Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan

BackgroundWhole-body CT scan is the cornerstone of trauma-related injury assessment. Several lines of evidence indicate that significant number of injuries may remain undetected after the initial hot report of CT. Missed injuries (MI) represent an important issue in trauma patients, for they may increase morbidity, mortality and costs. The aim of this study was to examine incidence and predictors of MI in trauma patients undergoing whole-body CT scan.Methods177 CT scan performed upon admission of trauma patients during year 2005 were reviewed by a radiologist blinded to patient's initial data. MI was defined as injuries not written in the initial report. Patients with and without MI were compared to determine predictors of MI by multivariable analysis.Results157 MI were diagnosed in 85 (47%) patients. MI was predominantly encoded AIS 2 (57%) or 3 (29%). Patients with MI had significantly higher SAPSII, higher ISS and were more frequently sedated. Age over 50 years (OR: 4.37, p = 0.003) and ISS over 14 (OR: 4.17, p < 0.0001) were independent predictors of MI. Median ISS after encoding MI was significantly higher than initial ISS (22 vs. 20 p < 0.0001). After adjustment for severity, mortality and length of stay were not different between patients with or without MI.ConclusionTrauma patients, especially aged and severe, experienced a high rate of missed injuries in the initial hot report which appeared to be predominantly minor and musculoskeletal, advocating a CT scan second reading.     

Missed injuries during the initial assessment in a cohort of 1124 level-1 trauma patients

IntroductionDespite the presence of diagnostic guidelines for the initial evaluation in trauma, the reported incidence of missed injuries is considerable. The aim of this study was to assess the missed injuries in a large cohort of trauma patients originating from two European Level-1 trauma centres.MethodsWe analysed the 1124 patients included in the randomised REACT trial. Missed injuries were defined as injuries not diagnosed or suspected during initial clinical and radiological evaluation in the trauma room. We assessed the frequency, type, consequences and the phase in which the missed injuries were diagnosed and used univariate analysis to identify potential contributing factors.ResultsEight hundred and three patients were male, median age was 38 years and 1079 patients sustained blunt trauma. Overall, 122 injuries were missed in 92 patients (8.2%). Most injuries concerned the extremities. Sixteen injuries had an AIS grade of ≥3. Patients with missed injuries had significantly higher injury severity scores (ISSs) (median of 15 versus 5, p < 0.001). Factors associated with missed injuries were severe traumatic brain injury (GCS ≤ 8) and multitrauma (ISS ≥ 16). Seventy-two missed injuries remained undetected during tertiary survey (59%). In total, 31 operations were required for 26 initially missed injuries.ConclusionDespite guidelines to avoid missed injuries, this problem is hard to prevent, especially in the severely injured. The present study showed that the rate of missed injuries was comparable with the literature and their consequences not severe. A high index of suspicion remains warranted, especially in multitrauma patients.     

The effect of prehospital time related variables on mortality following severe thoracic trauma

ObjectivesThe aims of this study is firstly to analyse the impact of prehospital time related variables on mortality, in a specific subset of HEMS patients and secondly to demonstrate any interactions between time related variables and factors taking place in the prehospital setting.MethodsRetrospective analysis of 688 consecutive London HEMS transfers with severe thoracic trauma and mean injury severity score (ISS) of 35, during a 9-year period (1994–2002). We have analysed the effect of the following time related variables on mortality: activation time, arrival on scene time (AoS), stay on scene time (SoS), total time (ToT), rush-hour time (RhT) and leisure-hour time (LhT). We have also investigated the interaction of the above mentioned variables with observations and interventions taken place on scene and at accident and emergency department (A&;E) following adjustment for type and severity of injury. For statistical analysis the time variables were grouped into quintiles.ResultsSix hundred eighty eight victims (510 males) with mean age of 38.5 ± 17.5 had total survival rate of 59.6%. The mean AoS and SoS were 11.6 ± 5.8 min and 36.6 ± 16.8 min, respectively. ToT > 65 min, as in quintiles III, IV and V with mean ToT of 65.3 min, 74.9 min and 102.7 min respectively, had an influence on mortality with calculated adjusted OR of 1.37 (95%CI = 0.47–3.94), 3.36 (95%CI = 1.22–9.23) and 1.43 (95%CI = 0.52–3.92) respectively with concomitant adjustment for type of injury, severity of injury, age, physiological variables on scene and on scene emergency thoracotomy (ET). ET on scene was an independent predictor for mortality (OR 3.94, 95%CI = 1.03–15.06). SoS of more than 34 min can lead to harmful changes on patients’ pathophysiological status. ISS has no significant effect on AoS or SoS. RhT and LhT have no significant effect on mortality and they did not influence the AoS and SoS.ConclusionThis study suggests that time related variables have a complex and heterogeneous effect on mortality. Thoracic trauma victims usually have high ISS, in such population, ToT <65 min may be associated with lower possibility of death. Neither AoS nor SoS was influenced by time of incident or severity of injury.     

