy. An initial SBP in the ED <90 was associated with a 46 per cent mortality rate, as compared with 4 per cent in those patients not in shock. A final OR core body temperature of less than 35 degrees C led to a 60 per cent mortality rate versus 8.3 per cent for warmer patients. Patients with a concomitant splenic injury were noted to have a 62.5 per cent mortality rate; those without had a 19.4 per cent mortality rate. The mean length of stay among survivors greater than 48 hours was 16.0 +/- 24.7 days. Univariate analyses revealed lowest OR core body temperature below 35 degrees C, initial OR SBP <90, presence of infection, >5 transfusions, initial ED SBP <90, final OR core temperature <35 degrees C, colon injury, spleen injury, and an injury severity score (ISS) >25 all to be significantly associated with increased length of stay. Multivariate analysis revealed an initial operating room blood pressure of less than 90 mm Hg systolic, the presence of an infection, and greater than 5 blood transfusions to be the factors most significantly correlated with increased length of stay (all P < 0.02). Of 182 patients surviving 48 hours, 98 (54%) developed an infection. Fifty-seven (31%) patients were noted to have wound-related infections, 92 (51%) patients had nosocomial infections, and 50 (27%) patients had both types. The presence of an abdominal arterial injury, an ISS >25, pancreatic injury, and lowest OR core body temperature <35 degrees C were the factors identified on multivariate analysis most significantly correlated with infectious morbidity (all P < 0.05). This data suggests that early efforts to prevent shock and rapidly control bleeding are the most likely efforts to reduce mortality rates in these patients. Those patients with duodenal injury presenting in shock or requiring a thoracotomy for resuscitation did poorly. Splenic injury was the associated injury found on multivariate analysis to be most closely associated with increased mortality. Early control of bleeding and the prevention of infection provide the most significant opportunity for decreasing length of stay. Infections are common with duodenal injuries, and aggressive surveillance should especially be performed in those patients with an abdominal arterial injury, an ISS >25, pancreatic injury, or lowest OR core body temperature <35 degrees C.     

Obesity does not affect mortality after trauma

Although obesity has been proposed as a risk factor for adverse outcomes after trauma, numerous studies report conflicting results. The objective of this study was to compare outcomes of obese and nonobese patients after trauma. The study population consisted of all trauma patients admitted to a surgical intensive care unit in a Level I trauma center from January 1999 to December 2002. Admission data, demographics, injury severity score (ISS), severity of illness, hospital course, complications, and outcomes were compared between obese (OB; body mass index [BMI] > or = 30), and nonobese patients (NOB; BMI < or = 29). A total of 918 patients was included in the study, 135 OB (14.7%) and 783 NOB (85.3%). There was no significant difference in demographic data, ISS, APACHE II score, and hospital stay. Intensive care unit stay was longer for OB patients (6.8 vs 4.8 days, P = 0.04). Overall mortality was 5.9 per cent for OB and 8.0 per cent for NOB patients (P = 0.48). Mortality by mechanism of injury was 3.4 per cent OB versus 7.4 per cent NOB (P = 0.26) for blunt and 10.6 per cent OB versus 10.2 per cent NOB (P = 0.9) for penetrating injury. The three most common complications associated with death were pulmonary, cardiovascular, and neurological deterioration. Using logistic regression analysis, age and ISS and APACHE II scores were associated with mortality, but BMI was not. We conclude that obesity does not appear to be a risk factor for adverse outcomes after blunt or penetrating trauma. Further research is warranted to uncover the reason for discrepant findings between centers.     

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

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

Is field hypotension a reliable indicator of significant injury in trauma patients who are normotensive on arrival to the emergency department?

There is a subset of trauma patients who are hypotensive in the field but normotensive on arrival to the emergency department (ED). Our objective was to evaluate the presence, type, and severity of injuries in these patients. Data were retrospectively reviewed from patients treated at a level 1 trauma center over 1 year. Hypotension was defined as systolic blood pressure (SBP) less than 90 mm Hg. Forty-seven patients were included. The mechanism of injury was blunt in 37 patients and penetrating in 10. The average field SBP was 76 +/- 11 mm Hg. The average SBP on arrival to the ED was 120 +/- 19 mm Hg. The average injury severity score (ISS) was 16.3 +/- 10.3 (range, 1-43). Twenty-four patients (51%) had significant injury (ISS > or = 16). Nine patients (19%) had critical injury (ISS > or = 25). Twenty-six patients (55%) required surgery, and 43 (91%) required ICU admission. Common injury sites included the head and neck (57%), thorax (44%), pelvis and extremities (40%), and abdomen (34%). Overall mortality was 10 per cent (n = 5). All patients that died had significant head and neck injuries (AIS > or = 3). Field hypotension was a significant marker for potential serious internal injury requiring prompt diagnostic workup.     

