Journal of Trauma Management & Outcomes - Most accessed articles

Real-world car-to-pedestrian-crash data from an urban centre

Uli Schmucker — 2010-02-16T00:00:00Z

Background: Pedestrians are at a high risk for crash and injury. This study aims at comparing data from real world crashes with data gathered from experimental settings. Methods: IMPAIR (In-Depth Medical Pedestrian Accident Investigation and Reconstruction) was a prospective, observational study performed in a metropolitan area. Data was collected on-scene, from clinical records, and interviews. Data comprise crash data, details on injury pattern and injury severity. Results: Thirty-seven pedestrians (of which 19 males) with a mean 37.1 years of age were included in the study. The mean collision speed was 49.5 km/h (SD 13.7, range, 28 - 93). The mean ISS (31.0, SD 25.4) and the 24% fatality rate indicate a substantial trauma load. The most common AIS 4+ injuries were to the head (23 subjects), followed by chest (8), pelvis (4), and abdomen (2). An association of impact side and injury side (right/left) was found for abdominal, chest, pelvic, and upper limb injuries. Primary head impacts were documented on the windscreen (19 subjects), hood (10), A-pillar (2), and edge of the car roof (2). With bivariate analysis, a significant increase of MAIS 4+ head injury risk was found for collision speeds of >40 km/h (OR 9.00, 95% CI 1.96-41.36). Conclusion: The real-world data from this study is in agreement with previous findings from biomechanical models and other simulations. This data suggest that there may be reason to include further pedestrian regulations in EuroNCAP.

Free Abdominal Fluid without obvious Solid Organ Injury upon CT imaging: an actual problem or simply over-diagnosing?

Vanessa Banz — 2009-12-15T00:00:00Z

Whereas a non-operative approach for hemodynamically stable patients with free intraabdominal fluid in the presence of solid organ injury is generally accepted, the presence of free fluid in the abdomen without evidence of solid organ injury not only presents a challenge for the treating emergency physician but also for the surgeon in charge. Despite recent advances in imaging modalities, with multi-detector computed tomography (CT) (with or without contrast agent) usually the imaging method of choice, diagnosis and interpretation of the results remains difficult. While some studies conclude that CT is highly accurate and relatively specific at diagnosing mesenteric and hollow viscus injury, others studies deem CT to be unreliable. These differences may in part be due to the experience and the interpretation of the radiologist and/or the treating physician or surgeon.A search of the literature has made it apparent that there is no straightforward answer to the question what to do with patients with free intraabdominal fluid on CT scanning but without signs of solid organ injury. In hemodynamically unstable patients, free intraabdominal fluid in the absence of solid organ injury usually mandates immediate surgical intervention. For patients with blunt abdominal trauma and more than just a trace of free intraabdominal fluid or for patients with signs of peritonitis, the threshold for a surgical exploration - preferably by a laparoscopic approach - should be low. Based on the available information, we aim to provide the reader with an overview of the current literature with specific emphasis on diagnostic and therapeutic approaches to this problem and suggest a possible algorithm, which might help with the adequate treatment of such patients.

Complications related to deep venous thrombosis prophylaxis in trauma: a systematic review of the literature

Indraneel Datta — 2010-01-06T00:00:00Z

Deep venous thrombosis prophylaxis is essential to the appropriate management of multisystem trauma patients. Without thromboprophylaxis, the rate of venous thrombosis and subsequent pulmonary embolism is substantial. Three prophylactic modalities are common: pharmacologic anticoagulation, mechanical compression devices, and inferior vena cava filtration. A systematic review was completed using PRISMA guidelines to evaluate the potential complications of DVT prophylactic options. Level one evidence currently supports the use of low molecular weight heparins for thromboprophylaxis in the trauma patient. Unfortunately, multiple techniques are not infrequently required for complex multisystem trauma patients. Each modality has potential complications. The risks of heparin include bleeding and heparin induced thrombocytopenia. Mechanical compression devices can result in local soft tissue injury, bleeding and patient non-compliance. Inferior vena cava filters migrate, cause inferior vena cava occlusion, and penetrate the vessel wall. While the use of these techniques can be life saving, they must be appropriately utilized.

Damage control orthopaedics in patients with delayed referral to a tertiary care center: experience from a place where Composite Trauma Centers don't exist

Shabir Dhar — 2008-01-29T00:00:00Z

Background: Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted on 51 cases after reviewing their records and complete management one year after the trauma. Results: At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality. Conclusion: In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases.

