Head injuries in skiers: an analysis of injury severity and outcome

To examine the incidence, injury severity, and outcomes of persons hospitalized as a result of ski-related head trauma, a cross-sectional survey was carried out from the Colorado traumatic brain injury database. This database is an ongoing population-based statewise surveillance system, compiled by the Department of Public Health and Environment. Participants were Colorado residents who sustained a head injury while skiing at Colorado ski resorts and hospitalized over three full ski seasons (1994-1997). Injury severity measures included GCS, ISS, AIS, and presence/absence of intracranial lesion, skull fracture and amnesia. Outcome measures included GOS and hospital length of stay. Mean injury severity scores were as follows: GCS 14.51 (SD=0.99), AIS 2.98 (0.99) and ISS 13.17 (6.71). Twenty-four per cent sustained skull fracture, 39% had intracranial lesions, and 79% demonstrated amnesia. Mean length of stay was 4.31 days (10.58). Head injury incidence was 0.77 per 100 000 ski visits (agespecific range=0.17-1.91). Males were more likely to have a skull fracture and evidence of intracranial lesion. Finally, children and older adults were at increased risk of ski-related head trauma, suggesting head injury prevention programmes geared toward these age groups should be emphasized.     

Pedestrians injured by automobiles: relationship of age to injury type and severity

BACKGROUND: There is little research on the effect of age on the nature and severity of injuries to pedestrians struck by automobiles. STUDY DESIGN: Trauma registry study included all auto versus pedestrian trauma admissions of pedestrians injured by automobiles at an academic Level I trauma center over 10 years and 4 months. Injury Severity Score, severe body area (head, chest, abdomen, extremities) trauma with Abbreviated Injury Score >3, specific organ injuries, and mortality were calculated according to age groups (< or =14 years, 15 to 55 years, 56 to 65 years, >65 years). RESULTS: During the study period 5,838 admissions were reviewed. There were 1,136 patients (19.4%) 14 years old or less, 3,741 (64.1%) who were 15 to 55 years, 420 (7.2%) 56 to 65 years, and 541 (9.3%) older than 65 years. Overall mortality was 7.7% and ranged from 3.2% in the age group 14 years or less to 25.1% in patients over 65 years. The incidences of severe trauma (Injury Severity Score >15) in the four age groups were 11.2%, 18.7%, 23.6%, and 36.8%, respectively. The incidences of critical trauma (Injury Severity Score >30) were 2.3%, 3.9%, 5.7%, and 13.9%, respectively. The incidence of severe head and chest trauma (Abbreviated Injury Score >3) increased with age. The incidence of solid organ and hollow viscus injuries was similar in all age groups. Spinal injuries increased significantly with age and ranged from 0.4% in the pediatric group to 8.5% in the elderly group. Pelvic and tibial fractures were significantly more common in adults; femur fractures were significantly more common in the pediatric group. CONCLUSIONS: Age plays an important role in the anatomic distribution and severity of injuries and survival outcomes after pedestrian injuries.     

Visual outcome and ocular survival in open-globe injuries

AIM: To detect the risk factors that predicts final visual acuity, retinal detachment, and ocular survival after penetrating trauma. METHODS: In a prospective case series study, 116 eyes with open-globe injuries were evaluated between 2001 and 2004. All data were filled in the questionnaire chart. Sex, age, involved eye, best-corrected visual acuity (BCVA), afferent pupillary defect (APD), location and wound length, cataract, iris prolapse, vitreous prolapse, retinal detachment (RD), intraocular foreign body (IOFB), vitrectomy procedure, and type of injury were evaluated as predisposing factors by logistic regression models for final visual acuity, RD, and ocular survival. RESULTS: Low BCVA, RD, and vitrectomy procedure were detected significant in the final visual acuity of 20/200 or less. APD and vitrectomy procedure were statistically significant in the final RD. BCVA 20/250 or less, wound length >10mm, scleral and corneoscleral lacerations, vitreous prolapse, vitreous hemorrhage, RD, and sharp injury were correlated with decreased globe survival. CONCLUSION: Low BCVA, APD, and vitrectomy procedure were effective in the visual outcome. RD and vitrectomy procedure were detected significant in the anatomic result. Establishment of predictors of visual outcome and ocular survival may assist clinicians in salvageable eyes for surgical repair.     

