Infection in hospitalized trauma patients: incidence, risk factors, and complications

BACKGROUND

Several factors place victims of multiple trauma at increased risk for infection. The purpose of this study was to delineate the frequency of, types of, and risk factors for infection in hospitalized trauma patients.

METHODS

Prospective surveillance for nosocomial infection was conducted for all trauma patients who were admitted for more than 24 hours to a tertiary-care regional trauma center between January 1 and December 31, 1996.

RESULTS

A total of 563 patients (414 males) with a mean age of 40 years (range, 15-97 years) were followed. Most (86%) sustained blunt traumatic injuries. A total of 367 infections occurred in 209 (37%) patients for an incidence of 32.1/1,000 patient-days. The hospital stay of 37% of patients was complicated by at least one infection, involving the following sites: lower respiratory tract (28%), urinary tract (24%), surgical wound (18%), skin/soft tissue (13%), intra-abdominal (5%), primary bloodstream (5%), and other sites (8%). Infection was complicated by septic shock in 36 (10%) cases, acute respiratory distress syndrome in 32 (9%) cases, and multiorgan failure in 13 (4%) cases. Death was attributed to infection in four patients. In a multivariate analysis, infected patients were more likely to have been ventilated (odds ratio [OR] = 2.6; p<0.001), to have had multiple surgical procedures (OR = 2.8; p = 0.02), to have received multiple blood transfusions (OR = 2.3; p = 0.04), and to have had a spinal cord injury (OR = 5.0; p = 0.002). First surgical procedure within 24 hours of admission was protective (OR = 0.4, p = 0.001).

CONCLUSION

Trauma patients are at high risk for developing infection. Identifying patients who are at increased risk for infection may allow for early intervention and subsequent decrease in infectious morbidity.

Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury

BACKGROUND

Although the routine use of FAST (focused assessment with sonography for trauma) in the evaluation of trauma victims is increasing, to our knowledge, a prospective comparison of contemporary adult trauma victims managed with and without FAST has not been reported in North America.

METHODS

Adult victims of blunt trauma for whom there was a suspicion of abdominal injury were managed with one of two diagnostic algorithms, FAST or no-FAST. The two algorithms were compared for diagnostic accuracy, cost, time, and delayed diagnoses.

RESULTS

Among 706 patients (mean Injury Severity Score, 23), 460 were managed with FAST and 246 with no-FAST. The two groups were similar with respect to age, Injury Severity Score, prehospital time, and mortality (p = not significant). There were 3 of 460 (0.7%) delayed diagnoses in the FAST group and 4 of 246 (1.6%) in the no-FAST group (p = not significant). The diagnostic accuracy for the FAST and no-FAST algorithms was 99% and 98%, respectfully. The FAST and no-FAST algorithms led to similar rates of laparotomy, 13% and 14%, respectfully, but nonoperative management was more common in the no-FAST group (p < 0.01). The mean diagnostic cost for the FAST algorithm was $156, compared with $540 with the no-FAST algorithm (p < 0.0001) and the mean time required for diagnostic work-up was 53 minutes with the FAST algorithm, compared with 151 minutes with the no-FAST algorithm (p < 0.0001).

CONCLUSION

This study has provided prospective evidence that a FAST-based algorithm for blunt abdominal injury was more rapid, less expensive, and as accurate as an algorithm that used computed tomography or diagnostic peritoneal lavage only. Trauma centers are encouraged to incorporate a FAST-based algorithm into their initial management of blunt trauma victims.

Early experience with simulated trauma resuscitation

Although trauma resuscitation is best taught through direct exposure with hands-on experience, the opportunities for this type of teaching in Canada are limited by the relatively low incidence of serious injury and the consolidation of trauma care to a small number of centres. Simulators have been used extensively outside the health care environment and more recently have been used by anesthetists to simulate intraoperative crises. In this paper early experience using a realistic mannequin, controlled by a remote computer, that simulates a variety of physiologic and injury specific variables is presented. The resource implications of simulated resuscitation are reviewed, including one-time and operating costs. Simulated trauma resuscitation may be an educational alternative to "real-life" trauma resuscitation, but careful evaluation of the benefits and resource implications of this type of teaching through well-designed research studies will be important.

The indeterminate abdominal sonogram in multisystem blunt trauma

BACKGROUND

North American trauma centers are beginning to note the limitations of emergent torso sonography. The purpose of this prospective study was to evaluate the frequency, causes, associations, and sequelae of indeterminate (IND) sonograms in blunt trauma.

METHODS

Among adult blunt trauma patients assessed with screening torso sonography, clinician sonographers recorded the abdominal sonogram as positive, negative, or IND for free fluid. Patients with IND sonograms were further investigated with repeat sonography, computed tomography, or diagnostic peritoneal lavage.

RESULTS

Among 417 patients with blunt trauma (mean Injury Severity Score = 21) managed with sonography, there were 28 (6.7%) IND and 389 (93.3%) non-IND sonograms. Sonograms were IND because of patient factors in 71% (20 of 28) and because of operator factors in 29% (8 of 28). None of the 28 patients were managed with repeat sonography alone. All 4 diagnostic peritoneal lavage examinations gave negative results, whereas 8 of 23 computed tomographic scans were abnormal (6 of 8 patients underwent laparotomy). The mean time required for diagnostic workup was 117 minutes in the IND group and 48 minutes in the non-IND group (p < 0.001 in both cases).

CONCLUSION

This prospective study has demonstrated that IND sonograms are not common at our center (6.7%), are usually attributable to patient factors, and are associated with greater diagnostic time. Patients with IND sonograms require further investigation because they often have injuries requiring laparotomy.

Head injury in young adults: long-term outcome

OBJECTIVE

To describe the long-term outcome 5 years after injury of young adults who were 15 to 19 years old at the time of their head injuries.

DESIGN

A retrospective cohort. The health records of 62 consecutive eligible subjects were abstracted for baseline sociodemographic, health, and injury variables. A telephone interview was administered to assess quality of life, impairment, disability, and handicap.

SETTING

Canada's largest trauma center, Sunnybrook Health Science Centre, Toronto, Canada.

SUBJECTS

Of the 58 subjects (94%) who were traced at follow-up, 51 agreed to participate.

MAIN OUTCOME MEASURES

The Medical Outcomes Study SF-36, Head Injury Symptom Checklist, selected disability measures, Community Integration Questionnaire.

