Blunt trauma pelvic fracture-associated genitourinary and concomitant lower gastrointestinal injury: incidence, morbidity, and mortality

PURPOSE

Limited data exist on the characteristics, risk factors, and management of blunt trauma pelvic fractures causing genitourinary (GU) and lower gastrointestinal (GI) injury. We sought to determine these parameters and elucidate independent risk factors.

METHODS

The National Trauma Data Bank for years 2010-2014 was queried for pelvic fractures by ICD-9-CM codes. Exclusion criteria included age ≤ 17 years, penetrating injury, or incomplete records. Patients were divided into three cohorts: pelvic fracture, pelvic fracture with GU injury, and pelvic fracture with GU and GI injury. Between-group comparisons were made using stratified analysis. Multivariable logistic regression was used to determine independent risk factors for concomitant GI injury.

RESULTS

In total, 180,931 pelvic fractures were found, 3.3% had GU, and 0.15% had GU and GI injury. Most common mechanism was vehicular collision. Injury severity score, pelvic AIS, and mortality were higher with combined injury (p < 0.001), leading to longer hospital and ICU stays and ventilator days (p < 0.001) with more frequent discharges to acute rehabilitation (p < 0.01). Surgical management of concomitant injuries involved both urinary (62%) and rectal repairs (81%) or diversions (29% and 46%, respectively). Male gender (OR = 2.42), disruption of the pelvic circle (OR = 6.04), pubis fracture (OR = 2.07), innominate fracture (OR = 1.84), and SBP < 90 mmgh (OR = 1.59) were the strongest independent predictors of combined injury (p < 0.01).

CONCLUSION

Pelvic fractures with lower GU and GI injury represent < 1% of pelvic fractures. They are associated with more severe injuries and increased hospital resource utilization. Strongest independent predictors are disruption of the pelvic circle, male gender, innominate fracture, and SBP < 90mm Hg.

Impact of Trauma Center Designation and Interfacility Transfer on Renal Trauma Outcomes: Evidence for Universal Management

BACKGROUND

Renal trauma may be managed differently in tiered trauma systems and among those who requireinterfaculty transfer.

OBJECTIVE

To evaluate the initial management of renal trauma, assess patterns of management based on hospital trauma level designation and interfacility transfer status, and analyze management trends over time.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of renal trauma from the National Trauma Data Bank 2010-2015.

INTERVENTION

Nephrectomy, angioembolization, or nonoperative management.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS

We used generalized estimating equations to compare odds of each management outcome in patients transferred and directly admitted to a level I center, versus those directly admitted to a non-level I center, adjusting for vital signs, injury, demographic, and facility characteristics. We also used generalized estimating equations to examine linear time trends in management outcome, adjusting for injury characteristics.

RESULTS AND LIMITATIONS

A total of 51798 renal trauma records were included: 44 838 low-grade (American Association for the Surgery of Trauma I-III) and 6359 high grade (IV-V) injuries. After adjusting for comorbidities, demographics, and hospital characteristics, odds of nephrectomy, angioembolization, and nonoperative management were similar in patients transferred or directly admitted to a level I center compared with those treated at a non-level I center. Changes in management over time demonstrated a decreased rate of nephrectomy (p=0.007) in high-grade injuries, while the rate of angioembolization remained constant (p=0.33). Study limitations include mortality prior to hospital transfer or arrival, and its retrospective nature.

CONCLUSIONS

In this contemporary trauma analysis, outcomes of both low- and high-grade renal trauma are similar across patients managed in tiered trauma centers and those undergoing transfer, signifying dissemination of collective renal trauma management. The rate of nephrectomy has decreased for high-grade renal injury over our study period, suggesting new adoption of kidney-sparing management.

PATIENT SUMMARY

Renal trauma is now managed similarly in tiered trauma centers and in patients requiring interfacility transfer. The rate of nephrectomy for high-grade renal injuries has decreased over time.

The impact of seat belts and airbags on high grade renal injuries and nephrectomy rate in motor vehicle collisions

PURPOSE

Motor vehicle collisions are the most common cause of blunt genitourinary trauma. We compared renal injuries with no protective device to those with seat belts and/or airbags using NTDB. Our primary end point was a decrease in high grade (grades III-V) renal injuries with a secondary end point of a nephrectomy rate reduction.

MATERIALS AND METHODS

The NTDB research data sets for hospital admission years 2010, 2011 and 2012 were queried for motor vehicle collision occupants with renal injury. Subjects were stratified by protective device and airbag deployment. The AIS was converted to AAST renal injury grade and nephrectomy rates were evaluated. Intergroup comparisons were analyzed for renal injury grades, nephrectomy, length of stay and mortality using the chi-square test or 1-way ANOVA. The relative risk reduction of protective devices was determined.

RESULTS

A review of 466,028 motor vehicle collisions revealed a total of 3,846 renal injuries. Injured occupants without a protective device had a higher rate of high grade renal injuries (45.1%) than those with seat belts (39.9%, p = 0.008), airbags (42.3%, p = 0.317) and seat belts plus airbags (34.7%, p <0.001). Seat belts (20.0%), airbags (10.5%) and seat belts plus airbags (13.3%, each p <0.001) decreased the nephrectomy rate compared to no protective device (56.2%). The combination of seatbelts and airbags also decreased total hospital length of stay (p <0.001) and intensive care unit days (p = 0.005). The relative risk reductions of high grade renal injuries (23.1%) and nephrectomy (39.9%) were highest for combined protective devices.

CONCLUSIONS

Occupants of motor vehicle collisions with protective devices show decreased rates of high grade renal injury and nephrectomy. Reduction appears most pronounced with the combination of seat belts and airbags.

Driving under the influence--a level-I trauma center's experience

Alcohol-impaired driving is a major issue confronting today's society. New legislation is emerging to help curtail this ongoing problem. To evaluate the legislative effects in terms of outcome pertaining to injured drivers, we analyzed the records of 116 consecutive motor vehicle drivers who were admitted to our trauma center over a 16-month period. Medical reports, police reports, and drivers' abstracts were reviewed. Of the 116 drives, 61 (53%) had blood alcohol concentrations that exceeded the legal limit (blood alcohol level greater than or equal to 100 mg/dL) on arrival at the emergency department. Only four of these patients were ticketed for driving under the influence and received the mandatory suspension of their driver's license. None was convicted of this offense, which carries criminal charges and a revocation of the driver's license. Mechanisms for efficient collection of blood specimens and mandatory occurrence reporting are two recommendations that merit investigation to obviate further escape of injured, intoxicated drivers from the legal net. In addition, alcohol rehabilitation and education cannot be overlooked and should warrant strong societal support.

Thoracic aortic trauma: role of dynamic CT

Two protocols were developed to study the efficacy of both chest radiography and dynamic computed tomography (CT) of the thorax in screening for traumatic aortic injury. Both protocols demonstrated a definite role for dynamic CT in excluding aortic injury in patients with normal initial chest radiographs. The authors studied 164 patients, and preliminary results indicated a high reliability for this method. Their algorithm, with 6-month follow-up, yielded both 100% sensitivity and a 100% negative predictive value. Unnecessary aortography, with its associated morbidity and cost, was decreased by 73%.