Journal of Trauma Management & Outcomes - Latest Articles

The song remains the same although the instruments are changing: complications following selective non-operative management of blunt spleen trauma: a retrospective review of patients at a level I trauma centre from 1996 to 2007

Aisling Clancy — 2012-03-13T00:00:00Z

Background: Despite a widespread shift to selective non-operative management (SNOM) for blunt splenic trauma, there remains uncertainty regarding the role of adjuncts such as interventional radiological techniques, the need for follow-up imaging, and the incidence of long-term complications. We evaluated the success of SNOM (including splenic artery embolization, SAE) for the management of blunt splenic injuries in severely injured patients. Methods: Retrospective review (1996-2007) of the Alberta Trauma Registry and health records for blunt splenic trauma patients, aged 18 and older, with injury severity scores of 12 or greater, admitted to the Foothills Medical Centre. Results: Among 538 eligible patients, 150 (26%) underwent early operative intervention. The proportion of patients managed by SNOM rose from 50 to 78% over the study period, with an overall success rate of SNOM of 87%, while injury acuity remained unchanged over time. Among SNOM failures, 65% underwent surgery within 24 hours of admission. Splenic arterial embolization (SAE) was used in only 7% of patients managed non-operatively, although at least 21% of failed SNOM had contrast extravasation potentially amenable to SAE. Among Calgary residents undergoing SNOM, hospital readmission within six months was required in three (2%), all of whom who required emergent intervention (splenectomy 2, SAE 1) and in whom none had post-discharge follow-up imaging. Overall, the use of post-discharge follow-up CT imaging was low following SNOM (10%), and thus no CT images identified occult hemorrhage or pseudoaneurysm. We observed seven cases of delayed splenic rupture in our population which occurred from five days to two months following initial injury. Three of these occurred in the post-discharge period requiring readmission and intervention. Conclusions: SNOM was the initial treatment strategy for most patients with blunt splenic trauma with 13% requiring subsequent operative intervention intended for the spleen. Cases of delayed splenic rupture occurred up to two months following initial injury. The low use of both follow-up imaging and SAE make assessment of the utility of these adjuncts difficult and adherence to formalized protocols will be required to fully assess the benefit of multi-modality management strategies.

Association of changes in the use of board-certified critical care intensivists with mortality outcomes for trauma patients at a well-established level I urban trauma center

Diana Petitti — 2012-03-06T00:00:00Z

Background: An intensivist-directed Intensive Care Unit is a closed-model unit in which a physician formally trained in critical care plays a leadership role in patient management. In the last decade, there has been a move toward closed Intensive Care Units. The purpose of this evaluation was to assess the association of changes in the use of intensivists to a closed-model with mortality outcomes in injured patients seen in a long-established urban Level I Trauma Center. Methods: This analysis used data from the Scottsdale Healthcare Osborn Medical Center trauma registry from January 1, 2002-December 31, 2008. Mortality prior to hospital discharge was compared in the pre-intensivist (intensivists were not employed and did not provide care), partial intensivist (intensivists were employed and provided care during some Intensive Care Unit shifts) and full-time intensivist (intensivists were employed and provided care in the Intensive Care Unit full time) periods. Multiple logistic regression analysis was used to estimate odds ratios for mortality adjusting for patient characteristics and injury severity for the partial intensivist and full-time intensivist periods compared with the pre-intensivist period. Results: Of 18,918 patients, 365 (1.9%) died before hospital discharge. After adjustment for demographic factors and injury severity score, for all patients, odds ratios comparing the partial intensivist and full-intensivist periods with the pre-intensivist period were 0.84 (95% confidence interval 0.64-1.11) and 0.99 (95% confidence interval 0.69-1.41). In patients with an injury severity score 16-24, the adjusted OR for death was 0.20 (95% CI 0.07-0.58) comparing the partial-intensivist with the pre-intensivist period and 0.30 (95% CI 0.11-0.88) comparing the full-time intensivist period with the pre-intensivist period. For patients age 65 + years, compared with the pre-intensivist period, odds ratio were 0.51 (95% confidence interval 0.31-0.84) and 0.61 (95% confidence interval 0.32-1.16) for the partial and full-time intensivist periods respectively. Conclusions: In our setting, a change to a closed Intensive Care Unit model was associated with improved mortality outcomes in patients with less severe injuries and patients age 65+ years.