RESULTS

Of the 8 summary items of the Medical Outcomes Study SF-36, subjects scored lowest on mental health. There were no significant differences between mild and more severely injured groups in all quality of life measures. Subjects classified with mild head injury overall reported more symptoms from the Head Injury Symptom Checklist. Subjects with more severe injuries had lower community integration scores (p < .05).

CONCLUSIONS

Overall, mental health is an important area of concern at follow-up for all subjects. Adolescents with apparent mild head injury can have disabling symptoms many years after injury.

Measuring injury severity: time for a change?

BACKGROUND

The Injury Severity Score (ISS) does not take into account multiple injuries in the same body region, whereas a New ISS (NISS) may provide a more accurate measure of trauma severity by considering the patient's three greatest injuries regardless of body region. The purpose of this study was to evaluate the ISS and NISS in patients with blunt trauma.

METHODS

Consecutive individuals treated from January of 1992 to September of 1996 at one institution were included if they had sustained blunt trauma and satisfied triage standards (n = 2,328). For each patient, we computed the ISS and the NISS to determine how often the two scores were identical or discrepant. Discrepant cases were then further analyzed using receiver operating characteristic curves to determine which score better predicted short-term mortality.

RESULTS

The mean ISS was 25 +/- 13, and the mean NISS was 33 +/- 18. The two predictive scores were identical in 32% of patients and discrepant in 68% of patients. Patients with identical scores had a lower mortality rate than patients with discrepant scores (10% vs. 13%; p < 0.02). In patients with discrepant scores, the area under the receiver operating characteristic curves was greater for the NISS than the ISS (0.852 vs. 0.799; p < 0.001), and greater amounts of discrepancy were associated with increasing rates of mortality (p < 0.001).

CONCLUSIONS

The NISS often increases the apparent severity of injury and provides a more accurate prediction of short-term mortality. The benefit associated with using the NISS rather than the ISS must be weighed against the disadvantages of changing a scoring system and the potential for still greater improvements.

Changes in red cell transfusion practice among adult trauma victims

BACKGROUND

Recent attention concerning the adverse outcomes of blood transfusion has resulted in decreased blood product usage for nonemergency care. We hypothesized that there has also been a decrease in blood product use in the management of seriously injured adults.

METHODS

A retrospective review of institutional database records was conducted at a regional trauma center for adults admitted during 1991, 1993, and 1995. Data was analyzed for trends in amount, type, and timing of blood product use.

RESULTS

A total of 1,738 patients were assessed, with 1,605 meeting inclusion. The three patient groups were similar, including injury severity (overall mean Injury Severity Score of 23.6), mechanism (88% blunt), and survival (87%). In 1991, 54% of the patients were transfused a total of 2,341 units of packed red blood cells (mean 4.67 units/pt treated) versus 42% of patients in 1995 (p < 0.0001) who received 2,018 packed red blood cells (mean 3.57 units/patient treated, p = 0.05). A significantly higher proportion of units was transfused in the first 24 hours of care in 1995 (64%) compared with 1991 (21%, p < 0.0001). A reduction in the use of universal donor type-O blood use was also found (1.21 vs. 0.65 units/patient transfused, p < 0.0001). Despite similar admission hemoglobin concentrations (124.1 vs. 125.3, not significant), significant reductions were found in the average 24-hour (109.2 vs. 103.8, p < 0.001), lowest (96.5 vs 92.1, p < 0.01) and discharge (115.8 vs. 110.5, p < 0.001) concentrations.

CONCLUSIONS

Between 1991 and 1995 there have been significant reductions in both the number of trauma patients receiving blood products and the total number of units transfused. These findings may reflect lower or abandoned hemoglobin transfusion triggers and increased awareness of complications related to transfusion.

Intraoperative angiography during minimally invasive direct coronary artery bypass operations

BACKGROUND

The technical demands of beating heart operations raise concerns about anastomotic patency. This feasibility study tested the usefulness of intraoperative angiography during minimally invasive direct coronary artery bypass grafting (MIDCABG).

METHODS

Ten patients underwent intraoperative angiography of the internal thoracic artery (ITA) after MIDCABG. Minimally invasive direct coronary artery bypass grafting was performed on a beating heart through the fourth or fifth intercostal space. Angiography was performed through the right or left femoral artery with a 7F introducer system placed before the operation. Views were obtained in the right and left anterior oblique and straight anterior projections.

RESULTS

There were no deaths or intraoperative morbidities related to MIDCABG or angiography. Seven patients demonstrated widely patent MIDCABG anastomoses with obliteration of all intercostals, widely patent ITA pedicles, good distal runoff, and placement of the ITA into the proper native coronary artery. Two patients had revisions of their ITA pedicles, which on repeated angiography showed correction. One patient's procedure was converted to a sternotomy because of poor distal runoff and haziness at the level of the MIDCABG anastomosis.

CONCLUSIONS

This feasibility study demonstrates the utility of intraoperative ITA angiography in identifying problems after MIDCABG. Intraoperative angiography may facilitate MIDCABG by documenting proper placement of conduits, obliteration of intercostal vessels, and patency of the MIDCABG anastomosis and ITA pedicle.

Cardiac tamponade following minimally invasive direct coronary artery bypass

We report a case of cardiac tamponade resulting in a death following minimally invasive direct coronary artery bypass. Despite absence of clinical symptoms at the time of hospital discharge, cardiac tamponade physiology may have been evident on close evaluation of Doppler studies of the left internal mammary artery. Performance of a predischarge transthoracic echocardiogram may have been confirmatory and lifesaving.

Lateral impact motor vehicle collisions: significant cause of blunt traumatic rupture of the thoracic aorta

BACKGROUND

This study was undertaken to determine the relationship between traumatic rupture of the thoracic aorta (TRA) and the direction of impact at the time of motor vehicle crash.

METHODS

Retrospective review of TRA patients from two different databases over a 4.5-year period (January 1, 1991 to June 30, 1995): (1) Ontario Coroner's Office records of motor vehicle deaths from Metropolitan Toronto, and (2) the trauma registries of Sunnybrook Health Science Centre and St. Michael's Hospital in Metropolitan Toronto.

