Mary-Margaret Brandt

The need for early angiographic embolization in blunt liver injuries.

BACKGROUND Although nonoperative management of blunt liver injury (BLI) has become standard practice, adjuncts to nonoperative therapy, such as angiographic embolization, have not been well characterized. METHODS Patients with BLI were retrospectively identified at our American College of Surgeons-verified Level I trauma center from January 1997 through February 2001. Patients were stratified into four groups: those who received angiographic embolization (AE) as an early intervention when BLI was initially diagnosed (EARLY-AE); those who underwent AE after liver-related operation or later in the hospital course (LATE-AE); those treated with operation only (OR-ONLY); and nonoperative patients who also did not undergo AE (NO-OR). RESULTS There were 126 patients with BLI, of whom 94 were NO-OR, 20 were OR-ONLY, 6 had LATE-AE, and 6 had EARLY-AE. The NO-OR group had significantly lower liver Abbreviated Injury Scale scores. Liver Abbreviated Injury Scale scores were not different between the EARLY-AE, LATE-AE, and OR-ONLY groups. Liver-related mortality was not lower for those treated with AE. There was a trend toward lower mortality for just the EARLY-AE group compared with the LATE-AE and OR-ONLY groups (0% vs. 50% and 35%). The number of units of packed red blood cells transfused and the number of liver-related operations were lower in the EARLY-AE compared with the LATE-AE group, but liver-related complications were not different between the EARLY-AE, LATE-AE, or OR-ONLY groups. AE was successful in arresting hemorrhage in 83% of the cases. CONCLUSION In this small series, we observed similar morbidity and mortality with AE compared with operative therapy. EARLY-AE did decrease blood use and the number of liver-related operations. AE can be performed on severely injured patients with comparable liver-related mortality and complications. Further study of the timing of and outcomes from AE is needed.

Hospital cost is reduced by motorcycle helmet use.

BACKGROUND The purpose of this study was to identify the impact of motorcycle helmet use on patient outcomes and cost of hospitalization, in a state with a mandatory helmet law. METHODS Patients admitted after motorcycle crashes from July 1996 to October 2000 were reviewed, including demographics, Injury Severity Score, length of stay, injuries, outcome, helmet use, hospital cost data, and insurance information. Statistical analysis was performed comparing helmeted to unhelmeted patients using analysis of variance, Students test, and regression analysis. RESULTS We admitted 216 patients: 174 wore helmets and 42 did not. Injury Severity Score correlated with both length of stay and cost of hospitalization. Mortality was not significantly different in either group. Failure to wear a helmet significantly increased incidence of head injuries (Students test, p < 0.02), but not other injuries. Helmet use decreased mean cost of hospitalization by more than

Venous thrombosis incidence in burn patients: Preliminary results of a prospective study

6,000 per patient. CONCLUSION Failure to wear a helmet adds to the financial burden created by motorcycle-related injuries. Therefore, individuals who do not wear helmets should pay higher insurance premiums.

The utility of endovascular stents in the treatment of blunt arterial injuries

There are few prospective data on the incidence of deep venous thrombosis (DVT) in burn patients. In an on-going prospective study, hospitalized burn patients 18 years or older with an expected hospital length of stay more than 72 hours were imaged with baseline venous duplex ultrasound of all extremities within the first 48 hours after admission and weekly until discharge. Patient demographics and clinical risk factors for DVT were assessed. At the time of submission, 40 patients met screening criteria, and 30 were enrolled. Ultrasound diagnosed seven patients with 11 acute DVT for an incidence of 23%. One pulmonary embolism was documented. DVT patients had a mean age of 49 +/- 23 years with an average TBSA burn of 15 +/- 4% compared with those without thrombosis with a mean age of 44 +/- 17 years (P = NS) and TBSA burn of 18 +/- 25% (P = NS). There were no statistically significant differences for DVT patients in terms of age, number of central line days, hospital length of stay, or TBSA burned. Given the preliminary findings of this small study, we believe that all hospitalized burn patients are at risk for DVT. On-going investigation will be helpful in defining level of risk and improved prevention strategies for thromboembolic complications in burn patients.

