Hayden L. Smith

Etiology, diagnosis, and characteristics of facial fracture at a midwestern level I trauma center

Study purpose was to describe facial fracture frequency, demography, injury characteristics, and diagnostic modalities at a Midwestern level I trauma center. A retrospective review was conducted on a Midwestern trauma center registry for years 2008 and 2009. Patient and injury data were collected along with diagnostic modality for facial fracture patients. Comparative statistics were conducted on the basis of the number of facial fractures, route of admission, presence of traumatic brain injury, and gender. There were 154 patients diagnosed with 443 facial fractures, representing 5% of the trauma population. Median patient age was 45 years. Median number of fractures was 2. Fractures were frequently present in orbit (32%), malar bone and maxilla (26%), and the nasal bones (19%). Motor vehicle crash was the most common mechanism (47%). Most fractures were diagnosed with maxillofacial computed tomography (78%). Males had an odds ratio of 2.5 (95% confidence interval, 1.15–5.43) for multiple facial fractures and composed 67% of the sample. Traumatic brain injury was diagnosed in 71% of patients. This study of a medium-sized city and its surrounding rural areas revealed differences from studies in large urban centers. Differences included lower gender ratio, older average age, and mechanism of injury. While urban trauma centers report assault as a leading cause of facial fracture, this study noted higher frequencies of motor vehicle crash and falls and fewer assaults.

The burden of unhelmeted and uninsured ATV drivers and passengers.

Objective: Injured all-terrain vehicle (ATV) riders contribute to the national trauma burden. The importance of helmet use on injury severity and outcomes in ATV drivers versus passengers that receive care is unknown along with the association of payor status and helmet use in this population. An investigation of whether helmet use protects ATV drivers and passengers resulting in less severe injuries, better outcomes, and a lower cost burden to society is to be conducted. Methods: A retrospective review of injured ATV riders in the National Trauma Data Bank from the United States for 2000–2004. Results: Helmet use status was recorded for 5897 drivers and 836 passengers; 83 percent of drivers were male; 41 percent of passengers were female. Helmets were not widely worn (35% of drivers, 19% of passengers, p < .0001) and were less common among female than male drivers who crashed and received care (26% versus 37%, p < .0001). Drivers were older than passengers (p < .0001) and had more thorax, spine, and upper extremity injuries (p < .05). Helmets protected drivers and passengers: decreased head injuries, face injuries, injury severity, and mortality with increased likelihood of being discharged home rather than elsewhere (p < .0001). Personal insurance was more frequent in helmeted riders: 66 percent versus 55 percent of helmeted versus nonhelmeted drivers (p < .0001) and 69 percent versus 55 percent of helmeted versus nonhelmeted passengers (p = .03). Conclusions: Helmets are frequently not worn by ATV riders. Helmets protect ATV drivers and passengers and decrease societal costs associated with ATV crashes.

What do the people who transport trauma patients know about tourniquets

BACKGROUND The primary study objectives were to gather information concerning the tourniquet knowledge, experience, training, protocols, preferences, and equipment of civilian prehospital providers. METHODS This is a survey of 151 prehospital care providers. RESULTS Survey respondents included 27 basic, 1 intermediate, and 75 paramedic emergency medical technicians; 1 registered nurse; 4 firefighters without medical certifications; 2 respondents not yet certified; and 1 respondent not listing certifications. Respondents had 2 months to 40 years of experience and came from emergency medical services in communities of 101 to 206,688 residents located 10 minutes to 103 minutes from a Level 1 or 2 trauma center. Twenty-five had used tourniquets: 5 in military and 22 in civilian settings. Civilian tourniquets were most frequently used for motor vehicle– then farm- and manufacturing-related injuries with severe bleeding. Tourniquet knowledge was poor for all groupings (with or without tourniquet experience, military experience, all certifications, all years of experience): 91% did not understand that wider tourniquets require less pressure for arterial occlusion, 69% did not know that stopping venous flow without arterial is harmful, and 37% did not know the correct tourniquet locations for distal limb injuries. Of the 81 on a service and without military experience, 44 had received any tourniquet training; 14 of the 44 had commercial emergency tourniquet access, and 27 indicated their service had a tourniquet protocol. Of the 37 on a service with no tourniquet training, 5 had access to a commercial emergency tourniquet, and 5 indicated their service had a tourniquet protocol. CONCLUSION Civilian prehospital providers encounter situations for tourniquet use, but many do not know information important for optimal tourniquet use. Therefore, if surgeons want civilian prehospital care to include the use of effective, arterial flow occluding tourniquets at appropriate limb locations, they need to communicate with their emergency medical service providers concerning tourniquet knowledge, training, protocols, and appropriate equipment.

