Paediatric burn injuries in the Jeddah area of Saudi Arabia: a study of 197 patients

A prospective study was conducted on paediatric thermal injury patients admitted to the Burns Unit at King Fahd Hospital, Jeddah, Saudi Arabia over a 2-year period (December 1985 to December 1987). A total of 197 patients (out of 319) were paediatric, aged up to 18 years. Infants and toddlers accounted for 59.4 per cent and adolescents for 14.2 per cent. Scalding and flame injuries accounted for 98 per cent with most injuries occurring at home (97.5 per cent) and the overall paediatric mortality rate was 4.4 per cent.     

Patterns of injury and outcomes associated with motocross accidents

Motocross has become a popular recreation activity in Southern California, particularly in the Inland Empire area. In order to evaluate the patterns of injury and outcomes associated with motocross accidents, the Trauma Registry data and charts of all patients with motocross-related injuries from January 2000 to December 2001 were reviewed. Of the 270 patients studied, 265 were males and 5 were females, with a mean age of 26 years (range, 5-61). The mean Injury Severity Score was 6.8 (range, 1-38). Injuries involved extremity trauma in 52 per cent of patients closed head injuries in 33 per cent, blunt chest trauma in 23 per cent, abdominal trauma in 15 per cent, spinal trauma in 14 per cent, and pelvic trauma in 8 per cent. Surgery was required in 96 patients (36%), most commonly for treatment of orthopedic injuries. After initial evaluation, 179 patients were admitted (66%), 60 were discharged home (22%), 29 were transferred for higher level of care (11%), and two expired (1%). The mean hospital length of stay was 2.3 days (range, 1-9). Motocross accidents are most commonly associated with extremity injuries and closed head trauma. Although the overall mortality is low, the morbidity is high, with a large proportion of patients requiring surgery.     

Burn injuries in the Dong Bei area of China: a study of 12,606 cases.

This survey analyses data from nine Chinese burn units with respect to age, causes, severity of burn injury, and survival or death of patients admitted to hospital during the past 10 years (from January 1980 to December 1989). Of 12,606 burned patients treated, 3391 were children (26.9 per cent) and over half the children (52.3 per cent) were up to 4 years old. Almost 60 per cent of the 12,606 patients treated were in the young adult group (15-44 years), and 86.9 per cent of 12,606 patients sustained thermal injuries mainly from fire flames followed by scald injuries (40.7 per cent). About 93 per cent of the patients had burns covering less than 50 per cent of the body surface area. The overall mortality rate was 1.24 per cent. The LD50 for the 12,112 patients less than 60 years old was a burned surface area exceeding 80 per cent of the total body surface area.     

Traumatic diaphragmatic hernia: review of 15 cases

From January 1985 to December 1987, 292 laparotomies were performed for injury in Riyadh Central Hospital. Of these, 15 cases were associated with diaphragmatic injuries (5.1 per cent). The diagnosis was missed in 5 cases (30 per cent) and was incidental (at laparotomy) in 3 cases (20 per cent). Therefore in about 50 per cent of the cases, the diagnosis was not made at the initial presentation. In this paper we stress the importance of maintaining a high degree of clinical suspicion in order not to miss traumatic diaphragmatic hernia in multiply injured patients.     

Major bladder trauma: mechanisms of injury and a unified method of diagnosis and repair

We reviewed 51 cases of bladder trauma seen at our hospital between 1976 and 1981. There were 32 nonpenetrating, 13 penetrating, 1 spontaneous and 5 iatrogenic injuries. Rupture of the bladder was confirmed at operation in all but 1 case. Extraperitoneal rupture was noted in 32 patients (62 per cent), intraperitoneal rupture in 13 (25 per cent), and combined intraperitoneal and extraperitoneal rupture in 6 (12 per cent). The most frequent clinical features were gross hematuria, abdominal tenderness and shock. Associated pelvic fractures were present in 30 of the 31 nonpenetrating ruptures. The most common area of bladder rupture was the dome in nonpenetrating injuries (35 per cent) and the lateral wall in penetrating injuries (42 per cent). Associated organ injuries were common (62 per cent of penetrating injuries and 93 per cent of nonpenetrating injuries). Cystography, including the use of drainage films, was accurate in all cases for which it was used. Mortality in this series was 22 per cent and reflects the severity of associated organ injury. Risk factors include older age status, pedestrian injuries and extensive associated organ injury rather than type of bladder rupture. To minimize mortality and morbidity in this high risk group of patients strict attention should be directed to rapid resuscitation, early diagnosis including cystography with drainage films and anticipation of associated organ injury at operation.     

The socioeconomic impact of assault injuries on an urban trauma center.