RESULTS

Ninety-seven patients (81 from the coroner's database and 16 from the adult trauma unit registries) sustained traumatic rupture of the thoracic aorta. Forty-eight cases (49.5%) were a result of lateral impact crashes. Twenty-eight drivers (22 ipsilateral and six contralateral) and 20 passengers (16 ipsilateral and four contralateral) sustained TRA from lateral impact crashes. Ninety-one TRAs (94%) occurred at the peri-isthmic region.

CONCLUSION

Lateral impact crashes are a significant cause of TRA. Traumatic rupture of the aorta should be considered with a high index of suspicion after serious lateral impact crashes, just as physicians now consider patients at high risk of TRA after serious frontal impact crashes.

Repair of congenital pulmonary incompetence by bicuspidization of the pulmonary valve

We report the successful repair of pulmonary incompetence in an adult due to the congenital absence of the posterior leaflet of the pulmonary valve. The repair consisted of bicuspidization of the pulmonary valve, which achieved competence and eliminated the symptoms and echocardiographic manifestations of right ventricular overload while preserving the native valve.

Long-term outcomes in blunt trauma: who goes back to work?

BACKGROUND

Trauma patients continue to improve after discharge from the trauma center, but the completeness of this recovery remains uncertain. The purpose of this study was to compare the characteristics of patients who do and who do not return to work after blunt trauma.

METHODS

Consecutive survivors of blunt trauma discharged from a regional trauma center over a 1-year interval (July of 1994 to June of 1995) were included in the study. Patients completed the SF-36 Health Survey and some additional questions related to employment status both at discharge and again after 1 year. Our principal analysis compared patients who were employed and unemployed at 1-year follow-up.

RESULTS

Complete data were available for 195 patients. The typical patient was a young man who had been in a motor vehicle collision and had an injury severity score of 25. At 1-year follow-up, 101 patients had returned to work and 94 remained unemployed. Employed individuals were younger (31 vs. 44 years, p < 0.0001), less severely injured (mean injury severity score 23 vs. 27, p < 0.001), and more likely to hold professional jobs (50 vs. 16%, p < 0.0001). Patterns of injury and operative procedures were similar for employed and unemployed patients. However, the average employed patient had fewer days in the intensive care unit (2 vs. 5 days, p < 0.001), a shorter total hospitalization (19 vs. 28 days, p < 0.01), and was more likely to be discharged to home (62 vs. 39%, p < 0.01). At discharge, those who went on to employment had marginally better SF-36 Health Survey scores on seven of the eight scales (all except general health). During the year after discharge, both groups improved significantly, although employed individuals to a greater extent on all scales of the SF-36 Health Survey.

CONCLUSIONS

Almost one half of the multiple system blunt trauma patients remain unemployed 1 year after hospital discharge. Those patients who return to work are usually young professionals with a lower severity of injury. Functional status at discharge predicts future employment status, but underestimates the extent of long-term recovery.

Predictors of fetal mortality in pregnant trauma patients

BACKGROUND

Fetal mortality after trauma is significant. This study was aimed at identifying factors responsible for this high fetal mortality.

METHODS

All pregnant trauma patients admitted to the two major Toronto trauma institutions during the period of November of 1991 to February of 1996 with an Injury Severity Score (ISS) > or = 12 were assessed. Data on age, gestation, hypotension, ISS, hemoglobin, blood transfusion, length of stay, disseminated intravascular coagulation (DIC), and specific maternal injury were analyzed retrospectively to determine predictors of fetal mortality by comparison of patients with and without fetal survival.

RESULTS

Twenty of a total of 68 pregnant trauma patients qualified for entry into the trauma registry by having an ISS > or = 12. Overall fetal mortality was 65% (13 of 20) for ISS > or = 12, and there was one maternal death (age, 29 years; ISS, 66). There were no statistically significant differences between the fetal death and fetal survival groups in age (29.2 +/- 6.2 vs. 30.4 +/- 3.9 years), gestation (25.3 +/- 10.5 vs. 24.1 +/- 9.2 weeks), lowest systolic blood pressure (98.3 +/- 33.8 vs. 112 +/- 18.0 mm Hg), head injury rate (3 of 13 vs. 1 of 7), extremity injury rate (8 of 13 vs. 2 of 7), abdominal injury rate (4 of 13 vs. 0 of 7), pelvic fracture rate (6 of 13 vs. 1 of 7), and chest injury rate (5 of 13 vs. 3 of 7). However, ISS (27.7 +/- 3.5 vs. 14.2 +/- 11.4), lowest hemoglobin level (78.8 +/- 17.0 vs. 101.9 +/- 17.1), blood transfusions (10.8 +/- 6.3 vs. 0.9 +/- 1.6 units), length of stay (20.9 +/- 16.7 vs. 8.2 +/- 4.9 days), and the incidence of DIC (8 of 13 vs. 0 of 7) were statistically significantly different between the two groups (p < 0.05). All eight patients with abruptio placentae had associated fetal mortality.

CONCLUSIONS

Apart from ISS, blood loss, and abruptio placentae; the presence of DIC was the most significant predictor of fetal mortality. This finding may represent stimulation of DIC by placental products entering the maternal circulation after significant intrauterine injury.

Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage

OBJECTIVE

Trauma victims with hypotension require a rapid and reliable localization of bleeding and expedient surgical triage. Our hypothesis is that emergent abdominal sonography (EAS) is a rapid and accurate test of the need for urgent laparotomy in blunt trauma victims with hypotension.

METHODS

Among 400 blunt trauma victims entered in a prospective blind study of EAS, a subgroup of 69 (17%) patients had a systolic blood pressure < or = 90 mm Hg during their initial assessment. Although the EAS results [(+) = fluid, (-) = no fluid] were not used in clinical decision making, the potential contribution of EAS to patient care was examined.

RESULTS

The mean Injury Severity Score was 32. Twenty-two (32%) patients were EAS (+), of which 19 required an acute laparotomy. No laparotomies were performed in the 47 EAS (-) patients. The EASs required 19 +/- 5 seconds in the EAS (+) group and 154 +/- 13 seconds in the EAS (-) group. Twenty of the 22 positive EASs had free fluid in Morison's pouch. All 13 patients with an ultrasound score > or = 3 had a laparotomy. The primary etiology of hypotension was blood loss in 42 patients, hemoperitoneum in 18, and retroperitoneal hemorrhage in 12.

CONCLUSION

EAS is a rapid and accurate indicator of the need for urgent laparotomy in the hypotensive blunt trauma victim. Further, a negative EAS can hasten the search for other causes of hypotension. Diagnostic peritoneal lavage may become obsolete in centers with EAS capabilities.