Clinical indicators of midface fracture in patients with trauma

BACKGROUND/AIM Midface fractures are commonly present and difficult to diagnose in trauma patients. The objective of this study was to determine clinically accessible indicators of midface fracture. MATERIAL AND METHODS A case-control study design was used to determine clinical indicators of midface fracture. Population source was a level I trauma center registry for years 2007-2009. Cases had a documented midface fracture. Patient and trauma characteristics were compared between cases and controls. Multivariate logistic regression analysis determined significant indicators of midface fracture. RESULTS Study sample included 83 cases and 83 frequency-matched controls. Cases had a total of 211 fractures with a median of two midface fractures per person. Common fractures were orbital (41%), malar and maxillary (28%), and nasal bones (19%). Patients with midface fracture were significantly different than patients without midface fracture in severity of injury and were more likely to have a traumatic brain injury. Significant clinical indicators of fracture were maxillary sinus opacification, ethmoid sinus opacification, forehead laceration, periorbital contusion, epistaxis, and injury mechanism (P < 0.05). Patients with midface fracture had a 63 times greater odds for maxillary sinus opacification. The multivariable model correctly classified the presence and absence of midface fracture in 95% of study sample. CONCLUSIONS Determined indicators of midface fracture provided a high level of discrimination in fracture status. Indicators can be used by clinicians to help detect possible midface fractures. Future prospective research on midface fracture indicators can assist in establishing their generalizability and impact on fracture detection, care, and outcomes.

Utility and Relevance of Diagnostic Peritoneal Lavage in Trauma Education

OBJECTIVES During the last 2 decades, the advent of new technologies in trauma patient care may have resulted in a decreased number of diagnostic peritoneal lavage (DPL) evaluations. In this study, it is hypothesized that fewer DPL are being performed at a midwestern trauma center. Such negative trends may make the inclusion of DPL in current trauma education potentially outdated and no longer universally appropriate in trauma evaluation algorithms. DESIGN, SETTING, AND PARTICIPANTS This retrospective observational study of a level I trauma center includes patients from January 1998 through September 2010. The total number of trauma-related DPL procedures performed annually during the study period was determined along with accompanying facility and trauma patient level data. RESULTS A total of 24 DPLs were performed at the target trauma center during the study period. There was a significant decrease (p = 0.0018) in the use of DPL despite a significant increase (p < 0.0001) in the proportion of trauma patients with an injury severity score > 15. CONCLUSIONS Study data demonstrated a decrease in the use of DPL as a diagnostic modality in the evaluation of blunt abdominal trauma patients at a medium-sized midwestern center. These data provide historic facility-level evidence of a practice change. Such information may support a recommendation that the American College of Surgeons revisit its current curriculum for Advanced Trauma Life Support (ATLS). Specifically, we propose the American College of Surgeons consider changing DPL instruction to an optional component of ATLS. COMPETENCIES: Patient Care, Medical Knowledge, Practice Based Learning and Improvement.

Examination of pneumonia risks and risk levels in trauma patients with pulmonary contusion.

Development of pneumonia in patients with pulmonary contusion can result in morbidity and mortality. This study examined the utility of a pneumonia risk tool for pulmonary contusion patients, which was originally developed using national level data. The study found a 21% prevalence of pneumonia diagnosis in pulmonary contusion patients at the examined level I trauma center, with patients in the high-risk group having 8 times greater odds for pneumonia diagnosis. The study also revealed increasing age and the use of mechanical ventilation as being significantly associated with pneumonia status. Early identification of risk factors for pneumonia could help direct clinician care strategies.