The influence of fault on health in the immediate post-crash period following road traffic crashes

ObjectiveTo compare the early health status of people who sustained injuries during road traffic crashes (RTC) in which they were at fault (AF), with people who sustained injuries in RTC in which they were not at fault (NAF).DesignProspective cohort study.SubjectsPeople presenting to the emergency department with mild to moderate musculoskeletal injuries following RTC.Main outcome measuresPhysical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure; Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI) recorded immediately post-crash.Results193 people participated in the study and were enrolled a mean of 9.3 days following the crash. The mean age was 37 years and 60% were female. 71% were NAF. There was a significantly higher number of females in the NAF group (65% compared with 35% males; p < 0.001). Neck and back injuries were reported by 90.4% of the NAF group compared to 69.1% of the AF group (p < 0.001). There were no significant differences in PCS, FRI or pain intensity between the two groups at a mean of 9.3 days after the crash. The mean MCS for the NAF group was significantly worse than for the AF group (31.4 compared to 37.3; p = 0.005). The SF-36 domain revealed a significantly worse adjusted mean role emotional score for the NAF group (23.4 compared to 32.5, p = 0.002). Females had significantly worse MCS score than males (30.6 and 38.1 respectively; p < 0.001) and worse adjusted mean anxiety and depression scores (10 compared to 7.8; p = 0.002 and 7.6 compared to 5.5; p = 0.002 respectively).ConclusionsDespite there being no difference in physical health status, the NAF group demonstrated more emotional and mental disturbance than the AF group; and this was significantly worse for females. Treatment strategies should focus on addressing early pain and disability as well as providing appropriate psychological interventions, particularly for people not at fault following RTC.     

Impaired quality of life after bicycle trauma

IntroductionBicycle crashes often affect individuals in working age, and can impair quality of life (QoL) as a consequence. The aim of this study was to investigate QoL in bicycle trauma patients and to identify those at risk of impaired QoL.Patients and methods173 bicycle trauma patients who attended a level I trauma centre from 2010 to 2012 received Hadorn's QoL questionnaire six months after their crash. Medical data was collected from the patient's records. Univariate ordinal logistic regression was used to investigate the association between QoL and other factors.Results148 patients returned the questionnaire (85.5%). The majority had only mild or minor injuries (85.1%; n = 126). However, 72.1% (n = 106) still suffered from pain or other physical symptoms more than six months after their bicycle crash. Patients with a Glasgow Coma Scale (GCS) ≤13 or an Injury Severity Score (ISS) >15 experienced impaired emotions/outlook on life (p-values 0.003 and 0.045, respectively). Physical suffering was reported by patients with a GCS ≤13 and in those with injuries to the cervical spine (p-values 0.02 and 0.025, respectively). Patients with an ISS >15 or facial fractures experienced limitations in daily activities (p-values 0.031 and 0.025, respectively).ConclusionsMore than 70% of bicycle trauma patients suffered physically more than six months after their crash, even though only 15% were severely injured. Risk factors for an impaired QoL were cervical spine injuries or facial fractures, a GCS ≤13 and an ISS >15.     

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank

IntroductionWhile geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims.Patients and methodsWe conducted a retrospective analysis of the 2008–2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable “intent of injury.”Results3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18–59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67 ± 7 vs. 74 ± 9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS ≥ 16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults.ConclusionsGeriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.     

