Peep Talving

Necrotizing soft tissue infections: delayed surgical treatment is associated with increased number of surgical debridements and morbidity.

BACKGROUND Early surgical treatment is crucial in the management of necrotizing soft tissue infections (NSTI), a severe, potentially life threatening, rapidly progressive infection. The purpose of this study was to determine the influence of surgical procedure timing on the number of surgical debridements required. METHODS A retrospective study including 47 patients with the diagnosis of NSTI admitted to a large academic hospital from December 2004 to December 2010 was conducted. Demographics, basic laboratories on admission, medical comorbidities, site of infection, and intraoperative culture results were compared between patients with early (≤12 hour) and late (>12 hour) surgical treatment. The x-y plot for the study population and linear regression analyses were used to define the time cut point. Outcomes included the total number of debridements, mortality, hospital length of stay, and complications. Adjustment for confounding factors was done with binary regression logistic model for categorical outcomes and analysis of covariants for continuous outcomes. RESULTS Overall mortality was 17.0%. The average number of surgical debridements in patients with delay surgical treatment >12 hours from the time of emergency department admission was significantly higher than those who had an operation within 12 hours after admission (7.4 ± 2.5 vs. 2.3 ± 1.2; p < 0.001). Delayed surgical debridement was associated with significantly higher mortality, higher incidence of septic shock and renal failure, and more surgical debridements than patients with early surgical debridements. After adjusting for possible confounding factors, the average number of surgical debridements and the presence of septic shock and acute renal failure were still significantly higher in patients in whom surgery was delayed >12 hours. CONCLUSION In patients with NSTI, a delay of surgical treatment of >12 hours is associated with an increased number of surgical debridements and higher incidence of septic shock and acute renal failure.

Prospective Evaluation of Multidetector Computed Tomography for Extremity Vascular Trauma

BACKGROUND Multidetector computed tomographic angiography (MDCTA) is increasingly being used for the assessment of extremity vascular injury. However, to date, there are only retrospective series and a single small prospective study evaluating its efficacy. Therefore, the objective of this study was to prospectively evaluate the ability of MDCTA to detect arterial injury in the injured upper and lower extremities. METHODS After institutional review board approval, all trauma patients aged 16 years or older admitted to a Level I trauma center who sustained extremity trauma and underwent initial evaluation with a 64-channel MDCTA from March 2009 to June 2010 were prospectively enrolled. The sensitivity and specificity of MDCTA were tested against an aggregate gold standard of operative intervention, conventional angiography, and clinical follow-up. RESULTS During the 20-month study period, 635 patients with extremity trauma underwent a structured clinical examination. Hard signs of vascular injury was observed in 5.5% of patients with a 97.1% incidence of clinically significant injury requiring operative intervention. Eighty-three percent of patients had no signs of vascular injury with no missed injuries detected during follow-up. Eighty-nine MDCTAs were performed in the remaining 73 patients (11.5%) with soft signs. The mechanism of injury was penetrating in 69.9% (42 gunshot wound, 5 stab wound, and 4 shotgun). There were 24 positive studies, 23 of which were confirmed at operation (5 brachial artery injuries, 2 radial, 1 ulnar, 1 external iliac, 2 common femoral, 5 proximal superficial femoral, 2 distal superficial femoral, 4 popliteal, and 1 posterior tibial artery injury). A left posterior tibial artery occlusion was managed nonoperatively. There were 58 negative studies with clinical follow-up available in 100%, for a mean of 10.6 days ± 11.7 days (median, 6 days; range, 1-41 days). MDCTA was nondiagnostic in seven patients (9.6%), five secondary to artifact from retained missile fragments (3 shotgun and 2 gunshot wound), and two secondary to technical errors in reformatting. In the absence of artifact, MDCTA achieved 100% sensitivity and 100% specificity in detecting all clinically significant arterial injuries. CONCLUSIONS Physical examination is critical in the decision-making process for the injured extremity and can accurately reduce unnecessary imaging. If imaging is required, MDCTA is a sensitive and a specific noninvasive modality for arterial evaluation and may replace conventional angiography as the diagnostic modality of choice for the evaluation of the acutely injured extremity.

Coagulopathy after isolated severe traumatic brain injury in children.