Atrio-esophageal fistula: A case series and literature review

Case series Patient: Male, 72 • Male, 29 • Male, 75 Final Diagnosis: Atrio-esophageal fistula Symptoms: Altered mental state • chest pain • fever • melena Medication: — Clinical Procedure: — Specialty: Critical Care Medicine Objective: Rare disease Background: Percutaneous catheter radiofrequency ablation (RFA) and cryoablation of the left atrium and pulmonary vein ostia have become successful therapeutic modalities in the management of atrial fibrillation. Atrio-esophageal fistula is a rare complication. Awareness of complication risk is imperative because without prompt diagnosis and urgent surgical intervention, the outcome is often fatal. We present 3 cases of atrio-esophageal fistula following percutaneous catheter radiofrequency ablation (RFA). Case Reports: Case 1: A 72-year old white male presented 27 days after percutaneous RFA for atrial fibrillation with fever, altered mental status, and melena. Esophagogastroduodenoscopy (EGD) revealed a 1-cm defect in the mid-esophagus. Upon thoracotomy, severe hemorrhage ensued from a concomitant injury to the left atrium. Multiple attempts to repair the left atrial perforation were unsuccessful and the patient died. Case 2: A 71-year old white male presented 29 days after percutaneous RFA for atrial fibrillation with fever and tonic-clonic seizure. Recognition of possible atrio-esophageal fistula was considered and confirmed on thoracotomy. Surgical fixation of the left atria and esophagus were performed. The patient survived and was discharged to a skilled care facility. Case 3: A 75-year old white male presented 24 days after percutaneous RFA for atrial fibrillation with chest pain. An echocardiogram revealed a large pericardial effusion and pericardiocentesis was performed. Despite aggressive measures, the patient died. The autopsy demonstrated a communicating esophageal fistula with the right pulmonary vein. Conclusions: Clinicians tending to patients who have recently undergone atrial ablation need to be aware of atrio-esophageal fistula as a rare but highly fatal complication.

Hospital discharge destinations for Hispanic and non-Hispanic white patients treated for traumatic brain injury.

Purpose: To examine hospital discharge destinations for Hispanic and non-Hispanic white patients treated for traumatic brain injury. Methods: Retrospective cohort study with patient matching. Findings: Ethnicity status not determined a significant predictor of discharge destination (P = .2150). Patient hospital length of stay determined a significant predictor of discharge destination (P = .0072), with every 1 day increase in length of stay, resulting in a 12% increase in odds of being discharged to care facility. Conclusions: Study data suggest that length of stay can predict discharge destination for both Hispanic and non-Hispanic white patients in a medium-sized trauma center in the Midwest.

Spontaneous coronary artery dissection: a case series and literature review

Spontaneous coronary artery dissection (SCAD) is a rare and often lethal cause of acute coronary syndrome, which typically affects young women and otherwise healthy individuals. SCAD can be diagnosed in patients undergoing coronary angiography and can be underestimated. Special techniques such as optical coherence tomography (OCT) and intravascular ultrasound should be used when there is suspicion of the condition. In the majority of cases, the left anterior descending (LAD) artery is involved; however, a few cases of the right coronary artery (RCA) involvement have been reported. This article describes three cases of SCAD in women of different ages, all presenting with chest pain. Coronary angiography in conjunction with OCT was used for diagnosis in two of the cases. One of the patients had involvement of the proximal RCA and underwent percutaneous coronary intervention, whereas the other two patients had mid-LAD disease and were treated conservatively with medical therapy. Presently, there are no specific guidelines for the treatment of SCAD, and therapy is individualized according to extent and severity of the condition.

Trauma patients over-triaged to helicopter transport in an established midwestern state trauma system

PURPOSE To characterize helicopter transport use in a mature Midwestern trauma system located in a low population density state, examine characteristics of patients over-triaged to helicopter transport, and determine predictors of over-triage to helicopter transport. METHODS A retrospective observational study conducted using State Trauma Registry data for years 2008-2009. Study sample included patients with medical helicopter transportation. Bivariate analyses compared patients defined and not defined as over-triaged to helicopter transport. Multivariate regression was used to determine predictors of over-triage. FINDINGS Of the 2,084 helicopter-transported study patients, 552 (26%) were defined as over-triaged. Differences in patients based on over-triaged status included race, age, injury mechanism, injury type, and injury intent (P < .05). Multivariate-based significant predictors of over-triage were transfer status, patient age, and injury mechanism (P= .0223; <.0001; and .0007, respectively). Patients transported from scene had a greater odds (OR: 1.29; 95% confidence interval: 1.04, 1.60) of being over-triaged to helicopter transport than interfacility transfers. Younger patients were also more likely to be over-triaged. Interactions between patient age and injury mechanism demonstrated varied likelihoods for over-triage. Younger patients injured in falls were more likely over-triaged than younger patients injured in a motor vehicle crash or by other non-fall causes. CONCLUSION Study data showed over-triage to helicopter transport was substantial in a mature trauma system. It is recommended that trauma systems develop and monitor compliance with criteria for appropriate use of air medical transport. These actions can assist in refinements to prehospital and interfacility transfer protocols.