A 20-year Experience with Portal and Superior Mesenteric Venous Injuries: Has Anything Changed?

ObjectivesTo identify predictive factors causing mortality in patients with injuries to the portal (PV) and superior mesenteric veins (SMV).DesignRetrospective analysis of prospectively collected data.Materials and methodsAdults admitted with blunt or penetrating PV and SMV injuries at an academic level I trauma center during a 20-year period.ResultsOf 26,387 major trauma victims admitted from 1987 through 2006, 26 sustained PV or SMV injuries (PV = 15, SMV = 11). Mechanism of injury was penetrating in 19 (73%) and 20 were in shock. Active hemorrhage occurred in 21. Most patients had associated injuries (2.9 ± 1.8/patient). Mean Injury Severity Score (ISS) was 27.8 ± 16.8. All PV injuries underwent suture repair and 27% of SMV injuries were ligated. Overall mortality was 46% (PV = 47%, SMV = 45%). Stab wounds had a lower mortality (31%) compared to gunshot wounds (67%) and blunt injuries (57%). Nonsurvivors had a higher ISS (35.8 vs. 20.9; p = 0.02), more associated injuries (3.7 vs. 2.2; p = 0.02), were older, and had active hemorrhage. Active hemorrhage (p = 0.04) was independently related to death while shock on admission (odds ratio = 6.1, p = 0.61) trended toward higher mortality.ConclusionDespite improvements in trauma care, mortality of PV and SMV injuries remains high. Shock, active hemorrhage, and associated injuries were predictive of increased mortality.     

Complications following thoracic trauma managed with tube thoracostomy

IntroductionTube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma.MethodsA retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007–12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann–Whitney test, and multivariate analysis.Results154 patients were included with 22.1% (n = 34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p = 0.02 and p < 0.001), increased chest AIS (p = 0.01), and the presence of an extrathoracic injury (p = 0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p = 0.03) was a significantly independent predictor of CTCs.ConclusionsCTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.     

Outcomes of trauma patients: direct transport versus transfer after stabilisation at another hospital

BackgroundIn this study, we attempted to identify differences in the outcomes of patients with severe trauma who were directly transported to our hospital, and those who were stabilised initially at other hospitals in south-central Taiwan.MethodsWe performed a prospective observational study to review the records of 231 patients with major trauma (Injury Severity Scores (ISS) >15) who visited our hospital's emergency department from January 2010 to December 2010. Among these patients, 75 were referred from other hospitals. Logistic regression was performed to assess the effects of transfer on mortality.ResultsPatients in the transfer group had a shorter interval between trauma and admission to the first hospital (25.3 min vs. 28.1 min), and the average interval between the two hospital arrivals was 138.3 min. Transfer from another hospital was not significantly correlated with mortality in this study (odds ratio: 1.124, 95% confidence interval: 0.276–4.578).ConclusionIn trauma patients with ISS > 15, there is no difference in mortality between those transferred from another hospital after initial stabilisation and those who visited our emergency department directly.     

Initial predictors associated with outcome in injured multiple traumatic limb amputations: A Kandahar-based combat hospital experience

IntroductionImprovised explosive devices (IEDs) are the defining mechanism of injury during Operation Enduring Freedom. This is a retrospective analysis of initial management for IED blast injuries presenting with bilateral, traumatic, lower-extremity (LE) amputations with and without pelvic and perineal involvement.MethodsA database of trauma admissions presenting to a North Atlantic Treaty Organization (NATO) Role 3 combat hospital in southern Afghanistan over a 7-month period was created to evaluate the care of this particular injury pattern. Patients were included if they were received from point of injury with at least bilateral traumatic LE amputations and had vital signs with initial resuscitation efforts.ResultsThirty-two presented with double LE amputations (36%) and nine with triple amputations (10%). After excluding 10 patients who failed to meet the inclusion criteria, 22 patients were analysed. The mean age was 29 years, and the average ISS and admission haemoglobin were 22 and 11.3 mg l^?1, respectively. Patients received an average of 54 units of blood products and underwent 1.6 operations with a mean operative time of 142.5 min. The pattern of injury was associated with an increase in the total blood products required for resuscitation (pelvis n = 12, p = 0.028, gastrointestinal tract (GI) n = 14, p = 0.02, perineal n = 15, p = 0.036). There was no relationship between ISS or admission haemoglobin and the need for massive transfusion. Low Glasgow Coma Scale (GCS) was associated with increased 30-day mortality. Hollow viscus injury and operative hemipelvectomy were also associated with mortality.ConclusionsEarly 30-day follow-up demonstrated that IED injuries with bilateral LE amputations with and without pelvic and perineal involvement are survivable injuries. Standard measures of injury and predictors of survival bore little relationship to observed outcomes and may need to be re-evaluated. Long-term follow-up is needed to assess the extent of functional recovery and overall morbidity and mortality.     