Work-related injuries: injury characteristics, survival, and age effect

Work-related injuries impose a significant burden on society. The goal of this study was to delineate the epidemiology and the effect of age on type and mortality after occupational injuries. Patients 16 years of age or older sustaining work-related injuries were identified from the National Trauma Databank 12.0. The study population was stratified into four age groups: 16 to 35, 36 to 55, 56 to 65, and older than 65 years old. The demographic characteristics, type of injury, mechanism of injury, setting of injury, use of alcohol or other illicit drugs, and mortality were analyzed and related to age strata. Overall 67,658 patients were identified. There were 27,125 (40.1%) patients in the age group 16 to 35 years, 30,090 (44.5%) in the group 36 to 55 years, 6,618 (9.8%) in the group 56 to 65 years, and 3,825 (5.7%) older than 65 years. The injury severity increased significantly with age. Elderly patients were significantly more likely to sustain intracranial hemorrhages, spinal, and other skeletal injuries. The overall mortality was 2.9 per cent (1938) with the latter increasing significantly in a stepwise fashion with progressing age, becoming sixfold higher in patients older than 65 years (OR, 6.18; 95% CI, 4.78 to 7.80; P < 0.001). Our examination illustrates the associations between occupational injury and significant mortality that warrant intervention for mortality reduction. There is a stepwise-adjusted increase in mortality with progressing age.     

Geriatric falls: injury severity is high and disproportionate to mechanism

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

Pedestrian injuries: the association of alcohol consumption with the type and severity of injuries and outcomes

BACKGROUND: Literature on the effect of alcohol ingestion on short-term outcomes for trauma patients shows conflicting results. We performed this study to investigate the prevalence of positive alcohol screens and the effect of alcohol level on injury patterns, injury severity, and outcomes in pedestrians and bicyclists involved in a collision with an automobile. STUDY DESIGN: The study population included all pedestrians and bicyclists older than 10 years, treated in any of the 13 trauma centers in the Los Angeles County Emergency Services System during the calendar year 2003, who were involved in a collision with an automobile and had a blood alcohol level measured. The alcohol negative group was defined as those patients with a blood alcohol level 0.05 g/dL to<0.08 g/dL and>/=0.08 g/dL, respectively. We compared the three study groups with respect to demographics, injury patterns, injury severity, complications, and outcomes. Logistic regression was used to determine if alcohol had an independent association with any outcomes. RESULTS: There were 1,042 patients who met study criteria. Overall, 606 patients (58%) had a negative alcohol screen, 84 (8%) had low alcohol levels, and 352 (34%) had high alcohol levels. Alcohol level was not notably associated with severity of injury, admission hypotension, ICU length of stay, major complications, and injury pattern (head, chest, abdomen, or extremity Area Injury Score). Mortality was similar in the three alcohol level groups, but the overall complication rate and hospital length of stay were markedly higher in the high alcohol level group than they were in the negative alcohol level group. CONCLUSIONS: In pedestrians and bicyclists involved in a collision with an automobile, a high alcohol level is not associated with body area severity of injury, overall severity of injury, and hospital mortality. But high alcohol level is notably associated with higher overall complication rate and longer hospital length of stay.     

Abdominal blast injuries: different patterns,severity, management,and prognosis according to the main mechanism of injury

Purpose

To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury.

Methods

A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS.

Results

Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties.

Conclusions

The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.     

