Marcel Martin

Trauma: the leading cause of maternal death

The records of the Cook County Medical Examiner were reviewed for the period January, 1986, to December, 1989. Ninety-five maternal deaths were identified. The causes of maternal death were categorized as direct maternal, indirect maternal, or nonmaternal. Direct maternal causes of death (18.9%) were the result of complications of pregnancy, labor, delivery, or its management. Indirect maternal causes of death (12.6%) occurred when pre-existing health problems were exacerbated by pregnancy. All other maternal deaths were the result of nonmaternal causes. Nonmaternal causes of maternal death were further classified as traumatic or nontraumatic. Traumatic maternal deaths (46.3%) were attributed to homicide in 57% and suicide in 9%. The mechanism of injury in traumatic maternal deaths included gunshot wounds (22.7%), motor vehicle crashes (20.5%), stab wounds (13.6%), strangulation (13.6%), blunt head injuries (9.1%), burns (6.8%), falls (4.5%), toxic exposure (4.5%), drowning (2.3%), and iatrogenic injury (2.3%). Trauma was therefore the leading cause of maternal death, accounting for 46.3% of deaths in this series.

Elderly trauma patients with rib fractures are at greater risk of death and pneumonia

BACKGROUND The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality. METHODS Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry. RESULTS Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old. CONCLUSION Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.

Preinjury warfarin use among elderly patients with closed head injuries in a trauma center.

BACKGROUND This study aimed to determine the impact of warfarin use on the severity of injury among elderly patients presenting with closed head injuries. METHODS A cohort of patients 55 years of age or older with closed head injuries taken to a tertiary trauma center between April 1993 and March 2001 was retrospectively identified. Patient characteristics, mechanism of injury, type and severity of injury, and hospital survival data were obtained from the trauma registry. Each case then was reviewed for completeness of information, assessment of preinjury warfarin use, and comorbidity. RESULTS Among the 384 patients presenting with closed head injuries, 35 (9%) were receiving warfarin before their trauma. As compared with nonusers, anticoagulated patients had a higher frequency of isolated head trauma (54% vs. 32%; p = 0.008), more severe head injuries (65.7% vs. 44.1%; p = 0.02), and a higher rate of mortality (40% vs. 21%, p = 0.01). These associations remained evident even after population differences in age, gender, comorbidities, and mechanism of injury were taken into account. Indeed, according to multivariate logistic regression models, warfarin use was associated with a statistically significant risk of death (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.22-6.12), statistically significant odds for more severe head injury (OR, 2.39; 95% CI, 1.10-5.17), and odds for isolated head injury that almost reached statistical significance (OR, 1.79; 95% CI, 0.82-3.90). CONCLUSIONS Among patients 55 years of age or older who present with closed head injury, the use of warfarin before trauma appears to be associated with a higher frequency of isolated head trauma, more severe head trauma, and a higher likelihood of death. The findings of this retrospective study support the concern about the adverse effects of anticoagulants in cases of head trauma.

Tension pneumopericardium following blunt injury

Pneumopericardium caused cardiac tamponade in a patient who was struck in the chest by a motor vehicle. Subxiphoid pericardial window and pericardial drainage successfully treated this condition. Diagnosis of this rare form of tamponade depends on clinical examination supported by chest radiographic findings.

TRIPLE-CONTRAST CT SCANS IN PENETRATING BACK AND FLANK TRAUMA

Triple-contrast CT scanning (3-CT) is a diagnostic modality that has been introduced recently for the work-up of patients with penetrating injuries to the back or flank. Triple-contrast CT consists of giving oral, intravenous (IV), and rectal contrast medium. Our hypothesis was that this test is an accurate predictor of the absence of a retroperitoneal injury requiring surgical repair. We prospectively enrolled 88 clinically stable patients who sustained penetrating wounds to the back or flank. Seventy-eight received a diagnostic peritoneal lavage (DPL) before 3-CT. The scans were classified according to the risk of a retroperitoneal injury requiring repair. Patients who did not go to the operating room (OR) were observed for 48 hours. Of 88 patients entered, nine had high-risk scans, five of these patients underwent exploratory laparotomy, two of whom had significant injuries. Seventy-nine patients had non-high-risk scans. Seventy-seven were observed without complication, and two were explored for positive DPL, with no significant lesion found. The negative predictive value of a low- or moderate-risk 3-CT scan is 100% +/- 11%.

Impact of deferred treatment of blunt diaphragmatic rupture: A 15-year experience in six trauma centers in Quebec

BACKGROUND The purpose of this study was to show that blunt diaphragmatic rupture does not require immediate emergency operation in the absence of other indications. METHODS We reviewed all patients with blunt diaphragmatic rupture admitted within 24 hours of injury to one of six university trauma centers providing trauma care for the province of Quebec from April 1, 1984, to March 31, 1999. Multivariate analysis of demographic profiles, severity indices, indications for operation, and preoperative delays was performed. RESULTS There were 160 patients (91 men and 69 women) with blunt diaphragmatic rupture. Mean age was 40.1 +/- 16.2 years. Mean Injury Severity Score was 26.9 +/- 11.5 and mortality was 14.4%. Patients undergoing emergency surgery for indications other than diaphragmatic rupture had a significantly higher Injury Severity Score than those undergoing surgery for repair of diaphragmatic rupture alone (34.7 +/- 10.7 vs. 22.0 +/- 9.0, p < 0.001). In patients undergoing surgery for diaphragmatic rupture alone, delay before repair of the diaphragmatic hernia did not lead to an increased mortality compared with patients undergoing immediate surgery (3.4% vs. 5.0%, p = NS). CONCLUSION Blunt diaphragmatic rupture in the absence of other surgical injuries carries low mortality. Operative repair of diaphragmatic rupture can be deferred without appreciable increased mortality if no other indication mandates immediate surgery.

Diagnostic peritoneal lavage: Is an isolated WBC count ≥ 500/mm3 predictive of intra-abdominal injury requiring celiotomy in blunt trauma patients?

: A 5-year retrospective review of 3,503 diagnostic peritoneal lavage (DPL) patients was conducted, identifying 48 (13%) blunt trauma patients who had a DPL WBC count greater than or equal to 500/mm3. The mean DPL WBC count was 1,646 +/- 2,275. Twenty (42%) of these patients were observed and discharged without subsequent operation or morbidity. Laparotomy was performed on 28 (58%) patients; 17 (61%) had a negative lap, 11 (39%) had intra-abdominal injuries requiring surgical repair or drainage (54% solid organ, 27% hollow viscus, 18% diaphragmatic). There were no significant differences between the three subgroups with regards to age, injury severity, time interval between injury and DPL, or mean DPL WBC count (p greater than 0.05). The negative-lap and no-lap groups had a significantly larger number of females; one presented with PID. The positive predictive value (PPV) of an isolated lavage WBC count of greater than or equal to 500/mm3 for intra-abdominal injury was 23% (11/48). The PPVs for DPLs performed less than and greater than or equal to 3 hours or those recalculated using WBC values higher than 500/mm3 were not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital Diaphragmatic Hernia with Liver Injury Presenting as Bilious Hydrothorax

Congenital diaphragmatic hernia is a rare occurrence in the adult population. We present herein a patient with blunt abdominal trauma who presented with a bilious right pleural effusion. Bile from a m