Impact of falls on early mortality from severe traumatic brain injury

Linda Gerber — 2009-07-30T00:00:00Z

Background: The causes of severe traumatic brain injury (TBI) vary by age and other demographic characteristics. Mortality after trauma is higher for elderly than younger patients. This study is based on 2779 patients with severe TBI treated at 24 trauma centers enrolled in a New York State quality improvement program. The prospectively collected database includes information on age, sex, mechanism of injury, initial Glasgow Coma Scale score, blood pressure, pupillary assessment, and CT scan findings. This multi-center study was conducted to explore the impact of falls on early mortality from severe TBI among the elderly. Results: After exclusion criteria were applied, a total of 2162 patients were eligible for analysis. Falls contributed to 21% of all severe TBI, 12% occurring from > 3 meters and 9% from < 3 meters. Two-week mortality ranged from 18% due to injuries other than falls to 31% due to falls from < 3 meters (p =< 0.0001). Mortality after a severe TBI is much greater among older people, reaching 58% for people 65 years and older sustaining a fall from < 3 meters. Conclusion: Among those 65 and older, falls contributed to 61% of all injuries and resulted in especially high mortality among individuals experiencing low falls. Preventive efforts directed toward older people to avoid falls from < 3 meters could have a significant impact on mortality.

Complex proximal femoral fractures in the elderly managed by reconstruction nailing - complications and outcomes: a retrospective analysis

Ulfin Rethnam — 2007-12-10T00:00:00Z

Background: Unstable proximal femoral fractures and pathological lesions involving the trochanteric region in the elderly comprise an increasing workload for the trauma surgeon as the ageing population increases. This study aims to evaluate use of the Russell-Taylor reconstruction nail (RTRN) in this group with regard to mortality risk, complication rates and final outcome. Methods: Retrospective evaluation of 42 patients aged over 60 years who were treated by reconstruction nailing for proximal femoral fractures over a 4 year period. Results: Over two-thirds of patients were high anaesthetic risk (ASA > 3) with ischemic heart disease the most common co-morbidity. 4 patients died within 30 days of surgery and 4 patients required further surgery for implant related failure. Majority of patients failed to regain their pre-injury mobility status and fewer than half the patients returned to their original domestic residence. Conclusion: Favourable fixation of unstable complex femoral fractures in the elderly population can be achieved with the Russell-Taylor reconstruction nail. However, use of this device in this frail population was associated with a high implant complication and mortality rate that undoubtedly reflected the severity of the injury sustained, co-morbidity within the group and the stress of a major surgical procedure.

Is mechanism of injury alone in the prehospital setting a predictor of major trauma - a review of the literature

Malcolm Boyle — 2007-11-26T00:00:00Z

Background: The literature identifying mechanism of injury came to prominence in the mid to late 1980s. The current Victorian prehospital triage guidelines do not necessarily reflect the conditions within the Victorian population as the triage guidelines are based on studies undertaken and validated in the U.S.A. The objective of this study was to identify the mechanism of injury alone literature and the predictability of the mechanism criteria. Methods: A search of the prehospital related electronic databases was undertaken utilising the Ovid and EMASE systems available through the Monash University library. The Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, and EMBASE databases were searched from their beginning until the end of June 2006. Selected non-electronic listed prehospital journals were hand searched. References from articles gathered were reviewed. Results: The electronic database search located 203 articles for review. Three additional articles were identified from the reference lists. Of these articles 17 were considered relevant. After reviewing the articles only five provided sufficient information about mechanism of injury alone and its triage capability. None of the articles identified mechanism of injury criteria as a good predictor of major trauma. Conclusion: This study identified only five articles on the predictability of the mechanism of injury criteria alone. All studies stated that the mechanism of injury criteria alone are not good predictors of major trauma or the need for trauma team activation. This study was the precursor of a Victorian prehospital study to determine the predictability of the mechanism of injury alone criteria for trauma patients in the Australian context.

Autologous bone graft versus demineralized bone matrix in internal fixation of ununited long bones

Oliver Pieske — 2009-12-15T00:00:00Z

Background: Non-unions are severe complications in orthopaedic trauma care and occur in 10% of all fractures. The golden standard for the treatment of ununited fractures includes open reduction and internal fixation (ORIF) as well as augmentation with autologous-bone-grafting. However, there is morbidity associated with the bone-graft donor site and some patients offer limited quantity or quality of autologous-bone graft material. Since allogene bone-grafts are introduced on the market, this comparative study aims to evaluate healing characteristics of ununited bones treated with ORIF combined with either iliac-crest-autologous-bone-grafting (ICABG) or demineralized-bone-matrix (DBM).Methods and resultsFrom 2000 to 2006 out of sixty-two consecutive patients with non-unions presenting at our Level I Trauma Center, twenty patients had ununited diaphyseal fractures of long bones and were treated by ORIF combined either by ICABG- (n = 10) or DBM-augmentation (n = 10). At the time of index-operation, patients of the DBM-group had a higher level of comorbidity (ASA-value: p = 0.014). Mean duration of follow-up was 56.6 months (ICABG-group) and 41.2 months (DBM-group). All patients were clinically and radiographically assessed and adverse effects related to bone grafting were documented. The results showed that two non-unions augmented with ICABG failed osseous healing (20%) whereas all non-unions grafted by DBM showed successful consolidation during the first year after the index operation (p = 0.146). No early complications were documented in both groups but two patients of the ICABG-group suffered long-term problems at the donor site (20%) (p = 0.146). Pain intensity were comparable in both groups (p = 0.326). However, patients treated with DBM were more satisfied with the surgical procedure (p = 0.031). Conclusion: With the use of DBM, the costs for augmentation of the non-union-site are more expensive compared to ICABG (calculated difference: 160 €/case). Nevertheless, this study demonstrated that the application of DBM compared to ICABG led to an advanced outcome in the treatment of non-unions and simultaneously to a decreased quantity of adverse effects. Therefore we conclude that DBM should be offered as an alternative to ICABG, in particular to patients with elevated comorbidity and those with limited availability or reduced quality of autologous-bone graft material.