Potential risk factors for deep venous thrombosis in burn patients.

BACKGROUND The objective of this review is to evaluate our institutional experience with percutaneously placed vascular stents in multiply injured patients with blunt arterial injuries. METHODS Patients were identified through our trauma registry from 9/95 through 12/99. All injuries were diagnosed by angiography. Palmaz and Wallstent prostheses were used. RESULTS Six patients had blunt arterial injuries. Age ranged from 20 to 67 years (average, 45). Each patient had one or more stents placed. There were no immediate complications related to stent placement. There were no deaths or complications attributable to stent placement. All of the patients survived to leave the hospital. Follow-up ranged from 1 month to 2 years with no occlusion, stenosis, or stent malfunction. CONCLUSION The use of interventional angiography and endovascular stenting is safe and efficacious in treating arterial injuries in certain circumstances.

Decreased juvenile arson and firesetting recidivism after implementation of a multidisciplinary prevention program.

Risk factors and prophylaxis for prevention of deep venous thrombosis (DVT) and pulmonary embolism remain controversial in burn patients. From January 1996 through June 1999, we reviewed all adult burn patients admitted to our burn center with the in-hospital diagnosis of DVT and assessed each affected patient for DVT risk factors. There were 8 symptomatic DVTs and 2 pulmonary embolisms detected in 327 adult burn patients (2.4% incidence). No DVT patient had the risk factors of morbid obesity, previous DVT, congestive heart failure, or neoplastic disease. One patient was older than 65 years. All of the DVTs occurred in veins draining a burned extremity. Seven of 8 patients had burn wound infections as complications. Burns on the extremity developing the DVT as well as the diagnosis of a burn wound infection were significant risk factors for DVT formation. These findings prompt us to consider routine screening for DVT in burn patients with these risk factors.

Acute renal failure in cardiothoracic surgery patients: what is the best definition of this common and potent predictor of increased morbidity and mortality

OBJECTIVES In 1999, we developed the multidisciplinary Trauma Burn Outreach Prevention Program (TBOPP), which focuses on the medical and societal consequences of firesetting behavior. The basis for this program development was a 17% increase in pediatric burn admissions. The purpose of this study was to determine the value of this trauma burn center prevention program from a financial, clinical, and recidivism perspective. METHODS Juveniles (ages 4-17 years) were enrolled into our 1-day program on the basis of referrals from the county court system, fire departments, schools, and parents. The programs interactive content focuses on the medical, financial, legal, and societal impact of firesetting behavior, with emphasis on individual accountability and responsibility. The court system and fire departments tracked all episodes of firesetting behavior within their respective communities. Arson is defined as behavior with the intent to produce damage, whereas firesetting is defined as having no ill intent. The recidivism rate was determined using fire department and court follow-up records. Follow-up was from 8 months to 2.5 years. A random control group that did not receive TBOPP education (noTBOPP group) with identical entry criteria was used for comparison. Institutional review board approval was obtained. RESULTS There were 132 juveniles in the TBOPP group (66 arsonists and 66 firesetters) and 102 juveniles in the noTBOPP group (33 arsonists and 66 firesetters). Fifty-nine TBOPP participants had a medical history of behavioral disorders. Property damage for arson averaged

Normal d-dimer levels do not exclude thrombotic complications in trauma patients

4,040, with additional court costs of

Burn centers should be involved in prevention of occupational electrical injuries

1,135 per incident. Family environment was an independent predictor for risk of repeat offense. The odds ratio for risk of repeat offense in foster care was 17.9 (p < 0.05) as compared with two-parent homes. The recidivism rate was 1 of 32 (<1%) for the TBOPP group and 37 of 102 (36%) for the noTBOPP group (adjusted odds ratio, 0.02; p < 0.001). CONCLUSION When compared with the noTBOPP group, TBOPP participants had essentially no recidivism. The financial impact of arson behavior was over

A hospital-based violence prevention tour: a collaborative approach to empower youth.

6,000 per incident. The implementation of a juvenile firesetting prevention program has demonstrable benefits to the participants and to society.