Murray J. Girotti

Prospective Study of Blunt Aortic Injury: Multicenter Trial of the American Association for the Surgery of Trauma

BACKGROUND Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.

Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997.

BACKGROUND The purpose of this study was to review the epidemiology of maxillofacial skeletal injuries in severely injured patients admitted to trauma hospitals in Ontario, Canada, with an Injury Severity Score > 12. METHODS The Ontario Trauma Registry was accessed to examine the epidemiology of maxillofacial skeletal injuries in severely injured patients treated at 12 trauma hospitals in the province of Ontario, Canada, between 1992 and 1997. Data were collected prospectively, and a descriptive analysis was performed to determine the pattern of maxillofacial injuries, including patient age, sex distribution, etiology of injury, time of injury, and injury profile. RESULTS There were 2,969 patients that met the inclusion criteria. The median age was 25 years, and men were injured at a 3:1 ratio over women. Most severely injured patients with maxillofacial fractures were injured as a result of motor vehicle collision (70%), with only 33% of the patients restrained with a seat-belt. The temporal distribution of injuries showed that most injuries occurred during evening hours, on weekends, and in the summer. The largest number of fractures was found in the maxilla and orbital bones. The Injury Severity Score of the patients in this study ranged from 13 to 75, with a median of 25. The injury most commonly associated with maxillofacial fractures was injury to the head and neck area. Of patients with injury to the head and neck, most had an altered level of consciousness or injuries to the skull, brain, or cranial vessels. CONCLUSION Many severely injured patients have maxillofacial injuries. Long-term collection of epidemiologic data regarding maxillofacial fractures is important for the evaluation of existing preventative measures and useful in the development of new methods of injury prevention. Furthermore, insight into the epidemiology of facial fractures and concomitant injuries is an integral component in evaluating the quality of patient care, developing optimal treatment regimens, and making decisions regarding appropriate resource and manpower allocations.

The use of prophylactic inferior vena cava filters in trauma patients: A systematic review §

INTRODUCTION Pulmonary embolisms (PE) are an often preventable cause of late morbidity and mortality after trauma. Although there is evidence for the use of therapeutic inferior vena cava (IVC) filters (defined as IVC filters implanted in those with proven deep venous thrombosis [DVT] in order to prevent PE), there is not as much evidence to support the use of prophylactic IVC filters. Thus, we undertook a systematic review of the literature to assess the following in prophylactic IVC filters: efficacy in PE reduction, prevalence of filter-related complications and the indications for use. MATERIALS AND METHODS After screening 249 studies, 24 studies met inclusion criteria for qualitative synthesis. RESULTS Overall, the literature is supportive of the use of prophylactic IVC filters in high-risk poly-trauma patients who may have contraindications to DVT prophylaxis. Filter-associated complications are uncommon and, when they do occur, tend to be of limited clinical significance. Limited data, mostly in the form of case series, supports a reduction in PE and PE-related mortality. There has been increasing use of retrievable filters as well as the ability to safely retrieve them at longer intervals. CONCLUSION Despite the addition of a few matched-control studies, the literature is still plagued by a lack of high quality data, and therefore the true efficacy of prophylactic IVC filters for prevention of PE in trauma patients remains unclear. Further studies are required to determine the true role of prophylactic IVC filters in trauma patient.

Open or closed diagnostic peritoneal lavage for abdominal trauma? A meta-analysis.

OBJECTIVES To perform a meta-analysis of prospective, randomized controlled trials comparing the closed and open technique of diagnostic peritoneal lavage (DPL) in trauma patients to determine whether there are any difference in outcomes. METHODS A search of MEDLINE database of English language articles published from 1977 to 1999 was conducted by using the terms diagnostic peritoneal lavage, trauma, and randomized controlled trials. A manual search and Cochrane Library database search was also conducted. Seven randomized controlled trials, including a total of 1,126 patients were identified that compared closed versus open technique. Two reviewers assessed the trials independently. Trial quality was critically appraised by using the Jadad Instrument, a validated published quality scale. Data extraction of major complications, technical difficulties, procedure times, and false-negative and false-positive rates was carried out. The fixed effects model was used for statistical analysis. The Peto odds ratio (OR), weighted mean differences and 95% confidence intervals (95% CI) were calculated. RESULTS The overall quality of studies was poor (mean, 2.4/7). Major complications did not differ significantly between closed versus open technique (OR, 0.65; 95% CI, 0.15 to 2.92. Technical failures and difficulties were significantly higher in the closed group, i.e., OR 4.33 (95% CI, 1.96 to 9.56) and OR 4.19 (95% CI, 2.842 to 6.19), respectively. Accuracy of closed and open DPL was comparable with no difference in false-negative or false-positive rates between the two techniques. Procedure time was consistently lower in the closed technique. CONCLUSIONS The closed DPL technique is comparable to the standard open DPL technique in terms of accuracy and major complications. The advantage of reduced time to perform the closed DPL is offset by the increased technical difficulties and failures of this group. Therefore, any significant benefit of routine closed DPL in improving outcomes can be excluded with more confidence based on pooled data than by the individual trials alone.