Injury pattern and severity in lateral motor vehicle collisions: a Canadian experience

OBJECTIVE

To determine the pattern and severity of injury and the outcome of front seat motor vehicle occupants after lateral impact crashes.

DESIGN

Retrospective review undertaken in a Regional Trauma Unit (Sunnybrook Health Science Centre).

MATERIALS AND METHODS

Review of seriously injured front seat motor vehicle occupants admitted to a Regional Trauma Unit over a 46-month period (September 15, 1989, to July 15, 1993) for whom vehicle crash information and occupant seat belt use were known.

MEASUREMENTS AND MAIN RESULTS

Three hundred forty-eight front seat vehicle occupants were available for study; one hundred forty-one (41%) were involved in a lateral impact motor vehicle crash. Driver side lateral crashes (57%) were more common than passenger side impacts. Victims of lateral impact crashes had a significantly higher mean Injury Severity Score (25 compared with 20 for nonlateral crashes: p < 0.05), and the direction of impact was strongly associated with injury severity (p < 0.05). Lateral impact crashes resulted in substantially more significant chest (p < 0.01) and intra-abdominal (p < 0.0001) injuries. Type of injury was significantly different between the lateral and nonlateral impact groups for facial, chest, abdominal, and musculoskeletal injuries.

CONCLUSIONS

The direction of impact in motor vehicle crashes is strongly associated with the pattern and severity of organ injuries. Further attention to automobile safety design is necessary to better protect occupants involved in lateral impact crashes.

Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma

Although there is an interest in emergent abdominal sonography (EAS), the clinical utilization of EAS in North America is minimal. The purpose of this study was to develop a new diagnostic algorithm for blunt abdominal injury based on a prospective blinded comparison of EAS, diagnostic peritoneal lavage (DPL), and computed tomography (CT). EAS (+ = fluid, - = no fluid) was performed before the DPL or CT, in 400 patients with a mean Injury Severity Score of 26; 293 had a CT and 107 had a DPL. The EASs required 2.6 +/- 1.2 minutes with 82% < or = 3 minutes. The accuracy of EAS for free fluid was 94% with a positive and negative predictive value of 82 and 96%, respectively. Only 1 of 338 patients with EAS- had an acute therapeutic laparotomy. Three patients with EAS- had a delayed laparotomy based on evolving clinical findings. The radiologists interpretation of the EAS video disagreed with the clinician sonographer in only 3% of cases. Based on these results, a diagnostic algorithm was developed using EAS as a screening test with selective use of DPL and CT. Emergent abdominal sonography performed by clinician sonographers is a rapid and accurate test for peritoneal fluid in blunt trauma victims, and the need for laparotomy in patients with a negative EAS is rare. Our study supports the routine use of EAS as a screening test in a diagnostic algorithm for the evaluation of blunt abdominal trauma.

Blunt abdominal trauma

Assessment and management of patients with blunt abdominal trauma remains a challenge for emergency physicians. The spectrum of injury ranges from the trivial to the catastrophic and the initial assessment, resuscitation, and investigation of patients with abdominal trauma must be individualized. This article covers the important aspects of patient history and physical examination and addresses the relevant investigative tools available. An approach to the assessment of patients with abdominal trauma is provided; the goal is to diagnose significant injuries as soon as possible and avoid the pitfall of a delayed or missed diagnosis.

Role of the trauma-room chest x-ray film in assessing the patient with severe blunt traumatic injury

OBJECTIVES

To examine the accuracy of standard trauma-room chest x-ray films in assessing blunt abdominal trauma and to determine the significance of missed injuries under these circumstances.

DESIGN

A retrospective review.

SETTING

A regional trauma unit in a tertiary-care institution.

PATIENTS

Multiply injured trauma patients admitted between January 1988 and December 1990 who died within 24 hours of injury and in whom an autopsy was done.

INTERVENTION

Standard radiography of the chest.

MAIN OUTCOME MEASURES

Chest injuries diagnosed and recorded by the trauma room team from standard anteroposterior x-ray films compared with the findings at autopsy and with review of the films by a staff radiologist initially having no knowledge of the injuries and later, if injuries remained undetected, having knowledge of the autopsy findings.

RESULTS

Thirty-seven patients met the study criteria, and their cases were reviewed. In 11 cases, significant injuries were noted at autopsy and not by the trauma-room team, and in 7 cases these injuries were also missed by the reviewing radiologist. Injuries missed by the team were: multiple rib fractures (11 cases), sternal fractures (3 cases), diaphragmatic tear (2 cases) and intimal aortic tear (1 case). In five cases, chest tubes were not inserted despite the presence (undiagnosed) of multiple rib fractures and need for intubation and positive-pressure ventilation.

CONCLUSIONS

Significant blunt abdominal trauma, potentially requiring operative management or chest-tube insertion, may be missed on the initial anteroposterior chest x-ray film. Caution must therefore be exercised in interpreting these films in the trauma resuscitation room.

A prospective study of emergent abdominal sonography after blunt trauma

In North America, the role of emergent abdominal sonography [ultrasonography (US)] after blunt trauma requires further definition. The purpose of this prospective study was to compare US to the gold standards, diagnostic peritoneal lavage (DPL), and computed tomography (CT), in a population of adults after blunt trauma. In 206 adults who required either CT or DPL to assess possible abdominal injury, US was performed, before DPL or CT, and was aimed at the detection of intraperitoneal fluid. The mean Injury Severity Score and Glasgow Coma Scale score were 24.0 and 11.9, respectively. One hundred thirty-seven patients (67%) had CT and 69 (33%) had DPL. The positive and negative predictive values of US for intraperitoneal fluid were 90% and 97%, respectively. The sensitivity, specificity, and accuracy of US for free fluid were 81%, 98%, and 96%, respectively. Of the six false-negative USs, only one required surgery. The US examinations required 2.6 +/- 1.4 min. Emergent abdominal sonography is an accurate, rapid test for the presence of intraperitoneal fluid in adult blunt trauma victims and in these patients may prove valuable as a screening test for abdominal injury.

