Seven hundred fifty-three consecutive deaths in a level I trauma center: the argument for injury prevention

BACKGROUND: The past century has seen improvement in trauma care, with a resulting decrease in therapeutically preventable deaths. We hypothesize that further major reduction in injury mortality will be obtained through injury prevention, rather than improvements in therapy. METHODS: Seven hundred fifty-three deaths in an American College of Surgeons-verified, Level I trauma center were reviewed as they occurred. Deaths were classified as therapeutically not preventable, possibly preventable, or preventable. These charts were also reviewed for factors that might have prevented or lessened the severity of the injury. RESULTS: Mean age was 43, mean Glasgow Coma Scale score was 5, mean Revised Trauma Score was 4, mean Injury Severity Score was 41, and mean probability of survival was 0.25 (according to TRISS). Forty-six percent underwent cardiopulmonary resuscitation in the field, 52% died within 12 hours, 74% died within 48 hours, and 86% died within 7 days. Primary causes of death included central nervous system injury in 51%, irreversible shock in 21%, multiple injuries (shock plus central nervous system injury) in 9%, multiple organ failure/sepsis and other causes in 3%, and pulmonary embolus in 0.1%. Seven hundred one (93%) were classified as not preventable with a change in therapy, 32 (4.2%) were classified as potentially preventable with a change in therapy, and 20 were classified as preventable with a change in therapy (2.6%). Forty-six percent had cardiopulmonary resuscitation performed before or immediately on arrival to the hospital. Another 23% had vital signs present on arrival, but had a Glasgow Coma Scale score of 相似文献   

Work-related deaths and traumatic brain injury

Background: Traumatic brain injury (TBI) at the workplace is a significant contributor to the number of work-related deaths that occur per year. This study aimed to quantify and characterize these deaths in Ontario.

Methods: The study design was a case series with analytic and surveillance components. Data was obtained from the Chief Coroner's Office of Ontario from 1996-2000.

Results: A total of 488 work-related injury fatalities were identified. Evidence of TBI was apparent in 45% of these cases (n = 211). Industries with the highest rate of work-related TBI mortality expressed per 100 000 working population included primary industry (59.1), agriculture (24.5), construction (20.0) and transportation/communications/utilities industries (13.9). Deaths involving TBI were more likely to be due to falls than non-TBI-related deaths among workers (p = 0.0001).

Conclusions: Results from this research indicate that prevention programmes should focus on decreasing falls at all ages and increasing the use of personal protective equipment.     

Anatomy of the accident scene: a prospective study of injury and mortality

This study of the accident scene focuses on the effects of vehicular deformity and restraint devices on occupant injury. In 500 patients evaluated in a Level I trauma center, seatbelts significantly reduced the likelihood of individuals' requiring the trauma center (P less than 0.0001). Seatbelts also significantly reduced the mortality rate of those who were transported to the trauma center (P less than 0.04). Dashboard intrusion correlated with pelvic (P less than 0.001) and femur (P less than 0.03) fractures, closed head injuries (P less than 0.001), and intraabdominal injuries (P less than 0.02). Steering wheel deformity correlated with pelvic fractures (P less than 0.001) and closed head injuries (P less than 0.005). Windshield violation correlated with closed head injuries (P less than 0.014) and spinal fractures (P less than 0.03). Irreparable vehicles correlated with pelvic (P less than 0.0001) and femur fractures (P less than 0.01), closed head injuries (P less than 0.0001) and intra-abdominal injuries (P less than 0.0001). The authors conclude that a careful examination of the accident scene for specific mechanisms of injury can lead to better prehospital care, more rapid and consistent diagnosis of injury, and improved patient outcome. Further prospective studies should accumulate data that will improve prehospital care, alert physicians to possible injury, increase community awareness of injury prevention, and improve vehicle construction.     

Urban helicopter response to the scene of injury

Metropolitan Houston with a population of four million has the nation's poorest freeway system. Its two Level I trauma centers are adjacent within a centrally located freeway loop, therefore the city is ideally suited for a trauma scene helicopter transport service. During 1981 there were 577 flights to the scene of injury (blunt, 466; penetrating, 111). Flights were requested by 60 agencies (EMS, law enforcement, etc.). All flights were manned by a surgical resident and flight nurse. The flight distances ranged from 2 to 57 miles (average, 14.4). Three hundred six flights (53%) were within the city, including 59 (10.2%) within the freeway loop. In approximately one half of the flights, the initial responding EMS unit was a paramedic unit. The average time at the scene was 28 minutes. The overall mortality for trauma scene flights was 35.7% (206/577). Eighty-nine patients (15.1%) died at the scene and were not transported (initial median scene Trauma Score, 2). The mortality among transported patients was 24.0% (117/488). Twenty-nine patients died during attempted emergency-center resuscitation (initial median scene Trauma Score, 5). Eight-eight patients died after hospital admission (initial median scene Trauma Score, 10). Only 27 patients (5.5%) did not require hospitalization. Scene treatment (intubation, hyperventilation and, when appropriate, mannitol administration) was routinely initiated for patients with severe head injuries. Two hundred seventy-nine patients required cardiopulmonary resuscitation, tracheal intubation, chest-tube placement, or other invasive procedures. Based upon these resuscitative efforts and invasive procedures, a physician in attendance was deemed medically desirable for one half of the flights.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pediatric spinal injury: review of 61 deaths.

Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. The authors present a unique review of 61 pediatric deaths associated with spinal injury. This group represented 28% of the total pediatric spine-injured population and 45% of the total pediatric spinal cord-injured group studied. The ratio of pediatric to adult spinal injury mortality was 2.5:1. Of the 61 children, 54 (89%) died at the accident scene. Thirty patients underwent a complete autopsy, 19 of whom had an Abbreviated Injury Scale Grade 6 injury (maximum score, untreatable). Spinal cord injury was found to be the cause of death in only eight children and was associated with injury to the high cervical cord and cardiorespiratory arrest. These children typically sustained severe multiple trauma. In this population, there appears to be little room for improved outcome through changes in treatment strategy.     

Analysis of deaths due to injury in Milano: preliminary results

We reviewed all trauma deaths occurring in the urban area of Milan during one year. Autopsy reports were cross-referenced with pre- and in-hospital records and the Injury Severity Score was calculated by a senior surgeon. Causes of deaths were defined as central nervous system injury (CNS), hemorrhage (HEM), combined central nervous system injury and hemorrhage (CNS + HEM), and burns (BURN). Places of death were considered the scene (DOS), during transportation (DOA), the emergency room (DER), and hospital. Two multidisciplinary commissions reviewed patient reports and deaths were judged non-preventable, possibly preventable or frankly preventable, using the unanimous decision rule. The TRISS method was used to calculate the probability of survival for in-hospital deaths. Overall trauma deaths were 255 with 78.04% blunt and 16.08% penetrating traumas. Burns accounted for 5.88%. CNS and CNS + HEM caused 171 (67.05%) deaths. DOS were 91, DOA 48, DER 34, and in-hospital deaths 33. Victims found dead (49 individuals) were excluded from further analysis. The commissions classified 56.31% of deaths as non-preventable, 32.03% as possibly preventable and 11.65% as frankly preventable. The Injury Severity Score decreased from DOS to in-hospital deaths (p < 0.05). The preventability rate was higher for in-hospital deaths (p < 0.05). The results of this study suggest that the development of a tiered trauma system in Milan is mandatory.     

The role of preliminary medication in the prevention of anesthetic deaths

It is now a common practice in some clinics to give oil-ether, evipal, nembutal, avertin, or some other drug in order to avoid the possibility of lung lesions and psychic reflexes and the unpleasant experiences usual with a patient anticipating and dreading the unknown, regardless of the terminal anesthetic or method of administration.     

Fatal respiratory distress syndrome after prolonged mechanical ventilation: its pathogenesis and prevention

Prolonged pulmonary atelectasis was shown to produce a highly lethal respiratory distress syndrome. Atelectasis with secondary hypoxemia occurred in open-chest animals ventilated for long periods with intermittent positive pressure (IPPV). These animals frequently died of progressive pulmonary insufficiency a few days after the period of thoracotomy and mechanical ventilation. Atelectasis did not occur in closed-chest animals subjected to long periods of IPPV and these animals did not manifest pulmonary insufficiency after the period of ventilation. Continuous positive-pressure ventilation (CPPV) prevented atelectasis in open-chest animals during prolonged mechanical ventilation and thoracotomy, and animals so treated developed postoperative pulmonary insufficiency infrequently.     

Fatal axillary artery injury following anterior dislocation of the shoulder

A case of longitudinal tearing of the axillary artery is reported following anterior dislocation of the shoulder in an 87-year old woman, resulting in fatal haemorrhage. Atherosclerosis of the axillary artery and a history of previous dislocation of the affected shoulder were predisposing factors.     