Clinical profiles and risk factors for outcomes in older patients with cervical and trochanteric hip fracture: similarities and differences

Alexander Fisher — 2012-02-15T00:00:00Z

Background: Data on clinical characteristics and outcomes in regard to hip fracture (HF) type are controversial. This study aimed to evaluate whether clinical and laboratory predictors of poorer outcomes differ by HF type. Methods: Prospective evaluation of 761 consecutively admitted patients (mean age 82.3 ± 8.8 years; 74.9% women) with low-trauma non-pathological HF. Clinical characteristics and short-term outcomes were recorded. Haematological, renal, liver and thyroid status, C-reactive protein, cardiac troponin I, serum 25(OH) vitamin D, PTH, leptin, adiponectin and resistin were determined. Results: The cervical compared to the tronchanteric HF group was younger, have higher mean haemoglobin, albumin, adiponectin and resistin and lower PTH levels (all P < 0.05). In-hospital mortality, length of hospital stay (LOS), incidence of post-operative myocardial injury and need of institutionalisation were similar in both groups. Multivariate analysis revealed as independent predictors for in-hospital death in patient with cervical HF male sex, hyperparathyroidism and lower leptin levels, while in patients with trochanteric HF only hyperparathyroidism; for post-operative myocardial injury dementia, smoking and renal impairment in the former group and coronary artery disease (CAD), hyperparathyroidism and hypoleptinaemia in the latter; for LOS > 20 days CAD, and age > 75 years and hyperparathyroidism, respectively. Need of institutionalisation was predicted by age > 75 years and dementia in both groups and also by hypovitaminosis D in the cervical and by hyperparathyroidism in the trochanteric HF. Conclusions: Clinical characteristics and incidence of poorer short-term outcomes in the two main HF types are rather similar but risk factors for certain outcomes are site-specific reflecting differences in underlying mechanisms.

Injury characteristics and Outcome of Road traffic crash victims at Bugando Medical Centre in Northwestern Tanzania

Phillipo Chalya — 2012-02-09T00:00:00Z

Background: Road traffic crash is of growing public health importance worldwide contributing significantly to the global disease burden. There is paucity of published data on road traffic crashes in our local environment. This study was carried out to describe the injury characteristics and outcome of road traffic crash victims in our local setting and provide baseline data for establishment of prevention strategies as well as treatment protocols. Methods: This was a prospective hospital based study of road traffic crash victims carried out at Bugando Medical Centre in Northwestern Tanzania between March 2010 and February 2011. After informed consent to participate in the study, all patients were consecutively enrolled into the study. Data were collected using a pre-tested questionnaire and analyzed using SPSS computer software version 15.0. Results: A total of 1678 road traffic crash victims were studied. Their male to female ratio was of 2.1:1. The patients ages ranged from 3 to 78 years with the mean and median of 29.45 (± 24.22) and 26.12 years respectively. The modal age group was 21-30 years, accounting for 52.1% patients. Students (58.8%) and businessmen (35.9%) were the majority of road traffic crash victims. Motorcycle (58.8%) was responsible for the majority of road traffic crashes. Musculoskeletal (60.5%) and the head (52.1%) were the most common body region injured. Open wounds (65.9%) and fractures (26.3%) were the most common type of injuries sustained. The majority of patients (80.3%) were treated surgically. Wound debridement was the most common procedure performed in 81.2% of the patients. The complication rate was 23.7%. The overall average length of hospital stay (LOS) was 23.5 ± 12.3 days. Mortality rate was 17.5%. According to multivariate logistic regression analysis, patients who had severe trauma (Kampala Trauma Score II ≤ 6) and those with long bone fractures stayed longer in the hospital and this was significant (P < 0.001) whereas the age of the patient, severe trauma (Kampala Trauma Score II ≤ 6), admission Systolic Blood Pressure < 90 mmHg and severe head injury (Glasgow Coma Score = 3-8) significantly influenced mortality (P < 0.001). Conclusion: Road traffic crashes constitute a major public health problem in our setting and contribute significantly to unacceptably high morbidity and mortality. Urgent preventive measures targeting at reducing the occurrence of road traffic crashes is necessary to reduce the morbidity and mortality resulting from these injuries. Early recognition and prompt treatment of road traffic injuries is essential for optimal patient outcome.