Acute and long-term outcomes of extremely injured blunt trauma victims

Long-term outcomes after blunt trauma remain poorly defined. The purpose of this study was to document such outcomes in extremely injured adults (Injury Severity Score > or = 50). From April 1990 to June 1993, 76 patients (5% of all trauma victims) had an ISS > or = 50 at a single trauma center. Thirty-five (46%) survived to hospital discharge. The mean duration of hospital stay was longer for survivors than for nonsurvivors (92 days versus 16 days, p < 0.001). Of the 35 survivors, 26% were discharged directly home, 60% to a rehabilitation hospital, 8% to a chronic care facility, and 6% to an acute care hospital. After a mean follow-up of 27 months, 6% had died, 9% refused participation, and the remaining 30 patients (91% of long-term survivors) demonstrated significant residual disabilities in physical, emotional, and mental health status. We suggest that extremely injured patients comprise a small proportion of blunt trauma victims, consume substantial acute care hospital resources, often survive, and yet frequently have residual disability. A reduction in this long-term disability may represent the greatest challenge in modern trauma care.

Early hospital discharge after direct angioplasty for acute myocardial infarction

To determine the feasibility and safety of early hospital discharge after myocardial infarction, we reviewed a 3-yr experience with direct angioplasty: 204 patients had direct angioplasty with in-hospital mortality of 3.4%. Of these patients, 125 were discharged < 5 days after infarction and 98% of these were available for 30-day follow-up. There was one early death (0.8% mortality), two early readmissions without complications, and three late readmissions. Thus early hospital discharge a mean of 3.4 days after infarction can be achieved in > 60% of patients undergoing direct angioplasty with no significant early complications and excellent 30-day survival (99.2%).

Injuries missed during initial assessment of blunt trauma patients

OBJECTIVE

To determine the incidence and clinical significance of undiagnosed injuries in blunt trauma patients at our institution.

DESIGN

Retrospective analysis of blunt trauma admissions over a 1-year period. Missed injury (MI) was defined as any injury recorded after the initial 24 hours.

RESULTS

Of 432 patients studied, 59 (13.6%) had MI. Fractures were the most common MI. Thirty-five percent of MI were detected during repeated physical examination and 28% after patients were conscious and able to voice concerns.

CONCLUSION

Over 10% of all blunt trauma patients had undiagnosed injuries. Forty percent of the MI had clinical implications. The most effective method of diagnosis consists of repeated clinical assessments. Special attention should be focused on patients with severe anatomical injuries, obtunded or intubated.

Psychosocial characteristics of alcohol-involved and nonalcohol-involved seriously injured drivers

This study compared two groups of alcohol-positive and alcohol-negative, seriously injured, crash-involved drivers on demographics, personality characteristics, driving-related attitudes, prior driving history, lifestyle, substance use, and antecedent driver condition. The study sample was drawn from motor vehicle accident admissions to the Sunnybrook Health Science Centre Regional Trauma Unit. One hundred and six interviews were completed between August 1986 and November 1989, with blood alcohol concentration (BAC) data available for 96 drivers. These data suggest no driving-related attitude differences between the two groups. Self-reported driving histories indicated significantly fewer graduates of driving schools and more licence suspensions for the BAC-positive group. The only consistently significant differences were found for the drinking-related variables, with a greater percentage of the BAC-positive group reporting: lower age of first intoxication; a greater self-perceived drinking problem; a greater frequency of intoxication in the month before the accident; and greater self-reported drinking-driving in the month before the accident. Principal-components factor analysis revealed a four-factor solution labelled: Alcohol Use, Deviant/Illicit Drug Use, Aggression, and Neuroticism. Alcohol Use was the only factor found to contribute substantially to the discriminant function, together with the job-related stress item. These data suggest that seriously injured, alcohol-positive and alcohol-negative crashed drivers are similar except that the alcohol-positive drivers show more signs of an alcohol problem.

Psychosocial characteristics and follow-up of drinking and non-drinking drivers in motor vehicle crashes

Eight hundred fifty-four consecutive motor vehicle crash (MVC) victims admitted from August 1, 1986, through August 31, 1989, were prospectively assessed including measurement of blood alcohol concentration (BAC). One hundred six in-hospital interviews were conducted on competent consenting drivers > or = 18 years old; 22.9% (n = 22) of those who were BAC tested (n = 96) were positive for alcohol on admission. The blood alcohol concentration positive [BAC(+)] and the BAC negative (-) drivers differed significantly on the following variables; driver education [BAC(-) > BAC(+): p < 0.01], license suspension < or = 2 years before admission [BAC(+) > BAC(-): p < 0.01], frequency of self-reported intoxication in month before crash [BAC(+) > BAC(-): p < 0.05], driving within 2 hours of drinking < or = 1 month before admission [BAC(+) > BAC(-): p = 0.01] and self-reported driving with BAC > 17 mmol/L < or = 1 month before admission [BAC(+) > BAC(-): p < 0.01]. Follow-up interviews (n = 106) were conducted 1 year after discharge; drivers originally testing BAC(+) were more likely to drive within 2 hours of drinking (p < 0.05), and were more likely to admit to driving with a BAC > 17 mmol/L (p < 0.01). Original BAC(+) drivers were also more likely to report a subsequent MVC in the year following discharge (not statistically significant). There is a need to develop an assessment system to identify high crash-risk drivers and establish rehabilitation programs to reduce crash recidivism.

A comparison between a Canadian regional trauma unit and an American level I trauma center

Although there has been recent comparison of the Canadian and American health care systems, the issue of trauma has received little attention. Data were collected on all adult motor vehicle crash (MVC) victims admitted to the Sunnybrook Trauma Unit (CAN), Toronto, Canada, and the R Adams Cowley Shock Trauma Center (USA), Baltimore, Maryland from July 1986 through July 1990. Similar MVC victims at CAN and USA had equivalent mortality rates with similar discharge dispositions (p = NS), but patients at USA were twice as likely to be admitted to the ICU and had longer ICU stays (p < 0.01). The hospital-based cost for an average MVC patient at CAN was significantly less than for an average patient at USA and professional charges were at least five times greater at USA. This study provides some insight into the differences in trauma care between Canada and the United States.