Changes in kidney stones type according to sex and age in Tunisian patients

BackgroundStudies that evaluate the effect of age and gender on the stone composition are scarce. The aim of this study is to highlight the modification of epidemiological characteristics of this pathology according to patients’ sex and age.Patients and methodsWe studied 1269 urolithiasic patients ranging from 6 months to 92 years old and known as having urinary stones (752 males and 517 females). Stone analysis was performed respectively using a stereomicroscope and infrared spectroscopy to determine, respectively, the morphological type and molecular composition of each.ResultsThe annual average incidence of new stone formation was 30.25 per 100000 inhabitants. In 1041 patients (81%), calculi were located in the upper urinary tract. Children and old man were more affected by bladder stone. Calcium oxalate monohydrate remains the most frequent stone component even if its frequency fell according to age (63.2% in teenagers and 40.6% in elderly [p < 0.05]) in favour of the increase of uric acid stones (3,5% in teenagers and 41.5% in elderly [p < 0.05]). Struvite stones were rare (3.5%) and more frequent in children.ConclusionThe analysis of these data shows that urinary stones in Tunisia are tending to evolve in the same direction as in industrialized countries.     

The outcome of volume reduction surgery according to the underlying type of emphysema

Lung volume reduction surgery (VRS) is widely performed to improve symptoms in patients with severe pulmonary emphysema; however, it remains unclear whether or not the underlying type of emphysema affects the surgical results. A total of 58 patients with advanced symptomatic emphysema underwent thoracoscopic VRS of emphysematous lung tissue. The resected lung tissue was examined microscopically, and the patients were classified into two groups according to the predominant pathological findings, as having either centrilobular-type or panacinar-type emphysema. A predominant pathological type was identified in only 34 patients (59%), 19 of whom had centrilobular-type emphysema and 15, panacinar-type emphysema. Patients with predominately panacinar emphysema had more compromised total lung capacity and residual volume than those with centrilobular emphysema. Significant improvements in forced expiratory volume in 1 s were evident 3 months after surgery in the group with centrilobular emphysema (+515 ± 141 ml) compared with that in the group with panacinar-type emphysema (+109 ± 40 ml, P = 0.03). The results of lung VRS were found to depend on the underlying type of emphysema, as the benefits of surgery for panacinar emphysema were less marked than those for centrilobular emphysema. Received: February 25, 2000 / Accepted: March 6, 2001     

Sonographic classification of idiopathic clubfoot according to severity

Our purpose was to develop a sonographic technique for clubfoot examination using measured angles to establish a classification system according to severity. Ultrasonography of 24 newborns with 32 clubfeet and 13 newborns with 22 normal feet was performed and measurements obtained. Analysis of components of variance was conducted. Patients with clubfeet showed higher dispersion in 95% confidence intervals for all angles than did patients with normal feet. A sonographic classification system was established: IIa, slight clubfoot; IIb, moderate clubfoot; IIc, severe clubfoot; IId, very severe clubfoot. Sonographic findings can be used to objectively assess various degrees of clubfoot severity.     

Alcohol and illicit drugs in traumatic deaths: prevalence and association with type and severity of injuries

BACKGROUND: My colleagues and I studied alcohol and illicit drug intoxication in trauma fatalities and their association with the nature and severity of injuries. STUDY DESIGN: We examined the trauma registry and autopsies of all trauma fatalities at an academic Level I trauma center. Statistical analysis was performed to evaluate the association of substance use with the Injury Severity Score, body areas with severe trauma (Abbreviated Injury Score >/= 3), and spinal injuries. RESULTS: From January 2000 to May 2003, 931 trauma deaths occurred; 600 victims were tested for alcohol and illicit drugs and 256 of these (42.7%) tested positive. Male victims were significantly more likely to have a positive screen than female patients (46.1% versus 26.7%, p = 0.0003). Penetrating trauma was significantly more likely to be associated with a positive screen than blunt trauma (53.0% versus 31.0%, p < 0.001). Hispanic and African-American victims were more likely to have a positive screen than Caucasians or Asians. Half the patients in the age group 15 to 50 years had a positive screen. Victims with penetrating trauma and positive screen were significantly more likely to be dead at hospital arrival than victims with negative toxicology (68.8% versus 48.8%, p = 0.05). Pedestrians killed by automobiles who had positive screens were more likely to have severe abdominal trauma (Abbreviated Injury Score >/= 3) than victims with negative toxicology (54.2% versus 25.0%, p = 0.02). CONCLUSIONS: There is a high rate of alcohol and illicit drug use in patients who die from trauma, especially penetrating trauma in men aged 15 to 50 years, who are Hispanic or African American. Victims with penetrating trauma and positive toxicology are considerably more likely to have no vital signs on admission than victims with negative toxicology. Pedestrians killed by automobiles who had positive screens have a higher incidence of severe abdominal injuries than victims with negative screens.     