Severity and treatment of “occult” intra-abdominal injuries in blunt trauma victims

Backgroundto assess the severity and treatment of “occult” intra-abdominal injuries in blunt trauma victims.MethodRetrospective analysis of charts and trauma register data of adult blunt trauma victims, admitted without abdominal pain or alterations in the abdominal physical examination, but were subsequently diagnosed with intra-abdominal injuries, in a period of 2 years. The severity was stratified according to RTS, AIS, OIS and ISS. The specific treatment for abdominal injuries and the complications related to them were assessed.ResultsIntra-abdominal injuries were diagnosed in 220 (3.8%) out of the 5785 blunt trauma victims and 76 (34.5%) met the inclusion criteria. The RTS and ISS median (lower quartile, upper quartile) were 7.84 (6.05, 7.84) and 25 (16, 34). Sixty seven percent had a GCS ≥ 13 on admission. Injuries were identified in the spleen (34), liver (33), kidneys (9), intestines (4), diaphragm (3), bladder (3) and iliac vessels (1). Abdominal injuries scored AIS ≥ 3 in 67% of patients. Twenty-one patients (28%) underwent laparotomy, 5 of which were nontherapeutic. The surgical procedures performed were splenectomy (8), suturing of the diaphragm (3), intestines (3), bladder (2), kidneys (1), enterectomy/anastomosis (1), ligation of the common iliac vein (1), and revascularization of the common iliac artery (1). Angiography and embolization of liver and/or spleen injuries were performed in 3 cases. Three patients developed abdominal complications, all of which were operatively treated. There were no deaths directly related to the abdominal injuries.ConclusionSevere “occult” intra-abdominal injuries, requiring specific treatment, may be present in adult blunt trauma patients.     

Analysis of radiation exposure to the orthopaedic trauma patient during their inpatient hospitalisation

PurposeThere has been considerable concern regarding radiation exposure to both the patient and treating surgeon and the possible risk of resulting malignancy. We sought to analyse the total effective dose of radiation that a cohort of orthopaedic trauma patients are exposed to during their inpatient hospitalisation and determine risk factors for greater exposure levels.MethodsFollowing approval from the Institution Review Board, a search was conducted of a level I trauma centre database for radiation exposures to patients over a 1 year period. Patients were included if they had an ICD-9 code from 805 to 828, indicating a fracture involving the trunk (805–811) or extremities (812–828). We compared the total effective radiation dose in various injury patterns as well as those considered to be polytrauma patients to those who were not according to their injury severity score (ISS).ResultsThe records of 1357 trauma patients were available for review. The average patient age was 40.6 years and the mean ISS was 14.1. The average effective radiation dose for all patients during their hospitalisation was 31.6 mSv. There was a statistically significant difference in radiation exposure between patients with an ISS greater than 16 (48.6 mSv) versus those with an ISS equal to or less than 16 (23.5 mSv), p < 0.001. Patients with spine trauma can be expected to get more than 15 mSv more radiation than non-spine patients, p < 0.001. Extremity injuries received the least amount of radiation, spine only patients were next, then finally spine and extremity injury patients had the greatest exposures. Having a spine fracture, a pelvic fracture, a chest wall injury, or a long bone fracture were all risk factors for having more than 20 mSv of effective dose exposure. Patients under the age of 18 years did receive less radiation than the remainder of the cohort, p < 0.001.ConclusionsThe average orthopaedic patient receives a total effective radiation dose of more than 30 mSv, much greater than is considered acceptable as a recommended permissible annual dose by the International Commission on Radiological Protection (20 mSv). These findings indicate that the average trauma patient (in particular those with polytrauma or fractures involving the spine, pelvis, chest wall, or long bones) is exposed to high levels of radiation during their inpatient hospitalisation. The treating physicians of such patients should take into consideration the large amounts of radiation their patients receive just during their initial hospitalisation, and be prudent with the ordering of imaging studies involving radiation exposure.     