Alcohol and drug use among motor vehicle collision victims admitted to a regional trauma unit: demographic, injury, and crash characteristics

This study examined the incidence of alcohol and drugs in a sample of seriously injured motor vehicle collision victims, and differences related to pre-crash use of alcohol and/or other drugs on demographic variables, injury severity measures, and crash variables. The sample selected were all motor vehicle collision admissions to the Regional Trauma Unit at the Sunnybrook Health Science Centre in Toronto, Ontario, over a 37-month period (N = 854). Prospective demographic and injury-related information were collected from hospital charts, and crash data were collected from motor vehicle collision police reports. Blood samples were routinely collected on admission and tested for blood alcohol concentration (BAC). We found 32.0% of the BAC-tested motor vehicle collision admissions and 35.5% of drivers tested positive for blood alcohol. The drivers' mean BAC on admission was found to be 145.2 mg/100 ml, and the mean estimated BAC at crash time was 181 mg/100 ml. Drug screens were performed on a two-year subsample (n = 474), of whom 339 were drivers. Drug screens revealed that 41.3% of drivers tested positive for other drugs in body fluids, and 16.5% were positive for alcohol in combination with other drugs. Other than alcohol, the drugs most frequently detected in the drivers were cannabinoids (13.9%), benzodiazepines (12.4%), and cocaine (5.3%). Investigation of differences on demographic, injury, and crash characteristics related to precrash use of alcohol and/or drugs yielded significant findings. In the drug screened sample we found sex, admission type, and occupant status were related to precrash alcohol use. Also, use of drugs was found to interact with admission type and mean BAC on admission. Elapsed time was found to be significantly different for BAC by other drug use, with a greater length of elapsed time found for the subjects testing other drug positive but BAC negative. We found that BAC-positive drug-screened drivers were significantly more likely to be male, involved in a single-vehicle collision, not wearing a seat belt, ejected from the vehicle, and travelling at higher speeds than BAC negative drivers. No significant differences were found between BAC and/or other drug use on injury severity measures.

Perioperative cardiovascular complications associated with blunt thoracic trauma

The purpose of this study was to examine the frequency and importance of intraoperative mortality, arrhythmias and hypotension in the presence of thoracic trauma and to determine the effect of myocardial contusion on these perioperative complications. Over a two-year period patients with evidence of blunt thoracic injury who required surgery within 24 hr of admission were studied. The anaesthetist filled in a questionnaire on intraoperative events. Patients were also studied for the presence of myocardial injury with radionuclide angiography (RNA), at autopsy or at thoracotomy. Two hundred and one patients were studied. The intraoperative and overall mortality was 7.9% and 22.9% respectively. Of the operating room survivors the incidence of intraoperative arrhythmias and hypotension was 3.8% and 26.5% respectively. Only 5.9% of patients had a suspected or confirmed myocardial contusion. Patients were divided into two groups, those without myocardial injury were designated Group I, while those with myocardial contusion were designated Group II. The Group II patients had a greater severity of injury and intraoperative mortality (54.4%) than those in Group I (4.6%) P < 0.05. Intraoperative deaths were attributed to, with one exception, non-cardiac causes. There were no differences in the incidences of arrhythmias and hypotension between patients with-or without myocardial injury surviving the operating room. All patients with blunt thoracic injury may develop intraoperative arrhythmias or hypotension.

Echocardiographic recognition of partial papillary muscle rupture

Acute papillary muscle rupture complicating acute myocardial infarction represents a potentially lethal complication of acute myocardial infarction. Survival depends on prompt recognition and institution of immediate medical and surgical therapy. We present two cases of partial papillary muscle rupture in the setting of acute myocardial infarction and describe the echocardiographic features that may allow early recognition of this condition before complete rupture.

Significance of myocardial contusion following blunt chest trauma

A prospective study was undertaken at a regional trauma unit (RTU) to determine the significance of cardiac complications in patients with blunt chest trauma. Radionuclide angiographic (RNA) imaging was performed as soon as possible after admission and Holter monitors were applied for 72 hours. Routine investigations included serial cardiac enzyme measurements and 12-lead electrocardiograms. Dysrhythmias were classified and ventricular dysrhythmias were stratified by ventricular ectopic score (VES) as ventricular tachycardia (4) or greater than 100 premature ventricular contractions (PVCs)/hour (3). Three hundred twelve patients were entered into the study. Analysis of dysrhythmias revealed 18 patients with a VES of 4 and nine patients with a VES of 3; there were no serious consequences. The most significant dysrhythmia as a marker of outcome was atrial fibrillation (n = 9); five of these patients died, but all of associated noncardiac injuries. A review of abnormal RNAs revealed that all associated mortalities were attributed to noncardiac injuries. A review of postmortem reports and hospital records revealed that no deaths were attributed to cardiac failure or dysrhythmia. Thus the incidence of clinically significant dysrhythmias or other cardiac complications resulting from blunt trauma to the heart may be overestimated.

Injury severity score, head injury, and patient wait days: contributions to extended trauma patient length of stay

The ability of level I trauma units to operate efficiently may be hampered by the presence of a number of patients with an excessive length of stay (LOS). In an attempt to determine causes for and suggest potential solutions to the long-term occupation of beds in an acute care trauma facility, the cases of patients with extended LOSs in a level I trauma unit were examined. Study patients were survivors admitted between January 1, 1986, and December 31, 1989. Patients with a LOS greater than one standard deviation above the mean (n = 221) were assigned to the Long LOS group, and the remaining 1250 patients to the Short LOS group. Long and Short LOS patient groups were compared on a number of variables including injury Severity Score, number of body systems injured, surgical procedures required, blood products used, AIS scores per body region, and patient wait days. Both an increased severity of injury and a lack of available chronic and rehabilitation beds for the head-injured patients contributed to excessive patient LOS in this acute care setting. Additional rehabilitation and chronic care beds are required to free acute care beds for the efficient operation of a level I trauma unit.

Air versus land transport of the critically injured patient

Trauma patients frequently require transport from the hospital to which they are admitted initially to a trauma unit for further assessment and management. Canada's geography and demography provide unique challenges when transporting the severely injured patient by air or land. The author describes and compares air and land transport for the trauma patient. These complementary modes of transport are an integral part of a comprehensive trauma system.