Dangerous toys

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

Venous thromboembolic events in hospitalized trauma patients

Venous thromboembolism (VTE) includes deep vein thrombosis and pulmonary embolus and is a significant cause of morbidity and mortality in injured patients. Absolute risk factors for VTE development are poorly defined. This study aimed to elucidate and evaluate risk factors in a large, population-based trauma registry. The trauma registry for a 10-year period of a single county was examined. VTE risk factors in 10,150 adult patients treated in the county's five trauma centers and seven nontrauma centers were identified. Chi2 and Student's t tests were used for statistical analysis. The incidence of VTE was low at 0.493 per cent. The rate was 0.096 per cent at nontrauma centers. Injury severity score (ISS), operative intervention, spinal cord injury, lower extremity fracture, and certain thoracic injuries were significant in VTE development. There were no differences in VTE rate by age, gender, injury mechanism, or admitting service. Hospital length of stay was doubled by VTE. The VTE rate at trauma centers was higher, which was expected, given the complexity of patients treated and higher ISS. Patients with ISS greater than 15, need for operation, spinal cord injuries, lower extremity fractures, and certain thoracic injuries are at risk for VTE.     

胸部闭合伤的损伤严重度评估及临床意义

目的：探讨胸部闭合伤的临床特点及其损伤严重度评估的临床意义。方法：分析456例胸部闭合伤的致伤因素和死亡率,并按有无合并伤（分为单纯胸伤组,合并伤组）和结局（分为生存组,死亡组）分组进行创伤评分,分别比较不同组间的损伤严重程度。结果：致伤原因为交通伤发生率最高（60．97％）,其次为高处坠落伤（13．82％）。456例中288例合并其它部位损伤,占63．16％,死亡18例,死亡率3．95％,单纯胸伤组的格拉斯哥昏迷指(GCS),睡正创伤评分（RTS）和生存概率（Ps)较高,损伤严重评分（ISS）低于合并伤组,胸部简明损伤定级（AIS）评分两组间差别无显著性意义,死亡组和生存组比较,前者生理评分低,解剖评分高,生存概率亦低。结论：胸部闭合伤常合并全身多发伤,伤情判断困难,合理使用创伤评分有助于判断损伤严重度,指导临床救治。     

Pediatric blunt trauma: a retrospective analysis in a Level I trauma center

This study consisted of an 8-year retrospective trauma registry analysis of blunt trauma and comprised of 2458 children (<18 years of age) and 4568 adults (18-64 years of age). Falls and motor vehicular crashes were seen in 30.4 per cent (749) and 23 per cent (566) of children, and 25.4 per cent (1158) and 41.9 per cent (1914) of adults. Children had a higher mean revised trauma score (7.69 vs 7.66) and Glasgow Coma Score (14.5 vs 14.3), and a lower Injury Severity Score (ISS; 6.68 vs 7.83 and hospital length of stay (2.8 vs 3.8 days) with P < 0.05. Overall mortality was 1.3 per cent in children and 1.9 per cent in adults (P = 0.05). Pedestrian accidents resulted in a 3.8 per cent (6/161) mortality rate. Pediatric nonsurvivors had a 6.4-fold higher ISS than survivors compared with a 5.2-fold increase in adults. Mortality progressively increased with higher ISS; 0.09 per cent in <15, 1.3 per cent, in 15 to 24, and 17 per cent in children with > or = 25 ISS. Mortality in multiple chest injuries was 19 per cent. The presence of chest trauma resulted in a 46-fold higher mortality in children. Most lethal injuries were combined head, chest, and abdomen trauma with a 25 per cent mortality in children and 28 per cent in adults. Admission Glasgow Coma Score <9 and systolic blood pressure below 100 mm Hg carried high mortality: 39 and 6 per cent in children vs 31 and 24 per cent in adults. Ninety-seven per cent of children and 89 per cent of adults were discharged home.     

严重多发脏器损伤的临床特点及诊治

目的探讨严重多发脏器损伤的临床特点和诊治方法.方法对1988～1998年间收治的合并有闭合性腹内脏器损伤的严重多发伤、ISS大于16的165例患者进行回顾性分析.结果3个或3个以上部位多发伤占28.5%.63例有腹内多脏器损伤.腹腔穿刺是确诊的主要检查手段,部分病例选用了腹部B超和CT,3项诊断检查阳性率均在90%以上.全组漏诊腹内伤21例(12.7%),死亡29例(17.6%).死亡病例平均ISS41.6,明显高于非死亡病例24.8(t=15.21,P<0.01).结论严重多发伤病例应常规行诊断性腹腔穿刺,酌情选择腹部B超和CT等检查,以排除腹内脏器损伤.对全身多发伤并存腹内伤的病例,要根据伤情确定急救处理顺序.剖腹手术中要注意多脏器损伤.ISS大于40提示预后不良.     