Inflicted head injury: future directions and prevention

Although described only a quarter century ago, progress in this area is rapid and increasing at an accelerated rate. As a group, neurosurgeons, and particularly pediatric neurosurgeons, potentially have a lot to offer, both in the hospital, the courtroom, and the laboratory. As practitioners who see large numbers of brain injuries, both accidental and inflicted, they can provide a unique perspective to child abuse colleagues; unfortunately, neurosurgeons shy away from doing so for a variety of reasons: (1) they are too busy with clinical practice and cannot afford to devote the (largely uncompensated) time involved in keeping up with the literature on the subject, reviewing the case files in detail, and testifying in court; (2) they are reluctant to take the stand and potentially be subjected to the ridicule (and even abuse) hurled by attorneys in the defense of their clients; (3) they are uncertain in their minds about the validity of the evidence in some cases, especially when the evidence is not iron-clad; and (4) they perhaps fear later retribution from people they have helped convict for these crimes. Whatever the reasons, neurosurgeons need to be more involved in these cases and to be both knowledgeable and reasonable in assessments of the cause of injury. In no other area of neurosurgery is the truth so critical, because the lives of the infants for whom they care, and those who might be accused unjustly of perpetrating a crime that they did not commit, hang in the balance. Neurosurgeons must be unerringly accurate in obtaining and recording clinical information and physical findings. When asked, they must not shy away from providing an answer, but only if well enough versed in the literature to be capable of so doing, because to provide false or inaccurate information is a disservice; to do so may condemn an innocent person to prison, or an innocent infant to death. If there is uncertainty, it is probably in the best interests of the child to have the case analyzed and represented by an expert who knows the literature well; there are many excellent and objective child abuse experts who can do this. Finally, the author believes that this should be a much more active area of research for neurosurgeons. Although there has been much progress, there are also a number of uncertainties that remain to be answered, only a few of which have been touched on here. There is much to be done in this important field; neurosurgeons must concentrate on finding adequate answers for those questions that remain.     

Preventable deaths after head injury: a clinical audit of performance.

A retrospective trauma audit of 267 consecutive patients presenting to the resuscitation room of an accident and emergency department identified 107 (M = 0.73) patients with CNS predominant injuries in a period of 1 year. The mortality rate was 33 per cent. Application of the TRISS method indicated that 18 (51 per cent) of the 35 deaths (Z = 5.74, P less than 0.001) were mathematically unexpected; no unexpected survivors were identified. Subsequent peer review agreed that death was preventable in 11 cases. The peer panel suggested that the lack of an on-site neurosurgical service may have affected the outcome of this group of patients adversely.     

Epidemiology and pathology of traumatic deaths occurring at a Level I Trauma Center in a regionalized system: the importance of secondary brain injury

We reviewed the hospital records and autopsy data of all deaths occurring at a Level I Trauma Center during a 1-year interval to determine the epidemiology of traumatic death in a regionalized system of care: 1,581 patients were admitted and 106 died (6.6%). Nonsurvivors (NS) differed significantly from survivors (S) in age, Trauma Score, Injury Severity Score, and probability of survival, but there was no difference between NS and S in scene time or transport time. Of the NS 91.4% died within 7 days; only 8.6% died after 7 days. Central nervous system (CNS) injury was responsible for 48.1% of deaths, followed by hemorrhage (36.8%) and cardiovascular disease (5.7%). Sepsis was responsible for 5.5% of deaths. Secondary brain injury was found at autopsy in 66% of patients dying of CNS injury. The relatively small number of septic deaths may be due, in part, to improvements in treatment associated with regionalization of trauma care. The frequency of secondary brain injury, despite rapid transport and evacuation of mass lesions, suggests that it may play a major role in the pathophysiology of CNS death occurring in a trauma system.     

The nerve injury and the dying neurons: diagnosis and prevention

Following distal nerve injury significant sensory neuronal cell death occurs in the dorsal root ganglia, while after a more proximal injury, such as brachial plexus injury, a sizeable proportion of spinal motoneurons also undergo cell death. This phenomenon has been undervalued for a long time, but it has a significant role in the lack of functional recuperation, as neuronal cells cannot divide and be replaced, hence the resulting nerve regeneration is usually suboptimal. It is now accepted that this cell death is due to apoptosis, as indicated by analysis of specific genes involved in the apoptotic signalling cascade. Immediate nerve repair, either by direct suturing or nerve grafting, gives a degree of neuroprotection, but this approach does not fully prevent neuronal cell death and importantly it is not always possible. Our work has shown that pharmacological intervention using either acetyl-L-carnitine (ALCAR) or N-acetyl-cysteine (NAC) give complete neuroprotection in different types of peripheral nerve injury. Both compounds are clinically safe and experimental work has defined the best dose, timing after injury and duration of administration. The efficacy of neuroprotection of ALCAR and NAC can be monitored non-invasively using MRI, as demonstrated experimentally and more recently by clinical studies of the volume of dorsal root ganglia. Translation to patients of this pharmacological intervention requires further work, but the available results indicate that this approach will help to secure a better functional outcome following peripheral nerve injury and repair.