Incidence of abnormal RNA studies and dysrhythmias in patients with blunt chest trauma

The incidence and significance of myocardial contusion and subsequent cardiac complications have recently been debated. A prospective study of patients with blunt chest trauma was undertaken at a Regional Trauma Unit between January 1, 1989 and March 31, 1990. One hundred ninety-one patients were entered into the study; 72-hour Holter monitoring was performed in 183 patients, and radionuclide angiography (RNA) was performed on 163 patients. All patients had CPK levels (with CPK-mb fractions) measured, and serial electrocardiographs. There were seven patients with abnormal RNA studies; five of the seven abnormal studies were attributable to previously undiagnosed coronary artery disease or myocardial infarction. Nine patients were diagnosed as having atrial fibrillation, seven of whom were in atrial fibrillation on admission. Ventricular dysrhythmias were classified by the number of premature ventricular contractions (PVCs) per hour or the presence of ventricular tachycardia. Twelve patients developed short runs of ventricular tachycardia, and clinically insignificant PVCs were common. Only one patient with ventricular dysrhythmias (frequent PVCs) was treated and there were no hemodynamically significant dysrhythmias. The incidence of clinically significant dysrhythmias or hemodynamically significant myocardial contusion appears to be low in this patient population. Aggressive investigation and monitoring solely for cardiac complications may not be indicated.

Mechanism of injury influences the pattern of injuries sustained by patients involved in vehicular trauma

The authors examined the patterns of injury and death rates of patients involved in vehicle-related accidents who were admitted to the Regional Trauma Unit of Sunnybrook Health Science Centre in Toronto. Information was collected prospectively over a 36-month period. The subjects were placed in one of three mechanism-of-injury categories: four-wheel passenger vehicles, motorcycles and pedestrians. The patterns of injury were classified as primarily to the craniofacial and neck area, the torso, the extremities or to multiple regions. There were 815 patients who were involved in vehicle-related crashes and who suffered moderate to severe injuries (at least one region scoring more than 3 on the abbreviated injury scale). The death rate was 13% overall but was 21% in the group receiving multiple injuries. By mechanism of injury the death rates were: pedestrian group 20%, motorcycle group 18% and passenger-vehicle group 11% (p less than 0.01, chi 2 analysis). There was no difference in the mean injury severity score among the mechanism of injury groups. A higher proportion of the passenger-vehicle group sustained isolated craniofacial and torso injuries, and the pedestrian and motorcycle groups sustained more extremity injuries (p less than 0.001, chi 2 analysis). The results reveal a clear association between mechanism of injury and the patterns of injury observed.

Early measurement of systemic lipid peroxidation products in the plasma of major blunt trauma patients

We sought evidence of oxidant-induced biological membrane damage in 43 resuscitated blunt trauma patients (average ISS, 36.9) within 2-6 hours of injury and before anaesthesia and surgery. The plasma levels of the lipid peroxidation products (conjugated dienes, CDs A 233 nm) and malondialdehyde (MDA, nMol/ml) and the oxidant-inducing effect of the trauma plasma on normal FMLP-stimulated neutrophils were compared to those of control subjects. No differences were observed in the plasma levels of MDA (1.73 +/- 2.15 vs. 1.45 +/- 0.70 nMol/ml) and CDs (2.07 +/- 2.16 vs. 1.28 +/- 0.60 A 233nm), or on stimulated neutrophil superoxide production (26.4 +/- 6.9 vs. 29.0 +/- 6.2 nMol O2-/2 x 10(6) PMNs). These observations persisted when the patients were analyzed based on injury severity, the presence of long bone fractures, and the class of shock at presentation. We conclude that there is no evidence of oxidant-induced membrane damage manifested by increased plasma levels of CDs or MDA within 2 to 6 hours of blunt injury.

Tetanus immunization status and immunologic response to a booster in an emergency department geriatric population

STUDY OBJECTIVES

Although effective procedures for the prevention of tetanus have long been available, serosurveys done since 1977 demonstrate that 49% to 66% of the elderly population lacks a protective antitoxin level (more than 0.01 IU/mL). This study was undertaken to assess the tetanus immunization status of patients presenting to an emergency department and to evaluate their immunologic response to a tetanus booster.

SETTING

The study was conducted in a tertiary care ED.

TYPE OF PARTICIPANTS

The patients enrolled were 65 or more years old and had breaks in their skin barriers.

DESIGN

At each patient's initial presentation, pertinent demographic data and tetanus immunization history were recorded. The patient was then followed for 21 days.

INTERVENTIONS

Each patient's antitoxin titer was determined on a serum sample by ELISA, and, if required by the Advisory Committee on Immunization Practices criteria, a booster was administered at the first visit.

MEASUREMENTS AND MAIN RESULTS

Serum antitoxin assays were repeated on days 7, 14, and 21 after the initial visit until seroconversion (titer more than 0.01 IU/mL). Forty-four patients (55%) had protective levels at initial presentation, and in 36 (45%) the levels were not protective. Age and sex were not predictive of protection. Past military service and a definite history of three or more previous immunizations were good predictors of protection. Of 34 patients who were followed serially for inadequate initial titers, only 19 (56%) seroconverted by day 14. Patients who did not seroconvert were more likely to be older (P less than .05).

CONCLUSIONS

This study demonstrated that a significant number of elderly patients lacked an initial protective level of tetanus antitoxin. Of these, 44% failed to seroconvert within 14 days and carried a potential risk of developing tetanus.

The relative influence of alcohol and seatbelt usage on severity of injury from motor vehicle crashes

Seatbelt usage has been consistently documented to decrease mortality and injury severity from motor vehicle crashes (MVC); however, conflicting results are available comparing mortality and injury severity, and blood alcohol positivity. Prospective testing on all MVC admissions showed that 51.5% of the non-belted, and 22% of the shoulder-belted drivers had a positive blood alcohol content (p less than 0.001). A comparison of belted and non-belted MVC drivers revealed a significantly higher mean length of stay (LOS) (p less than 0.05) and Injury Severity Score (ISS) (p less than 0.01) for the non-belted drivers. A comparison of groups positive and negative for blood alcohol revealed no significant differences in LOS or ISS, suggesting that these parameters are related to seatbelt use and not alcohol consumption.