Management of polytrauma patients in the UK: Is there a ‘weekend effect’?

Background/purposeIt has been suggested that hospital admission during weekends poses a risk for adverse outcomes and increased patient mortality, the so-called ‘weekend effect’. We undertook an evaluation of the impact of weekend admissions to the management of polytraumatised patients, in a Level I Major Trauma Centre (MTC) in the UK.Materials and methodsA retrospective review of prospectively documented data of polytrauma patients (injury severity score (ISS) > 15), admitted between April 2013 and August 2015 was performed. Exclusion criteria included patients initially assessed in other institutions. All patients were initially managed at the emergency department (ED) according to ATLS^® principles and underwent a trauma computed tomography (CT) scan, unless requiring immediate surgical intervention.ResultsDuring the study period 1735 patients (pts) were admitted under the care of the MTC. Four hundred and five pts were excluded as they were transferred from other institutions and 300 pts were excluded as their ISS was less than 16. Overall 1030 patients met the inclusion criteria, out of which 731 were males. Comparing the two groups (Group A: weekday admissions (670), Group B: weekend admissions (360)), there was no difference in pts gender, mechanism of injury, GCS at presentation, need for intubation and time to CT. Patients admitted over the weekend were younger (p < 0.01) and presented with haemodynamic instability more frequently (p = 0.02). Time to operating room was also lower during the weekend, but this did not reach statistical significance (p = 0.08). Mortality was lower in Group B: 39/360 pts (10.8%) compared to Group A: 100/670 pts (14.9%) (p = 0.07). The relative risk (RR) of weekend mortality was calculated as 0.726 (95% CI: 0.513–1.027).Discussion/conclusionWeekend polytrauma patients appear to be younger, more severely injured and present with a higher incidence of haemodynamic instability (shock). Overall, we failed to identify a “weekend effect” in relation to mortality, time to CT and time to operating room. On the contrary, a lower risk of mortality was noted for patents admitted during the weekend.     

Alcohol and psychoactive drugs increased the pre-hospital mortality in 655 fall-related fatalities in Greece: a call for management protocols

IntroductionThe frequency of alcohol and psychoactive drugs in fall-related fatalities and their effect on type, severity of injury and location of death constitute the subjects of this study.MethodsA retrospective analysis based on autopsy and toxicology compared demographics, location of injury; intention for the injury, height of fall, Abbreviated Injury Scale – 90 (AIS-90), post-mortem Injury Severity Score (ISS), and location of death.ResultsAmongst 655 fall-related fatalities screened for alcohol and psychoactive drugs 123 (18.8%) were classified in the positive toxicology group (PTG) and the remaining in the negative toxicology group (NTG).The median ages were 48 (16–94) years for the PTG and 62 (12–96) years for the NTG.The screened represent 31% of the national toll. The median height of fall was 7 m and the median blood alcohol concentration was 53 (1.5–630) mg/dl.Males were more likely to be included in the PTG than females (21.6 versus 13.6%; p = 0.014) as were the aged between 11 and 60 years.The odds of severe (AIS ≥ 3) head, thoracic, abdominal, extremity, and spine injuries were not influenced by toxicology status.Fatalities of the PTG were as likely to have severe trauma (ISS ≥ 16) as were fatalities of the NTG (93.5 versus 90.8%; p = 0.34).There was no significant difference of ISS between PTG (median ISS 43, range: 6–75) and NTG (median ISS 35, range: 3–75).Nevertheless, 76.4% of the subjects of the PTG died during the pre-hospital stage of care compared to 60.5% of the subjects of the NTG, which was highly significant (or = 2.80, p = 0.001) after controlling for confounders as age, gender, intention for injury, height of fall, and ISS.ConclusionsIn fall related trauma, alcohol and psychoactive drugs increased the risk of death during the pre-hospital stage by 2.80 times. This is strong evidence that specific protocols for their early management should be instituted.     