Trauma center accessibility for road traffic injuries in Hanoi, Vietnam

Takashi Nagata — 2011-09-30T00:00:00Z

Background: Rapid economic growth in Vietnam over the last decade has led to an increased frequency of road traffic injury (RTI), which now represents one of the leading causes of death in the nation. Various efforts toward injury prevention have not produced a significant decline in the incidence of RTIs. Our study sought to describe the geographic distribution of RTIs in Hanoi, Vietnam and to evaluate the accessibility of trauma centers to those injured in the city. Methods: We performed a cross-sectional study using Hanoi city police reports from 2006 to describe the epidemiology of RTIs occurring in Hanoi city. Additionally, we identified geographic patterns and determined the direct distance from injury sites to trauma centers by applying geographical information system (GIS) software. Factors associated with the accessibility of trauma centers were evaluated by multivariate regression analysis. Results: We mapped 1,271 RTIs in Hanoi city. About 40% of RTIs occurred among people 20-29 years of age. Additionally, 63% of RTIs were motorcycle-associated incidents. Two peak times of injury occurrence were observed: 12 am-4 pm and 8 pm-0 am. "Hot spots" of road traffic injuries/fatalities were identified in the city area and on main highways using Kernel density estimation. Interestingly, RTIs occurring along the two north-south main roads were not within easy access of trauma centers. Further, fatal cases, gender and injury mechanism were significantly associated with the distance between injury location and trauma centers. Conclusions: Geographical patterns of RTIs in Hanoi city differed by gender, time, and injury mechanism; such information may be useful for injury prevention. Specifically, RTIs occurring along the two north-south main roads have lower accessibility to trauma centers, thus an emergency medical service system should be established.

International benchmarking of tertiary trauma centers: productivity and throughput approach

Antti Peltokorpi — 2011-08-03T00:00:00Z

Background: Care process in tertiary trauma centers consists of a chain of care phases in different departments from the emergency department (ED) to post-operative rehabilitation. The historical evolution of healthcare systems and organizations has led to variations in trauma patient processes in different countries. The present study is aimed at revealing differences in the throughput and productivity of trauma patient processes between German (UKB) and Finnish (HUS) tertiary trauma centers. Problems related to the comparison of different healthcare systems were also identified. The share of patients discharged was used as a control measure. Results: The biggest differences between the hospitals were found in the use of resources in the ED and in post-operative care. Despite problems in defining comparable patients and resources, ED productivity was significantly higher in UKB. Post-operative care was, on average, 41% shorter in HUS. However, the share of patients discharged was significantly higher in UKB (96.5% vs. 68.9%). Differences were also found in the pre-operative length of stay of patients with proximal femoral fractures (UKB: 0.97 days, HUS: 1.57 days). The productivity of the operating unit was quite similar in the hospitals. In terms of ED mortality, no statistically significant differences were found. Conclusions: The results of the present study showed significant differences in the use of resources and throughput times in trauma patient processes between Finnish and German hospitals. However, due to system-level differences between German and Finnish healthcare, the results cannot be directly transformed into development proposals for the organizations. On the other hand, in spite of certain differences regarding the healthcare systems, the demographic data of the trauma patients and medical procedures are comparable. Based on the present study, the ED process of severe trauma, pre-operative care, and operating unit processes were the most comparable parts of trauma care between the hospitals. The study also showed that the international benchmarking approach could be used to reveal bottlenecks in system-level policies and practices.