Human Immunodeficiency Virus, Hepatitis B, and Hepatitis C Seroprevalence in a Canadian Trauma Population

BACKGROUND The current seroprevalence of human immunodeficiency virus (HIV), hepatitis B, and hepatitis C in the Canadian trauma population is unknown. Establishing the seroprevalence of these diseases is vital for education, postexposure prophylaxis, and counseling, and to establish potential screening guidelines. The purpose of this study was to determine the seroprevalence of HIV, hepatitis B, and hepatitis C in the trauma population of London, Ontario, Canada. METHODS All adult (aged > or = 18 years) trauma patients treated by the trauma team at London Health Sciences Centre were prospectively studied from January to December 2003. The study was conducted as a linked, confidential serosurvey with delayed full disclosure. Serum was analyzed for HIV, hepatitis C antibody, and Hepatitis B surface antigen. RESULTS A total of 287 (76%) of 377 consecutive trauma patients had blood testing completed. Of the 287 patients tested, 1 (0.3%) was positive for hepatitis B, 8 (2.8%) were positive for hepatitis C, and no patients tested positive for HIV. Hepatitis C-positive patients were predominantly men (63%) with a mean age of 46 years and a mean Injury Severity Score of 19; 63% were injured in a motor vehicle crash, and 88% were discharged alive. There were no statistically significant differences in the demographic and injury profiles from the hepatitis C-negative patients (p > 0.2 for all). CONCLUSION This is the first study to determine the rates of HIV, hepatitis B, and hepatitis C in the Canadian trauma population. Our trauma population demonstrated a threefold higher hepatitis C seroprevalence rate compared with the general population. Hepatitis C poses the highest risk to the trauma team of the three bloodborne diseases studied. With no vaccine or postexposure prophylaxis currently available for hepatitis C, this study highlights the importance of prevention and the strict use of universal precautions in the setting of trauma.

Is a full team required for emergency management of pediatric trauma

Pediatric trauma centers often do not meet the guidelines requiring a trauma team as recommended by the American Academy of Pediatrics (AAP). We reviewed our experience with a team consisting of a pediatric emergency physician, resident, nurse, and respiratory therapist. The surgical and pediatric critical care residents and staff were available within 5 minutes. We conducted a retrospective chart review of 146 patients (aged 8.1 +/- 4.8 years) between 1987 and 1989, with Injury Severity Scores (ISS) greater than or equal to 16 or admitted to the pediatric critical care unit. The time of presentation, surgical services consulted, and the nature of the injury were obtained from chart review. The Pediatric Trauma Score (PTS), the Revised Trauma Score (RTS), the Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, and Pediatric Risk of Mortality (PRISM) were used to determine the severity of insult and physiologic derangement on admission. The Modified Injury Severity Score (MISS) was determined and the Delta score for Disability Assessment was assigned at discharge. The Delta score was also determined at 3-month intervals up to one year. The probability of survival (Ps) was calculated, using the ISS and RTS. The Z statistic for this group of patients was then determined, using the Major Trauma Outcome Study (MTOS) methodology. The percentages of patients who were normal, disabled, and dead were 61%, 31.5%, and 7.5%, respectively, at 6 months follow-up. Eleven deaths were expected based on PRISM and TRISS analysis. Our mortality and morbidity figures were comparable with those of centers with teams based on AAP guidelines.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric trauma in southwestern Ontario: linking data with injury prevention initiatives

BACKGROUND Our objective was to provide an epidemiologic description of pediatric trauma in SW Ontario using multiple data sets. Injury prevention (IP) initiatives were linked with predominant injury mechanisms to determine whether IP programs were supported by data. METHODS Descriptive analysis was undertaken for five pediatric age groups (<1 year, 1-4 years, 5-9 years, 10-14 years, 15-19 years) using the Ontario Trauma Registrys Death Data Set, Comprehensive Data Set (Lead Trauma Hospitals [LTH] patients), and Minimal Data Set (hospital admissions), 1999-2000, for all pediatric patients residing in SW Ontario. National Ambulatory Care Reporting System (NACRS) data from the Childrens Hospital of Western Ontario/London Health Sciences Centre were used to capture the Emergency Room (ER) injury data. Information on IP initiatives for children and youth was gathered through an Internet search, supplemented by a survey. RESULTS Injury in SW Ontario resulted in 13,197 ER visits, 1,616 hospital admissions, 70 severe trauma (ISS > 12) cases treated at a LTH and 47 deaths to children and youth. More males than females were injured, with the sex differential more pronounced as age increased. Falls were the leading mechanism for ER visits (37%) and hospital admissions (26%). Recreational injuries represented approximately 30% of injuries to the 10-14 yr age group. As ISS increased, MVCs emerged as an important mechanism, representing 71% of LTH cases and 53% of pediatric injury deaths in SW Ontario. There were 61 pediatric IP programs identified in SW Ontario. Eighty-four percent of programs (51/61) were supported by data, and were related to one of the predominant injury mechanisms. CONCLUSIONS Injury is a serious problem for children in SW Ontario. Data can be used to identify modifiable risk factors to develop and implement new IP initiatives with the goal of reducing childhood injury and death. There is a need to integrate and link IP programs in SW Ontario for full coverage of all injury mechanisms.