Assessment of the severity of hand injuries using "hand injury severity score", and its correlation with the functional outcome

INTRODUCTION: Objective assessment of hand injuries is a complex subject. However, an objective assessment, leading to a score, can help in predicting outcome and can be used as a research tool. Campbell and Kay have devised one such score known as "hand injury severity score" or HISS [J. Hand. Surg. [Br.] 21 (3) (1996) 295]. A study on this score has been carried out in our institute. The idea was to see if the hand injury severity score, correlates with the functional outcome as measured by disability arm shoulder and hand score (DASH), after a period of minimum 2 years. METHOD: All the hand injury patients admitted in the hospital were assessed at the time of admission, and objective information was documented on a hand injury documentation form. The form captured all the data required to calculate "hand injury severity score" . A sample of 70 patients admitted during the first 6 months of 1999 was taken and their scores were calculated. The sample was selected such, that it had a reasonable representation of hand injuries of all severities. After obtaining a due approval from ethics committee, all these 70 patients were sent a DASH questionnaire. A total of 23 patients replied. Spearman's rank correlation test was used to analyse the correlation between the severity of hand injury as assessed using HISS, and functional outcome as measured using DASH. Correlations between the outcome and skeletal component score, outcome and motor component scores, and outcome and Integument component scores, were assessed separately. RESULTS: The study shows a statistically significant association ( r = 0.7182, P = 0.000165) between the severities of injury and the functional outcome. The functional outcome also shows a statistically significant association with the severity of injury to skeletal component (r = 0.5151, P = 0.014083) and motor component (r = 0.6797, P = 0.000507). However, the severity of injury to integument component, as measured by HISS, does not show any association with the outcome (r = 0.3571, P = 0.102736). This study supports the overall structure of the HISS. However an improvement in the integument component scoring is required to improve overall accuracy.     

Venous severity scoring: An adjunct to venous outcome assessment

Some measure of disease severity is needed to properly compare the outcomes of the various approaches to the treatment of chronic venous insufficiency. Comparing the outcomes of two or more different treatments in a clinical trial, or the same treatment in two or more reports from the literature cannot be done with confidence unless the relative severity of the venous disease in each treatment group is known. The CEAP (Clinical-Etiology-Anatomic-Pathophysiologic) system is an excellent classification scheme, but it cannot serve the purpose of venous severity scoring because many of its components are relatively static and others use detailed alphabetical designations. A disease severity scoring scheme needs to be quantifiable, with gradable elements that can change in response to treatment. However, an American Venous Forum committee on venous outcomes assessment has developed a venous severity scoring system based on the best usable elements of the CEAP system. Two scores are proposed. The first is a Venous Clinical Severity Score: nine clinical characteristics of chronic venous disease are graded from 0 to 3 (absent, mild, moderate, severe) with specific criteria to avoid overlap or arbitrary scoring. Zero to three points are added for differences in background conservative therapy (compression and elevation) to produce a 30 point-maximum flat scale. The second is a Venous Segmental Disease Score, which combines the Anatomic and Pathophysiologic components of CEAP. Major venous segments are graded according to presence of reflux and/or obstruction. It is entirely based on venous imaging, primarily duplex scan but also phlebographic findings. This scoring scheme weights 11 venous segments for their relative importance when involved with reflux and/or obstruction, with a maximum score of 10. A third score is simply a modification of the existing CEAP disability score that eliminates reference to work and an 8-hour working day, substituting instead the patient's prior normal activities. These new scoring schemes are intended to complement the current CEAP system.     

Comparison of mortality of patients with multiple injuries according to type of fracture treatment--a retrospective age- and injury-matched series

In a retrospective review of 71 patients with multiple injuries matched for age and severity, 28.5 per cent of those whose fractures were treated conservatively died compared with 4.5 per cent of those whose fractures were fixed. Early stable fixation of fractures is recommended in patients with multiple injuries.