In 1983, Los Angeles County designated 23 level I or II trauma centers. During the subsequent 7 years, ten centers closed because of adverse financial impact. To analyze the causes of this trend, hospital admissions for gunshot and stabbing injuries were reviewed for two separate 1-year periods at a level I urban trauma center. Of 1,160 patients arriving with injuries meeting county triage criteria from January 1, 1986 through December 31, 1986, 323 (27%) sustained penetrating assault, of which 96 were with firearms (30%). From January 1, 1988 through December 31, 1988, 1,213 met triage criteria; 301 (25%) were intentional, of which 179 (59%) were due to firearms. Epidemiologic and clinical data from the two periods is similar with 90 per cent of the patients being men ages 25 to 30 and of minority ethnic background. Seventy-five per cent of the patients required a truncal operative procedure and needed about 5.5 days of hospitalization. Overall, mortality averaged 4.7 per cent and morbidity 14.5 per cent. Complete financial data was available on 561 of the 624 intentionally injured patients for which costs totaled $2,481,346 (mean = $5,260 for gunshots; mean = $3,640 for stab wounds). The total collections were $545,896 (22% of total charges). Only 5 per cent of the charges were reimbursed from insurance; MediCal reimbursed 13 per cent and only 1 per cent was from Medicare. Eighty-one per cent of the patients had no financial resources, resulting in a hospital deficit of $1,861,009 (75% of the total charges).(ABSTRACT TRUNCATED AT 250 WORDS)     

The last 10 years in a burn centre in Ankara, Turkey: an analysis of 5264 cases

This is a retrospective study analysing 5264 patients treated in the burn centre at Gülhane Military Medical Academy from 1 January 1986 to 31 December 1995. Our burn centre is not only the firs, but one of the best established and supported in Turkey. Our present study has the largest patient group of other previously published studies from Turkey. Of the total patients studied, 4464 patients had minor burns and were treated on an outpatient basis and 800 patients had moderate to major burns. Although our centre is in a military area in Ankara, only 1047 (20 per cent) patients were military personnel and the military-related burn causes comprised only 6 per cent of the total. The remaining 4217 (80 per cent of the total patients) were civilians. Flame injuries were also more frequent in military patients than civilians. Minor burns were most common in the age group 0–10 years old (40 per cent) and moderate to major burns in the age group 21–30 years (54 per cent). Scalds were the main cause of paediatric burns. Male patients were dominant. The overall mortality among inpatients was 18.2 per cent and mean total body surface area (TBSA) was 57.6 per cent in patients who died. 134 patients demonstrated inhalation injury and 82 per cent of these patients died. The epidemiological pattern of our patients is similar to that in other studies from developed countries, although some ethnic causative factors could be found. Our study indicates that emergency measures should be taken to prevent flame injuries at military barracks and industrial workplaces and scalding accidents to children at home and throughout the country.     

Early management of war missile spine and spinal cord injuries: experience with 21 cases

Between 1991 and 1994, 21 patients with war missile injuries of the spine and spinal cord were treated; there were 17 men and four women, with a mean age 30.7 years; 52.4 per cent were civilians. The wounds were caused by shells (54.6 per cent) and bullets (45.4 per cent). The thoracic and lumbar spines were most commonly injured, and the injuries were frequently associated with lesions of other organs (47.6 per cent). There was extensive initial neurological deficit (tetraplegia, paraplegia) in 47.6 per cent of cases in whom there was no postoperative neurological recovery. All patients were treated operatively and associated injuries of other organs received priority management. A decompressive laminectomy was performed in 80.9 per cent of patients. Penetrating injuries of the dura were recorded in 61.9 per cent, while the spinal cord was injured in 28.5 per cent of patients. The dural defect was reconstructed in these patients. There was a low incidence of postoperative complications (14.5 per cent) which emphasizes the importance of early surgery.     

Injuries of the inferior vena cava

The treatment of 77 patients with wounds of the inferior vena cava admitted to Grady Hospital, Atlanta, Georgia, from January 1972 through December 1983, was reviewed. All injuries were identified by laporotomy and/or thoracotomy. Trauma resulted from gunshot wounds in 79 per cent of patients, stab wounds in 18 per cent, and blunt trauma in 3 per cent, with an overall mortality of 30 per cent. The chief determinates of survival were preoperative hypotension, location of the injury and the presence of other major vascular injuries. Of the 49 patients admitted in shock, 22 (45%) died, all of complications related to organ ischemia. Only one patient not hypotensive on admission succumbed. Of the 29 patients with at least one additional injury to a major vascular structure, 45 per cent died. The mortality of infrarenal and suprarenal injuries was relatively low (22% and 33% respectively), compared with retrohepatic and supradiaphragmatic injuries, both of which were fatal in 67 per cent of the cases. Despite advances in the care of the trauma patient, significant improvement in survival has not occurred, and the patient mortality has remained at 30 per cent.     