Patients Referred to a Norwegian Trauma Centre: effect of transfer distance on injury patterns, use of resources and outcomes

Thomas Kristiansen — 2011-06-16T00:00:00Z

Background: Triage and interhospital transfer are central to trauma systems. Few studies have addressed transferred trauma patients. This study investigated transfers of variable distances to OUH (Oslo University Hospital, Ullevål), one of the largest trauma centres in Europe. Methods: Patients included in the OUH trauma registry from 2001 to 2008 were included in the study. Demographic, injury, management and outcome data were abstracted. Patients were grouped according to transfer distance: ≤20 km, 21-100 km and > 100 km. Results: Of the 7.353 included patients, 5.803 were admitted directly, and 1.550 were transferred. The number of transfers per year increased, and there was no reduction in injury severity during the study period. Seventy-six per cent of the transferred patients were severely injured. With greater transfer distances, injury severity increased, and there were larger proportions of traffic injuries, polytrauma and hypotensive patients. With shorter distances, patients were older, and head injuries and injuries after falls were more common. The shorter transfers less often activated the trauma team: ≤20 km -34%; 21-100 km -51%; > 100 km -61%, compared to 92% of all directly admitted patients. The mortality for all transferred patients was 11%, but was unequally distributed according to transfer distance. Conclusion: This study shows heterogeneous characteristics and high injury severity among interhospital transfers. The rate of trauma team assessment was low and should be further examined. The mortality differences should be interpreted with caution as patients were in different phases of management. The descriptive characteristics outlined may be employed in the development of triage protocols and transfer guidelines.

HIV seroprevalence and its effect on outcome of moderate to severe burn injuries: A Ugandan experience

Phillipo Chalya — 2011-06-09T00:00:00Z

Background: HIV infection in a patient with burn injuries complicates the care of both the patient and the treating burn team. This study was conducted to establish the prevalence of HIV among burn patients in our setting and to compare the outcome of these patients who are HIV positive with those who are HIV negative. Methods: This was a prospective cohort study involving burn injury patients admitted to Mulago Hospital between November 2005 and February 2006. Patients were stratified into HIV positive (exposed) group and HIV-negative (unexposed) group. Data was collected using a pre-tested coded questionnaire and analyzed using SPSS statistical computer software version 11.5. Results: Of the 130 patients included in the study, 17 (13.1%) patients tested HIV positive and this formed the study (exposed) group. The remaining 113 patients (86.9%) formed the control (unexposed) group. In the HIV positive group, females outnumbered males by a ratio of 1.4:1 and the mean age was 28.4 ± 21.5 years (range 3 months-34 years). 64.7% of HIV positive patients reported to have risk factors for HIV infection. Of these, multiple sexual partners [Odds Ratio 8.44, 95% C.I. (3.87-143.23), P = 0.011] and alcoholism [Odds Ratio 8.34, 95% C.I. (5.76-17.82), P = 0.002] were found to be independently and significantly associated with increased risk to HIV infection. The mean CD4 count for HIV positive and HIV negative patients were 394 ± 328 cells/μL and 912 ± 234 cells/μL respectively which is statistically significant (P = 0.001). There was no difference in the bacteria cultured from the wounds of HIV positive and negative patients (P = 0.322). Patients with clinical signs of sepsis had lower CD4+ counts compared to patients without sepsis (P < 0.001). ). Skin grafting was carried out in 35.3% of HIV negative patients and 29.4% of HIV positive patients with no significant difference in skin graft take and the degree of healed burn on discharge was the same (P = 0.324). There was no significant difference in hospital stay between HIV positive and negative patients (P = 0.674). The overall mortality rate was 11.5%. Using multivariate logistic regression analysis, mortality rate was found to be independently and significantly related to the age of the patient, HIV positive with stigmata of AIDS, CD4 count, inhalation injury, %TBSA and severity of burn (p-value < 0.001). Conclusion: HIV infection is prevalent among burn injury patients in our setting and thus presents an occupational hazard to health care workers who care for these patients. All burn health care workers in this region need to practice universal precautions in order to reduce the risk of exposure to HIV infection and post-exposure prophylaxis should be emphasized. The outcome of burn injury in HIV infected patients is dependent upon multiple variables such as age of the patient, inhalation injury and %TBSA and not the HIV status alone.