Blood alcohol testing of motor vehicle crash admissions at a regional trauma unit

Motor vehicle crashes remain a leading cause of death and injury in the industrialized world. Alcohol consumption is implicated as a major factor in fatal motor vehicle crashes (MVCs), but only poor estimates of blood alcohol concentrations among nonfatally injured crash victims are available. A 3-year study was undertaken at a Regional Trauma Unit to determine the demographics, injury severity, and alcohol positivity of motor vehicle crash victims. Between August 1, 1986 and July 31, 1989, 825 motor vehicle crash victims were available for study; 368 drivers were admitted to the unit within a period of 4 hours. Of 715 patients tested for alcohol, 31.0% were positive. A total of 333 drivers were tested for blood alcohol; 128 (38.4%) were positive. The mean blood alcohol concentration (BAC) at admission for the drivers was 145.6 mg/100 ml; the estimated mean BAC at crash was 180.9 mg/100 ml. The mean age of BAC positive drivers was 31.4 years, compared to a mean age in the BAC negative drivers of 35.2 years (p less than 0.02). Male patients represented 76.6% of the drivers, yet represented 83.6% of the BAC positive drivers (p less than 0.05). There was a marked seasonal variation in BAC positivity, with 46.1% of drivers positive during the summer months. Alcohol appears to be a significant factor in nonfatal MVCs.

Acute lymphocytosis after trauma--early recognition of the high-risk patient?

An absolute lymphocyte count is included in the routine results provided by most automated blood cell counters, providing a prompt indication of peripheral blood lymphocytosis. Transient lymphocytosis is seen in many acutely ill patients, including those with multiple injuries. We have observed a significantly higher death rate among trauma patients with lymphocytosis at presentation; patients with lymphocytosis, on subsequent assessment of injury, proved to have higher Injury Severity Scores than those without lymphocytosis. Investigation of lymphocyte subsets in nine patients with lymphocytosis showed an increase in T cells, reversal of the CD4:CD8 ratio, and, in seven patients, an increase in "natural killer" cells. The presence of lymphocytosis and its early detection as part of a routine blood count may supply a readily available means of identifying a high-risk trauma patient.

Comparative efficacy of chlorpromazine and meperidine with dimenhydrinate in migraine headache

Approximately 20% of the population suffers from migraine headache, and a significant number develop "fixed" migraines, refractory to oral medications. Of this group, many become habitual narcotic users. A previously published case series using IV chlorpromazine suggested efficacy, so a randomized, double-blind, controlled trial was conducted. The study compared IV chlorpromazine against IV meperidine with dimenhydrinate. Entry criteria were emergency department patients from 18 to 60 years of age with a clinical diagnosis of common or classic migraine headache. After informed consent was obtained, an IV line with normal saline was established, and a bolus of 5 mL/kg was administered. Patients were randomized into two groups: chlorpromazine and meperidine with dimenhydrinate. The chlorpromazine group received a bolus injection of 5 mL normal saline placebo followed by 0.4 mL/kg chlorpromazine solution (0.1 mg/kg). The chlorpromazine was repeated every 15 minutes as needed up to a total of three doses. The meperidine with dimenhydrinate group received 5 mL dimenhydrinate solution (25 mg) followed by 0.04 mL/kg meperidine (0.4 mg/kg). Again, the meperidine solution was repeated in the same dosage every 15 minutes as needed up to a total of three doses. If response was inadequate 15 minutes after the third dose, the sequence was broken, and the other medication given. Blood pressure and response were assessed at 15-minute intervals for one hour. Pain was assessed by both visual and verbal analogue scales every 15 minutes. In all, 46 patients were entered in the study (24 chlorpromazine and 22 meperidine with dimenhydrinate).(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial infarction due to multiple coronary-ventricular fistulas

Coronary-ventricular fistulas have been described in both right and left coronary arteries and have been implicated in causing cardiac symptoms and coronary ischemia. We present a case of three-vessel coronary-ventricular fistulas emptying into both ventricles, associated with a left-to-right shunt and a myocardial infarction.

Inadvertent Swan-Ganz catheter placement in the left pericardiophrenic vein

Placement of flow-directed Swan-Ganz catheters without fluoroscopic guidance occasionally results in placement in positions other than the pulmonary artery. In the case presented, the inadvertent placement of such a catheter into the left pericardiophrenic vein was probably facilitated by distortion of the right heart and systemic venous anatomy.

Two cases of accidental immersion hypothermia with different outcomes under identical conditions

Two cases of accidental immersion hypothermia are presented, both occurring during the same aircraft ditching. One victim survived while the other patient died despite identical immersion time and environmental conditions. Pertinent literature is reviewed to attempt to explain the different patient outcomes. The most important discriminating factor appears to be skinfold thickness, which reflects body fat.

Effect of whole-bowel irrigation on the antidotal efficacy of oral activated charcoal

Whole-bowel irrigation was studied in three volunteer subjects and compared with oral activated charcoal as a gastrointestinal decontamination procedure for acute drug overdose. The volunteer subjects were given 650 mg aspirin and were assigned randomly to the following treatment groups: 24-hour urine collection only; immediate whole-bowel irrigation with a polyethylene glycol solution; 50 g oral activated charcoal followed by whole-bowel irrigation; and oral activated charcoal alone. The cumulative 24-hour urinary salicylate excretion was measured in each trial. Catharsis was achieved rapidly with whole-bowel irrigation. Oral activated charcoal without catharsis was most effective in decreasing aspirin absorption (P = .011). These results do not support the routine use of a cathartic in combination with oral activated charcoal.

Seven years experience with group O unmatched packed red blood cells in a regional trauma unit

The introduction of a blood component system has made Group O unmatched packed red blood cells (G O UPRBCs) available for emergency resuscitation from hypovolemic shock. A seven-year retrospective review is presented, describing the use of 537 units of G O UPRBCs for the resuscitation of 133 trauma patients. This represented 9.1% of all patients admitted to the Regional Trauma Unit who received blood for resuscitation. Ten of 116 patients on whom further blood bank testing was performed developed positive direct antiglobulin tests (seven of these were demonstrated to be negative 48 hours after transfusion); seven of the ten patients had received more than eight units of G O UPRBCs. No clinical complications were encountered. G O UPRBCs are safe and efficient for emergency resuscitation. Non-group O patients receiving eight or more units of G O UPRBCs should not receive unmatched type-specific blood.

Bilateral lower extremity amputations after prolonged application of the pneumatic antishock garment: case report

The authors describe the case of a 29-year-old man with multiple trauma who suffered compartment syndromes necessitating bilateral lower limb amputations as a result of the prolonged (9.5 hours) application of a pneumatic antishock garment (PASG). There was no evidence of lower limb trauma before the garment was put on. Despite the apparent benefits of the PASG in traumatized hypovolemic patients, the lowest possible inflation pressures should be used and removal attempted as soon as hemodynamic stability can be assured.