Advocating "spine damage control" as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis

Philip Stahel — 2009-05-11T00:00:00Z

Background: The "ideal" timing and modality of fracture fixation for unstable thoracolumbar spine fractures in multiply injured patients remains controversial. The concept of "damage control orthopedics" (DCO), which has evolved globally in the past decade, provides a safe guidance for temporary external fixation of long bone or pelvic fractures in multisystem trauma. In contrast, "damage control" concepts for unstable spine injuries have not been widely implemented, and the scarce literature in the field remains largely anecdotal. The current practice standards are reflected by two distinct positions, either (1) immediate "early total care" or (2) delayed spine fixation after recovery from associated injuries. Both concepts have inherent risks which may contribute to adverse outcome.Presentation of hypothesisWe hypothesize that the concept of "spine damage control" – consisting of immediate posterior fracture reduction and instrumentation, followed by scheduled 360° completion fusion during a physiological "time-window of opportunity" – will be associated with less complications and improved outcomes of polytrauma patients with unstable thoracolumbar fractures, compared to conventional treatment strategies.Testing of hypothesisWe propose a prospective multicenter trial on a large cohort of multiply injured patients with an associated unstable thoracolumbar fracture. Patients will be assigned to one of three distinct study arms: (1) Immediate definitive (anterior and/or posterior) fracture fixation within 24 hours of admission; (2) Delayed definitive (anterior and/or posterior) fracture fixation at > 3 days after admission; (3) "Spine damage control" procedure by posterior reduction and instrumentation within 24 hours of admission, followed by anterior 360° completion fusion at > 3 days after admission, if indicated. The primary and secondary endpoints include length of ventilator-free days, length of ICU and hospital stay, mortality, incidence of complications, neurological status and functional recovery.Implications of hypothesisA "spine damage control" protocol may save lives and improve outcomes in severely injured patients with associated spine injuries.

Alcohol-positive multiple trauma patients with and without blood transfusion: an outcome analysis

Manuel Struck — 2009-03-06T00:00:00Z

Background: Blood transfusion is a common therapy for multiple trauma patients, and is often performed soon after hospital admission. It is unclear whether the need for a blood transfusion in multiply injured patients presenting with a positive blood alcohol concentration (BAC) is associated with increased morbidity/mortality, since their risk behavior differs significantly from patients with a negative BAC. In this study, we evaluated the role of blood transfusion in the treatment of BAC-positive multiple trauma patients.PatientsIn a three-year period, 164 patients at a single trauma center presented with a positive BAC, and 145 met the inclusion criteria for further evaluation and regression analysis. We compared patients who were transfused (n = 76) with those who were not transfused (n = 69). Results: In both groups, the most common causes of trauma were traffic accidents and falls. Most patients were admitted to the hospital from the scene of the accident (77.2%) and were male (89.0%). Transfused patients had a lower GCS (p ≤ .001) and her ISS (p ≤ .001), were more likely to have severe head injuries (p ≤ .001), tended to have higher BACs (p = .053), had lower hemoglobin levels and prothrombin times in the first 24 hours (p ≤ .001), had lower lactate levels, had higher rates of intubation (p ≤ .001) and ICU admission, and had longer ICU stays and artificial ventilation times (p ≤ .001). Mortality was significantly higher in transfused patients (n = 15 vs. n = 3, p ≤ .001). Non-survivors were more likely to have severe head injuries; be intubated and ventilated; be older; have higher ISS scores, lactate levels, and numbers of transfusions in the first 24 hours; and have lower GCS scores, hemoglobin measurements, and prothrombin levels. In a binary logistic regression model, only age (p = .009) and ISS (p = .004) independently predicted mortality. Conclusion: In our single-center study, the BAC of multiple trauma patients and the number of blood transfusions they received did not predict mortality in multiple trauma patients if used as independent predictors. Prospective studies with greater sample sizes should be performed to clarify the role of blood transfusions in the outcome of this sub-population.