Work-related burns: a 6-year retrospective study

During the 6 years from July 1984 to May 1990, 193 patients (30.2 per cent of all patients) were admitted to our regional adult burn centre, for treatment of work-related burn injuries. The median age of patients was 32.5 years (range 18-64 per cent), and 94 per cent were males. Fifty-nine per cent of the patients came from metropolitan Toronto, and 40 per cent from rural Ontario. Most of the patients (97.3 per cent) were referred to the burn centre within 24 h of their injury. The most common aetiology was electrical injury (29.5 per cent), followed by flame (24.4 per cent), contact (10.4 per cent), flash (9.8 per cent), tar and asphalt (9.3 per cent), scald (7.8 per cent), chemical (5.1 per cent), steam (4.7 per cent) and grease (1 per cent). Within the electrical burn group, about one-half were flash burns, one-quarter were clothing fire injuries, and one-quarter were contact injuries. These occupational burns tended to be extensive injuries. The median body surface area (BSA) was 16.5 per cent, with a median full thickness (FT) component of 5.0 per cent. The average length of stay was 20.0 days. Inhalation injury requiring intubation occurred in 14.8 per cent of patients. Sepsis--confirmed by positive blood cultures--developed in 14 per cent of the patients, at an average time of 8.8 days postburn. Staphylococcus aureus was the commonest organism isolated from blood cultures. Pneumonia occurred in 6.3 per cent of patients. A total of 207 surgical procedures was performed on 113 of the 193 patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cranial nerve injuries are associated with specific craniofacial fractures after blunt trauma

Identification of cranial nerve (CN) injuries after blunt trauma is often delayed due to concomitant life-threatening trauma, altered mental status, and associated bony or soft tissue injuries. We hypothesized that specific craniofacial fracture (FX) patterns are associated with CN injuries, permitting earlier diagnosis. The trauma registry at a single institution was queried for all CN injuries and craniofacial FXs. Associations were determined by Fisher's exact test. Ninety CN injuries were identified in 59 patients. CN injuries were diagnosed on the day of admission in 24 (41%) patients. The most frequently injured CNs were CN VII (22), CN I (16), and CN VI (14). Occipital FXs were associated with CN I injury (P = 0.001). Sphenoid and ethmoid FXs were correlated with CN III trauma (P = 0.019 and 0.04). Temporal bone FXs were associated with CN VII injuries (P = 0.025). Maxillary FXs were associated with CN V injuries (P = 0.041). Complete or partial recovery was documented after 17 per cent and 39 per cent of CN injuries, respectively. Diagnostic delay was documented in 59 per cent of patients. Specific craniofacial FXs were correlated with certain CN injuries. Partial or complete recovery of function occurred after 56 per cent of CN injuries.     

Urethral injury due to external trauma

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.     

Hand injuries as an indicator of other associated severe injuries

The purpose of this study was to investigate the incidence of disabling or life-threatening injuries in patients with hand injuries. Retrospective data were collected from a level 1 trauma center registry. A total of 472 patients with hand injuries were admitted to the trauma unit between January 2000 and March 2004. Forty-four per cent of patients with hand injuries had life-threatening injuries. Fifty-one per cent of them had motor vehicle crash-related injuries. Motorcycle crashes were the next most common cause followed by explosions, falls, gunshots, machinery, stabs, bites, crushes, and so on. Frequency of associated injuries was as follows: head injuries, 31 per cent, including skull fractures, 22 per cent; spine injuries, 18 per cent, including spine fractures 18 per cent; chest injuries, 36 per cent, including rib fractures, 15 per cent; and abdominal injuries, 13 per cent. The authors focused on the incidence of disabling or life-threatening injuries in patients with hand injuries. Motor vehicle crashes were most common cause of hand injuries. The most common organs to be injured were chest and head. The most common head injury was skull fracture. Other injuries in decreasing order were spine and rib fractures. These data may be helpful in assessing ambulatory patients in the emergency room, in those hand injuries maybe indicative of other simultaneous life-threatening or disabling injuries.     

Management of Gulf War casualties.

During the Gulf War 84 patients underwent surgery in the Jubail Armed Forces Hospital, Saudi Arabia. The median time to evacuate casualties to hospital was 8 h 40 min. Fragments caused 88 per cent of injuries; 11 per cent were caused by bullets. Multiple lesions were encountered in 70 per cent of patients. The extremities (76 per cent) were the most frequently injured site, the lower limbs more so than the upper. Soft tissue injuries prevailed (59 per cent).     