Fractures and dislocations of the hand in polytrauma patients: Incidence,injury pattern and functional outcome

IntroductionInjuries of the hand can cause significant functional impairment, diminished quality of life and delayed return to work. However, the incidence and functional outcome of hand injuries in polytrauma patients is currently unknown. The aim of this study was to determine the incidence, distribution and functional outcome of fractures and dislocation of the hand in polytrauma patients.MethodsA single centre retrospective cohort study was performed at a level 1 trauma centre. Polytrauma was defined as patients with an Injury Severity Score of 16 or higher. Fractures and dislocations to the hand were determined. All eligible polytrauma patients with hand injuries were included and a Quick Disability of Arm, Shoulder and Hand questionnaire (QDASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) were administered. Patients were contacted 1–6 years after trauma.ResultsIn a cohort of 2046 polytrauma patients 72 patients (3.5%) suffered a hand injury. The functional outcome scores of 52 patients (72%) were obtained. The Metacarpal (48%) and carpal (33%) bones were the most frequently affected. The median QDASH score for all patients with hand injury was 17 (IQR 0–31) and the PRWHE 14 (IQR 0–41). Patients with a concomitant upper extremity injury (p = 0.002 for PRWHE, p0.006 for QDASH) and those with higher ISS scores (p = 0.034 for PRWHE, QDASH not significant) had worse functional outcome scores. As an example, of the 5 patients with the worst outcome scores 3 suffered an isolated phalangeal injury, all had concomitant upper extremity injury or neurological injuries (3 plexus injuries, 1 severe brain injury).ConclusionThe incidence of hand injuries in polytrauma patients is 3.5%, which is relatively low compared to a general trauma population. Metacarpal and carpal bones were most frequently affected. The functional extremity specific outcome scores are highly influenced by concomitant injuries (upper extremity injuries, neurological injuries and higher ISS).     

Helicopter rescue operations involving winching of an emergency physician

ObjectiveWe sought to study the epidemiologic and medical aspects of alpine helicopter rescue operations involving the winching of an emergency physician to the victim.MethodsWe retrospectively reviewed the medical and operational reports of a single helicopter-based emergency medical service. Data from 1 January 2003 to 31 December 2008 were analysed.ResultsA total of 921 patients were identified, with a male:female ratio of 2:1. There were 56 (6%) patients aged 15 or under. The median time from emergency call to helicopter take-off was 7 min (IQR = 5–10 min). 840 (91%) patients suffered from trauma-related injuries, with falls from heights during sports activities the most frequent event. The most common injuries involved the legs (246 or 27%), head (175 or 19%), upper limbs (117 or 13%), spine (108 or 12%), and femur (66 or 7%). Only 81 (9%) victims suffered from a medical emergency, but these cases were, when compared to the trauma victims, significantly more severe according to the NACA index (p < 0.001). Overall, 246 (27%) patients had a severe injury or illness, namely, a potential or overt vital threat (NACA score between 4 and 6). A total of 478 (52%) patients required administration of major analgesics: fentanyl (443 patients or 48%), ketamine (42 patients or 5%) or morphine (7 patients or 1%). The mean dose of fentanyl was 188 micrograms (range 25–750, SD 127). Major medical interventions such as administration of vasoactive drugs, intravenous perfusions of more than 1000 ml of fluids, ventilation or intubation were performed on 39 (4%) patients.ConclusionsThe severity of the patients’ injuries or illnesses along with the high proportion of medical procedures performed directly on-site validates emergency physician winching for advanced life support procedures and analgesia.     

Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma

ObjectTo evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma.Patients and methodsThe records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group).ResultsThirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n = 12), thoracotomy (n = 1), craniotomy (n = 1), and haemostasis of the lower extremities (n = 1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n = 12), endovascular stent or stent-graft placement (n = 2), and embolisation of a portal vein by laparotomy (n = 2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72] min vs. 355 [SD 169] min; p = 0.007). The mortality were 15 (95% CI 2–45) % in the intraoperative IVR group vs. 36 (95% CI 22–51) % in the control group.ConclusionHybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.     