An appraisal of trauma in the elderly

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

Changing patterns of severe craniomaxillofacial trauma in Auckland over eight years

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

Perils of rib fractures

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

The effect of trauma center designation and trauma volume on outcome in specific severe injuries

OBJECTIVE: The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries. BACKGROUND: Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated. METHODS: The National Trauma Data Bank study, which included patients >14 years of age and had injury severity score (ISS) >15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and II trauma centers and between centers within the same level designation but different volumes of severe trauma (<240 vs > or =240 trauma admissions with ISS >15 per year). The outcomes were adjusted for age (<65 > or =65), gender, mechanism of injury, hypotension on admission, and ISS (< or =25 and >25). RESULTS: A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71-0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44-0.69; P < 0.001) than level II centers. Subgroup analysis showed that cardiovascular injuries (N = 2004) and grades IV-V liver injuries (N = 1415) had a significantly better survival in level I than level II trauma centers (adjusted P = 0.017 and 0.023, respectively). Overall, there was a significantly better functional outcome in level I centers (adjusted P < 0.001). Subgroup analysis showed level I centers had significantly better functional outcomes in complex pelvic fractures (P < 0.001) and a trend toward better outcomes in the rest of the subgroups. The volume of trauma admissions with ISS >15 (<240 vs > or =240 cases per year) had no effect on outcome in either level I or II centers. CONCLUSIONS: Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation.     

Predictors of mortality and management of patients with traumatic inferior vena cava injuries

The aim of this study was to determine factors that predict mortality in patients with traumatic inferior vena cava (IVC) injuries and to review the current management of this lethal injury. A 7-year retrospective review of all trauma patients with IVC injuries was performed. Factors associated with mortality were assessed by univariate analysis. Significant variables were included in a multivariate regression analysis model to determine independent predictors of mortality. Statistical significance was determined at P < or = 0.05. A literature review of traumatic IVC injuries was performed and compared with our institutional experience. Thirty-six IVC injuries were identified (mortality, 56%; mechanisms of injury, 28% blunt and 72% penetrating). There was no difference in mortality based on mechanism of injury. Injuries with closer proximity to the heart were associated with increased mortality (P < 0.001). Univariate analysis demonstrated that nonsurvivors had a higher injury severity scale, a lower systolic blood pressure in the emergency department, a lower Glasgow coma score (GCS), and were more likely to have thoracotomies performed in the emergency department or operating room. Multivariate analysis revealed that only GCS (P = 0.03) was an independent predictor of mortality. Typical factors predicting mortality were identified in our cohort of patients, including GCS. The mechanism of injury is not associated with survival outcome, although mortality is higher with injuries more proximal to the heart. The form of management by IVC level is reviewed in our patient population and compared with the literature.     

Assessment of nonoperative management of blunt spleen and liver trauma

An 8-year analysis of nonoperative management (NOM) of spleen and liver trauma was done in a level 1 trauma center. Spleen and liver trauma was diagnosed in 279 patients: 93 children (<18), 137 younger adults (18-54), and 49 older adults (> or = 55). Nineteen patients who failed resuscitations died within 0-60 minutes of arrival and were excluded from treatment analysis. Operative management (OM) was done in 39 (15%) and NOM in 221 (85%) patients with failure (NOMF) in 11 (5%). NOM and NOMF was 82 per cent and 5.6 per cent in spleen, 74 per cent and 14.3 per cent in combined spleen/liver, and 96 per cent and 1.5 per cent in liver trauma (P value <0.001). NOM was done in 99 per cent of children, 81 per cent of younger adults, and 68 per cent of older adults with 0 per cent, 8 per cent, and 10 per cent NOMF. Higher grades of splenic trauma and CT fluid had higher OM rate. NOM success rates were 93.8 per cent in grade 3 and 90.3 per cent in higher grades of spleen trauma. There was no NOMF in higher grades of liver trauma. CT fluid grade had no impact on NOMF. Female patients had higher mean injury severity score, age, and mortality compared to cohorts. NOM should be attempted in hemodynamically stable patients. Age over 55, higher grades of injury, and large hemoperitoneum were not predictors of failure of NOM.     

Popliteal artery injuries in an urban trauma center with a rural catchment area: do delays in definitive treatment affect amputation?

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 (P < 0.01), and length of stay, 43 versus 15 days (P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent (P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.     

Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury

BACKGROUND: Assessment of injury severity is important in the management of patients with brain trauma. We aimed to analyze the usefulness of the head abbreviated injury score (AIS), the injury severity score (ISS), and the Glasgow Coma Scale (GCS) as measures of injury severity and predictors of outcome after traumatic brain injury (TBI). METHODS: Data were prospectively collected from 410 patients with TBI. AIS, ISS, and GCS were recorded at admission. Subjects' outcomes after TBI were measured using the Glasgow Outcome Scale (GOS-E) at 12 months postinjury. Uni- and multivariate analyses were performed. RESULTS: Outcome information was obtained from 270 patients (66%). ISS was the best predictor of GOS-E (rs = -0.341, p < 0.001), followed by GCS score (rs = 0.227, p < 0.001), and head AIS (rs = -0.222, p < 0.001). When considered in combination, GCS score and ISS modestly improved the correlation with GOS-E (R = 0.335, p < 0.001). The combination of GCS score and head AIS had a similar effect (R = 0.275, p < 0.001). Correlations were stronger from patients 8). CONCLUSIONS: GCS score, AIS, and ISS are weakly correlated with 12-month outcome. However, anatomic measures modestly outperform GCS as predictors of GOS-E. The combination of GCS and AIS/ISS correlate with outcome better than do any of the three measures alone. Results support the addition of anatomic measures such as AIS and ISS in clinical studies of TBI. Additionally, most of the variance in outcome is not accounted for by currently available measures of injury severity.     

Blood transfusion is associated with infection and increased resource utilization in combat casualties

Combat casualty care has made significant advances in recent years, including administration of blood products in far-forward locations. However, recent studies have shown blood transfusion to be a significant risk factor for infection and increased resource utilization in critically injured patients. We therefore sought to investigate the incidence of blood transfusion and its association with infection and resource utilization in combat casualties. Prospective data were collected and retrospectively reviewed on 210 critically injured patients admitted to the USNS Comfort over a 7-week period during the 2003 assault phase of Operation Iraqi Freedom. Patients were stratified by age, gender, and injury severity score (ISS). Multivariate regression analyses were used to assess blood transfusion and hematocrit (HCT) as independent risk factors for infection and intensive care unit (ICU) admission controlling for age, gender, and ISS. The study cohort had a mean age of 30 +/- 2 years, a mean ISS of 14 +/- 3, 84 per cent were male, and 88 per cent sustained penetrating trauma. Blood transfusion was required in 44 per cent (n = 93) of the study cohort. Transfused patients had a higher ISS (18 +/- 4 vs. 10 +/- 3, P < 0.01), a higher pulse rate (105 +/- 4 vs. 93 +/- 3, P < 0.0001), and a lower admission HCT (27 +/- 1 vs. 33 +/- 2, P < 0.0001) compared with patients not transfused. Patients receiving blood transfusion had an increased infection rate (69% vs. 18%, P < 0.0001), ICU admission rate (52% vs. 21%, P < 0.0001), and ICU length of stay (6.7 +/- 2.1 days vs. 1.4 +/- 0.5 days, P < 0.0001) compared with nontransfused patients. However, there was no significant difference in mortality between transfused and nontransfused patients. Multivariate binomial regression analysis identified blood transfusion and HCT as independent risk factors for infection (P < 0.01) and blood transfusion as an independent risk factor for ICU admission (P < 0.05). Combat casualties have a high incidence of blood transfusion. Blood transfusion is an independent risk factor for infection and increased resource utilization. Therefore, consideration should be given to the use of alternative blood substitutes and recombinant human erythropoietin in the treatment and management of combat casualties.     

Predictors of morbidity and mortality in patients with traumatic duodenal injuries

The aim of our study is to determine factors that predict morbidity and mortality in patients with traumatic duodenal injury (DI). A retrospective review from July 1996 to March 2003 identified 52 patients admitted to our trauma center (age 24.4 +/- 2.1 years, ISS = 18.8 +/- 1.76). The mortality rate for patients with duodenal injury was 15.4 per cent (n = 8). The mechanisms of injury were blunt (62%), gun shot wound (GSW) (27%), and stab wound (SW) (11%). There was no difference in mortality based on mechanism of injury. Management was primarily nonoperative [n = 30 (57%)]. Of those with perforation (n = 22), 64 per cent underwent primary repair (n = 14), 23 per cent duodenal resection (n = 5), 9 per cent duodenal exclusion (n = 2), and one patient pancreaticoduodenectomy. The method of initial surgical management was not related to patient outcome. Univariate analysis demonstrated that nonsurvivors were older, more, hypotensive in the emergency department, had a more negative initial base deficit, had a lower initial arterial pH, and had a higher Injury Severity Score. Nonsurvivors were also more likely to have an associated inferior vena cava (IVC) injury. Multivariate regression analysis revealed age, initial lowest pH, and Glasgow Coma Score to be independent predictors of mortality, suggesting that the physiologic presentation of the patient is the most important factor in predicting mortality in patients with traumatic DIs.