Blunt bladder trauma: manifestation of severe injury

Twenty-nine patients with bladder injuries requiring operative treatment as a result of blunt trauma are presented. Motor vehicle accidents accounted for 86 per cent of the injuries. Hypotension and gross hematuria were the most prevalent clinical features, 68 per cent and 97 per cent, respectively. All patients had multiple associated injuries requiring operative treatment, average 2.9 per patient. Pelvic fractures occurred in 93 per cent and intra-abdominal injuries in 48 per cent of patients. The majority of ruptures (72%) were intraperitoneal. Mortality, related to associated injuries, was high (34%), attesting to the magnitude of injury sustained by the victim.     

Penetrating injuries to the iliac arteries

Despite advances in the management of traumatic truncal and peripheral vascular injuries, penetrating trauma to the iliac arteries carries a high mortality. Among more than 600 patients with arterial trauma seen at the Ben Taub General Hospital between January 1958 and December 1977, eighty-three had penetrating injury to the iliac arteries. Thirty-two patients (39 per cent) died within thirty days of injury, none of these dying within 48 hours of injury. Injuries were managed by resection and end-to-end anastomosis (36 per cent), lateral arteriorrhaphy (27 per cent), ligation (20 per cent), and prosthetic interposition (10 per cent). Three perigraft infections occurred with ultimate removal of the graft and ligation of the common iliac artery.Among patients with penetrating injuries who arrive alive at a hospital, iliac artery wounds result in massive intraperitoneal blood loss, in contrast to aortic injuries which frequently have a protective tamponade for a period of time. Delay in surgery, irreversible shock, dilutional bleeding diathesis, and respiratory insufficiency result in a high mortality. A high index of suspicion and prompt aggressive surgery are necessary to improve chances of survival of patients with this highly lethal injury.     

Gunshot wounds of the colon: A review of 100 consecutive patients,with emphasis on complications and their causes

The cases of one hundred civilian patients with gunshot wounds of the colon treated at the Louisville General Hospital have been reviewed. Most injuries were in the transverse colon (44 per cent), followed by the ascending colon (27 per cent), rectosigmoid (19 per cent), and descending colon (10 per cent). Associated injuries occurred in 81 per cent of the patients; the small bowel was the most common structure injured.Primary closure was used in 52 per cent of the patients, with a resultant 19 per cent rate of wound infection and 14 per cent rate of serious complication. When the extent of contamination or tissue destruction required resection, an attempted primary anastomosis was followed by a high rate of wound infection (57 per cent) and serious complications (36 per cent) as compared with end-colostomy and mucous fistula, which resulted in a 24 per cent rate of wound infection and 24 per cent rate of serious complication. The rate of wound infection between these groups is significant (p = 0.05). Results with end-colostomy and mucous fistula were better than with attempted primary anastomosis.Primary closure of missile injuries of the colon is feasible but should not be attempted in the presence of gross fecal peritonitis or massive tissue destruction. If resection is undertaken, end-colostomy (or ileostomy) and distal mucous fistula should be performed in the presence of intra-abdominal contamination to reduce the incidence of postoperative wound infection and serious complications. Delayed primary closure should also reduce the rate of wound infection in these patients.     

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.     

Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries

This is a retrospective review of 731 patients sustaining diaphragmatic trauma over a 22 year period (1980-2002) at an urban level I trauma center. Patients had an average injury severity score (ISS) of 22 +/- 12. The mortality rate (MR) was 23 per cent (168/731). There were a total of 460 left-sided diaphragmatic injuries (L-TDR), 263 right-sided diaphragmatic injuries (R-TDR), and 8 bilateral diaphragmatic injuries (B-TDR). There were no significant differences in mortality with L-TDR versus R-TDR. Shotgun wounds had the highest MR (42%) (P = 0.0028). Emergency thoracotomies were performed in 31 per cent (225) with a 62 per cent (140) MR. Bilateral thoracotomies had a significantly higher MR of 85 per cent (33/39) compared to the 58 per cent (107/186) for unilateral thoracotomies (P = 0.0028). Multivariate analysis revealed the most significant independent predictors of mortality to be the revised trauma score, transfusion of pRBCs > 10 units, and need for thoracotomy (P < 0.0001). The infection rate was 41 per cent. Multivariate analysis revealed blunt trauma, blood transfusions, ISS, and pancreatic injury as the most significant independent predictors of infection (P < 0.001). The initial physiologic presentation of the patient and the severity of hemorrhagic shock are the primary determinants for survival. Prompt identification of associated injuries with rapid control of bleeding is paramount to survival.     

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.