Epidemiology of livestock-related injuries in a major trauma center in Kashan, Iran

Objective:Livestock-related injuries are one of the important factors causing morbidity and mortality in patients admitted to hospital.Treatment of these patients is still a major problem in health car...     

Epidemiology and mortality of glacier crevasse accidents

IntroductionCrevasse accidents can lead to severe injuries and even death, but little is known about their epidemiology and mortality.MethodsWe retrospectively reviewed helicopter-based emergency services rescue missions for crevasse victims in Switzerland between 2000 and 2010. Demographic and epidemiological data were collected. Injury severity was graded according to the National Advisory Committee for Aeronautics (NACA) score.ResultsA total of 415 victims of crevasse falls were included in the study. The mean victim age was 40 years (SD 13) (range 6–75), 84% were male, and 67% were foreigners. The absolute number of victims was much higher during the months of March, April, July, and August, amounting to 73% of all victims; 77% of victims were practicing mountaineering or ski touring. The mean depth of fall was 16.5 m (SD 9.0) (range 1–35). Overall on-site mortality was 11%, and it was higher during the ski season than the ski offseason (14% vs. 7%; P = 0.01), for foreigners (14% vs. 5%; P = 0.01), and with higher mean depth of fall (22 vs. 15 m; P = 0.01). The NACA score was ≥4 for 22% of the victims, indicating potential or overt vital threatening injuries, but 24% of the victims were uninjured (NACA 0). Multivariable analyses revealed that depth of the fall, summer season, and snowshoeing were associated with higher NACA scores, whereas depth of the fall, snowshoeing, and foreigners but not season were associated with higher risk of death.ConclusionThe clinical spectrum of injuries sustained by the 415 patients in this study ranged from benign to life-threatening. Death occurred in 11% of victims and seems to be determined primarily by the depth of the fall.     

Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank

Introduction and objectivesLower extremity (LE) arterial trauma and its treatment may lead to extremity compartment syndrome (ECS). In that setting, the decision to perform fasciotomies is multifactoral and is not well delineated. We evaluated the outcomes of patients with surgically treated LE arterial injury who underwent early or delayed fasciotomies.MethodsThe National Trauma Data Bank (NTDB) was retrospectively reviewed for patients who had LE arterial trauma and underwent both open vascular repair and fasciotomies. Exclusion criteria were additional non-LE vascular trauma, head or spinal cord injuries, crush injuries, burn injuries, and declaration of death on arrival. Patients were divided into those who had fasciotomies performed within 8 h (early group) or >8 h after open vascular repair (late group). Comparative analyses of demographics, injury characteristics, complications, and outcomes were performed.ResultsOf the 1469 patient admissions with lower extremity arterial trauma that met inclusion criteria there were 612 patients (41.7%) who underwent fasciotomies. There were 543 and 69 patients in the early and late fasciotomy groups, respectively. There was no significant difference in age, injury severity, mechanism of injury, associated injuries, and type of vascular repair between the groups. A higher rate of iliac artery injury was observed in the late fasciotomy group (23.2% vs. 5.9%, P < .001). Patients in the early fasciotomy group had lower amputation rate (8.5% vs. 24.6%, P < .001), lower infection rate (6.6% vs. 14.5%, P = .028) and shorter total hospital stay (18.5 ± 20.7 days vs. 24.2 ± 14.7 days, P = .007) than those in the late fasciotomy group. On multivariable analysis, early fasciotomy was associated with a 4-fold lower risk of amputation (Odds Ratio 0.26, 95% CI 0.14–0.50, P < .0001) and 23% shorter hospital LOS (Means Ratio 0.77, 95% CI 0.64–0.94, P = .01).ConclusionEarly fasciotomy is associated with improved outcomes in patients with lower extremity vascular trauma treated with surgical intervention. Our findings suggest that appropriate implementation of early fasciotomy may reduce amputation rates in extremity arterial injury.