Major trauma in elderly adults receiving lipid-lowering medications

BACKGROUND

Some clinical trials, laboratory experiments, and in vitro studies suggest that lipid-lowering medications predispose a person to traumatic injury.

METHODS

We used population-based administrative database analysis to study adults age 65 years or more over a 5-year interval (n = 1,348,259).

RESULTS

About 12% of the cohort received a prescription for a lipid-lowering medication and about 88% did not. The two groups had similar distributions of age, gender, and income. Overall, 2,557 (0.2%) were hospitalized for major trauma. Those who received a lipid-lowering medication were 39% less likely to sustain a major trauma than those who did not receive such medication (95% confidence interval, 29 to 47). Similar results were observed after adjustment for age, gender, and income; cardiac and neurologic medications; and lethality. No other cardiac or neurologic medication was associated with an apparent safety advantage.

CONCLUSION

Lipid-lowering medications do not lead to a clinically important increase in the absolute risk of major trauma for elderly patients in the community.

Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit

STUDY DESIGN

Retrospective analysis of a prospectively collected trauma database of a Level 1 (tertiary) trauma center.

OBJECTIVE

To define the features of the cervical spinal injuries in polytrauma population admitted to the regional trauma unit.

SETTING

Canada, Ontario Province, Toronto, Sunnybrook Health Sciences Center.

METHODS

All trauma admissions between 1987 and 1996 entered prospectively into a trauma registry database were studied for incidence, demographic and epidemiological details of cervical spine (cord and column) injuries.

RESULTS

A total of 468 patients (66% male) with cervical spinal injury (CSI) from 1198 spinal injuries admitted to the regional trauma center were identified. Seventy-five per cent of the CSI involved were aged less than 50 years; nearly 30% were in the third decade alone. Overall, the commonest spinal level injured was C2 (27%) followed by C5 (22%). Older population (above 60 years of age) had C1 + 2 involved more often than the young (P=0.02). Motor vehicular crashes (MVC) accounted for 71%, followed by pedestrian trauma (10%), sport injuries (7%). Spinal cord injury (SCI) was noted in 27%; complete in 16% and incomplete in 11% and more frequently at C4 or C5 level compared with C1, C2 (P<0.00001); the former level had more often a complete SCI (P=0.06). Though MVC produced 74% of SCI, only 27% had neurological deficits. Recreational trauma produced SCI in 45%, motor cycle crashes (MCC) in 37% and a rear passenger in MVC in 34% that was complete in 78%, 71% and 73% respectively. Front seat passenger and driver in MVC had a C5 level injury while a rear seat passenger had at C4 (P<0.001). The C1 level injury had high association with severe and life threatening head and neck and facial injuries compared with the more frequently injured spinal levels; either C2 (P=0.03) or C5 (P=0.004). Similarly C1 injuries had higher ISS compared with C2 (P<0.0001) and C5 (P<0.008).

CONCLUSIONS

C2 was the commonest fractured spine while SCI was more frequent at C5. Older and pedestrian population had higher incidences of injuries at C1 and C2. Sport and MCC resulted in severe SCI. The level of spine injured was different between a front and a rear seat occupant in MVC.

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.

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.

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 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.

Quality assurance for patients with head injuries admitted to a regional trauma unit

The efficacy of trauma systems in reducing preventable deaths has been established but the methods of auditing care are still evolving. Various "audit filters" to identify which patients' charts should be reviewed have been proposed. An analysis of all patients admitted to the Regional Trauma Unit (RTU) over a 19-month period was conducted. Of 729 patients, 135 were identified as having suffered a traumatic intracranial hemorrhage (TICH). On review, neither delay in transfer from the emergency room to the operating room nor increasing time from the incident to the operating room correlated with increasing mortality. In contrast to delay, the Glasgow Coma Scale (GCS) score on admission correlated well with outcome. The charts of patients with anomalous outcomes based on admission GCS score were reviewed, and two possibly preventable deaths were identified. There were 48 patients with TICH who had no operations but there were no deaths attributable to a missed operation. There were 76 patients for whom the GCS score at the referring hospital and the GCS score on admission to the RTU were available. Seven of 19 patients who worsened on transfer declined because of significant pulmonary injuries. Anomalous outcomes based on admission GCS score and declining GCS scores are recommended as quality assurance filters.

Diagnosis of cervical spine injury in motor vehicle crash victims: how many X-rays are enough?

As delay in diagnosing unstable cervical spine injuries unnecessarily exposes patients to risk of neurologic injury, it is often recommended that complex radiologic investigations be performed on alert patients with neck pain, tenderness, or neurologic deficit despite normal plain radiographs. The optimal investigation of patients unable to reliably provide such information is less clear. How many X-rays are enough to clear the cervical spine? In order to answer this question, a retrospective review of 775 motor vehicle crash (MVC) victims was conducted. Ninety-two (12%) sustained cervical spine injury. Sixteen of these injuries were missed initially and, in a further 18 cases, the lateral cervical spine X-ray was wrongly interpreted as positive. Fifty-five per cent of patients with cervical injury had a Glasgow Coma Score (GCS) of less than 15 on admission. Lateral radiographic visualization of the complete cervical spine (including a swimmer's view as required) had a sensitivity of 83% and a specificity of 97%. The addition of open mouth (OM) and anteroposterior (AP) views detected all patients with unstable fractures except one man with a head injury who was unable to provide clinical clues to the diagnosis, but who suffered no additional harm as a result. A single lateral X-ray of the cervical spine is inadequate to exclude cervical spine injury in severely traumatized patients and the addition of OM and AP views still failed to identify unstable fractures in one of 385 patients in this series of MVC victims with GCS less than 15.(ABSTRACT TRUNCATED AT 250 WORDS)