Drug use and screening in pediatric trauma.

Background: There is a paucity of research on substance use in the pediatric trauma population. This study aims to describe trends in substance use and screening in the Canadian pediatric trauma population. Materials and Methods: A retrospective review of the London Health Sciences Centre trauma database from April 1999 to January 2009 identified patients less than 18 years old admitted after major trauma [injury severity score (ISS) > 12]. Data extracted included age, gender, ISS, blood alcohol concentration (BAC), and results of toxicology screens. Results: BAC data were available for 799 patients and toxicology screens for 761 patients. BAC testing was completed in 30% (21% positive). Toxicology screens were completed in 7% (44% positive). Increasing age was associated with screening for alcohol (odds ratio = 1.4; 95% confidence interval 1.3-1.5). Screening for drug use had a bimodal distribution, with no children aged 4-10 years screened. Those screened for drugs and alcohol had a significantly higher ISS than those not tested (BAC 28 versus 23, P < 0.001, toxin screening 29 versus 24, P = 0.003). The most common ingestions were alcohol, benzodiazepines, cannabinoids, and opiates. Conclusions: Screening for drugs and alcohol is sporadic in the pediatric trauma population. Further study utilizing a universal approach to drug and alcohol screening is needed to further delineate the true prevalence of substance use in this population.

Induced immunoglobulin secretion by T-cell-replacing products from blunt trauma patients.

The capacity to induce immunoglobulin (Ig) secretion by soluble T-cell-replacing (TCR) factors derived from alloantigen-stimulated T lymphocytes of blunt trauma patients (n = 15, mean ISS = 24) was examined in Staphylococcus aureus (SAC)-activated normal B-cell cultures. The majority of the patients studied demonstrated a profound suppression of the T-cell-dependent, pokeweed-mitogen-induced Ig production. However, the activity to induce Ig secretion associated with TCRs from the same patients was not reduced compared with that of TCRs from normal subjects. IgM synthesis was normal and IgG secretion induced by TCRs was within the control range (in 6 of 15 patients) or significantly higher (p less than 0.05) than that in the remaining patients. Both patient-derived and control TCRs failed to induce Ig synthesis in cultures of resting B cells and had comparable mitogenic effects on normal SAC-activated and phytohemagglutinin A-activated B and T lymphocytes, respectively. Thus, the intrinsic ability of T lymphocytes to produce B-cell helper factors appears to be unaffected following blunt trauma. Suppression of the T-cell-regulated Ig secretion in traumatized patients may therefore reflect an altered B lymphocyte response to such factors.

Evaluation of a youth unsafe driving video: a comparison of two communities

Objectives To evaluate and compare the effectiveness of an injury prevention video (iDrive2) designed to raise awareness of youth about the risks and consequences of aggressive, unsafe driving in two Canadian communities, with different injury experiences. Methods The video with accompanying presentation was delivered to two high schools in different communities. A survey was designed and distributed to students to evaluate program effectiveness. Program components were scored on Likert-scales, with open-ended questions included. Ç2 and t tests were used to compare groups. Results There was a total of 651 completed surveys (462 (71%) Brantford; 189 (29%) London)). While <1/3 of each school responded that this was new information, the majority of students (91% Brantford; 83% London; p<0.001) found the program effective in raising awareness of unsafe driving, rating it 5 (London) and 6 (Brantford) out of 7 (p<0.001). The Brantford students were more likely to find the video effective to educate on driving distraction, speeding, drugs and buckling up (p<0.001). More Brantford students reported to better understand risks and learnt strategies (87% vs 69%; 87% vs 70%; p<0.001) and nearly all (97% vs 88%) would recommend the video. Conclusion While the majority of students found this program effective in raising awareness of unsafe driving (distractions, drugs, speeding, no seatbelt use), the results from Brantford group were more favourable. This high school had a fatal crash involving students in the months preceding the program. The context of this experience created a learning opportunity when students are more receptive, thereby maximising program effectiveness.