Etiological spectrum, injury characteristics and treatment outcome of maxillofacial injuries in a Tanzanian teaching hospital

Phillipo Chalya — 2011-06-02T00:00:00Z

Background: Maxillofacial injuries pose a therapeutic challenges to trauma, maxillofacial and plastic surgeons practicing in developing countries. This study was carried out to determine the etiology, injury characteristics and management outcome of maxillofacial injuries at our teaching hospital.Patients and MethodsA prospective hospital based study of maxillofacial injury patients was carried out at Bugando Medical Centre from November 2008 to October 2009. Data was collected using a structured questionnaire and analyzed using SPPS computer software version 11.5. Results: A total of 154 patients were studied. Males outnumbered females by a ratio of 2.7:1. Their mean age was 28.32 ± 16.48 years and the modal age group was 21-30 years. Most injuries were caused by road traffic crushes (57.1%), followed by assault and falls in 16.2% and 14.3% respectively. Soft tissue injuries and mandibular fractures were the most common type of injuries. Head/neck (53.1%) and limb injuries (28.1%) were the most prevalent associated injuries. Surgical debridement (95.1%) was the most common surgical procedures. Closed reduction of maxillofacial fractures was employed in 81.5% of patients. Open reduction and internal fixation was performed in 6.8% of cases. Complications occurred in 24% of patients, mainly due to infection and malocclusion. The mean duration of hospital stay was 18.12 ± 12.24 days. Mortality rate was 11.7%. Conclusion: Road traffic crashes remain the major etiological factor of maxillofacial injuries in our setting. Measures on prevention of road traffic crashes should be strongly emphasized in order to reduce the occurrence of these injuries.

Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability

Robert Cherry — 2011-05-13T00:00:00Z

Background: This case series report discusses patients presenting with hemorrhage and hemodymanic compromise due to severe pelvic fractures and undergoing intraoperative angioembolization (IAE) with other resuscitative procedures. Methods: We used portable digital subtraction fluoroscopy units for IAE in patients with severe pelvic hemorrhage and hemodynamic instability (5/03-4/09). Data was collected on demographics, injury severity, resource utilization, and outcomes at our Level 1 trauma center. Results: There were 6,538 adult admissions with 912 having pelvic fractures and 65 of these undergoing pelvic angioembolization. Twelve hemodynamically compromised patients (10 males, 2 females) had intraoperative pelvic angiography (age: 22-79 years; mean 51.3 ± 17.4). Injury severity score (ISS) was 37.5 ± 8.4 (22-50). Mean emergency department (ED) length of stay (LOS) was 57.4 min ± 47.9 with 10 patients transported directly to the OR and 2 to the SICU prior to OR. Ten of 12 patients underwent exploratory laparotomy followed by angioembolization. Mortality was 50%. Among the 6 survivors (ISS 22 - 50), all had a pre-op CT scan, five had an initial base deficit <13, and four were transfused ≤ 6 units pre-incision/pre-procedure. Four of the 6 survivors had unilateral embolization. In contrast, all 6 non-survivors (ISS 29-41) required massive transfusion prior to OR (>6 units PRBCs) with 4 having a based deficit >13. Three of these patients bypassed CT and five underwent bilateral internal iliac embolization (BIIE). Conclusions: IAE for severe pelvic hemorrhage can be successfully performed concurrently with exploratory laparotomy, pelvic packing or other resuscitative procedures. Patients most likely to benefit have a base deficit <13, and do not require massive transfusion prior to IAE or suffer from a vertically unstable pelvis fracture.