INTRODUCTION Few previous studies have been conducted on the severe traumatic brain injury (sTBI)-associated coagulopathy in children. The purpose of this study was to evaluate the incidence and risk factors of sTBI coagulopathy in a pediatric cohort and to evaluate its impact on outcomes. METHODS Retrospective analysis of pediatric patients (younger than 18 years) sustaining isolated sTBI [head Abbreviated Injury Scale (AIS) score ≥3 and extracranial injuries AIS score <3]. Criteria for sTBI-associated coagulopathy included thrombocytopenia (platelet count <100,000 per mm(3)) and/or elevated international normalized ratio >1.2 and/or prolonged activated partial thromboplastin time >36 seconds. Incidence and risk factors of sTBI coagulopathy and its impact on in-hospital outcomes were analyzed. RESULTS Overall, 42.8% (n = 137) of the 320 patients studied developed coagulopathy, with increasing incidence in a stepwise fashion with escalating head AIS score (31.1, 46.2, and 88.6% for head AIS score 3, 4, and 5, respectively; p < 0.001). Depressed GCS, increasing age, an ISS ≥16, and brain contusions/lacerations were independently associated with the presence of coagulopathy. The case fatality rate was 7.8% (n = 25); 17.5% versus 0.5% in coagulopathic versus noncoagulopathic patients, respectively. After logistic regression to adjust for confounders, no statistical significant mortality difference in patients with and without coagulopathy was noted (adjusted p = 0.912). CONCLUSIONS Incidence of coagulopathy in children suffering isolated sTBI is exceedingly high at 40% and reflect the head injury severity. A low GCS, increasing age, ISS ≥16 and intraparenchymal lesions proved to be independently associated with TBI coagulopathy.

Clinical examination is insufficient to rule out thoracolumbar spine injuries.

PURPOSE The role of clinical examination in the diagnosis of thoracolumbar (TL) spine injuries is highly controversial. The aim of this study was to assess the sensitivity and specificity of a standardized clinical examination for diagnosing TL spine injuries after blunt trauma. METHODS This was a prospective observational study conducted at a level I trauma center from March 2008 to September 2008. After Institutional Review Board approval, all evaluable blunt trauma patients older than 15 years were evaluated by a senior resident or attending surgeon for TL spine deformity, tenderness to palpation, and neurologic deficits. Patients were followed through their hospital course to capture all TL spine injury diagnoses, all imaging performed, and any immobilization or stabilization procedures. RESULTS Of the 884 patients enrolled, 81 (9%) had a TL spine injury. More than half (55.6%) had two or more fractures with 30.9% having three or more. Isolated L-spine fractures occurred in 56.8%, T-spine fractures occurred in 34.6% only, and combination injuries sustained in 8.6%. The most commonly identified fractures were of the transverse process (67.9%) followed by the vertebral body (30.9%) and spinous process (12.3%). Among the 666 patients who were evaluable, 56 (8%) had a TL spine fracture. Of these, 29 (52%) had a negative clinical examination, of which 2 (7%) had clinically significant compression fractures. For evaluable patients who had localized pain or tenderness elicited on examination, although the finding triggered imaging appropriately, the site of pain correlated to the site of actual injury in only 61.5% of cases. The sensitivity and specificity of clinical examination for TL spine fractures were 48.2% and 84.9%, respectively, for all fractures and 78.6% and 83.4% for those that were clinically significant. CONCLUSION Clinical examination as a stand-alone screening tool for evaluation of the TL spine is inadequate. In this series, all the clinically significant missed fractures were diagnosed on computed tomography (CT) obtained for evaluation of the visceral torso. A combination of both clinical examination and CT screening based on mechanism will likely be required to ensure adequate sensitivity with an acceptable specificity for the diagnosis of clinically significant injuries of the TL spine. Further research is warranted, targeting the at-risk patient with a negative clinical examination, to determine what injury mechanisms warrant evaluation with a screening CT.

Civilian Duodenal Gunshot Wounds: Surgical Management Made Simpler

IntroductionLow-velocity gunshot wounds cause most civilian duodenal injuries. The objective of this study was to describe a simplified surgical algorithm currently in use in a South African civilian trauma center and to verify its validity by measuring morbidity and mortality.MethodsA retrospective chart review of patients with duodenal gunshot injuries during the study period January 1999 to December 2003 was performed. Data points accrued included patient demographics, admission hemodynamic status and resuscitative measures, laparotomy damage control procedures, methods of surgical repair of the duodenal injury, associated injuries, length of intensive care and hospital stays, complications, and mortality.ResultsA total of 75 consecutive patients with gunshot injuries to the duodenum were reviewed. Primary repair was performed in 54 patients (87%), resection and reanastomosis in 7 (11%), and pancreatoduodenectomy in 1 (2%) during the initial phases. The overall morbidity and mortality were 58% and 28%, respectively. Duodenum-related complications were recorded in nine (15%) patients: two duodenal fistulas, one duodenal obstruction, and six cases of suture-line dehiscence. Overall and duodenum-related morbidity rates in patients with combined pancreatoduodenal injuries were 83% and 17%, respectively. Duodenum-related mortality occurred in three (4.8%) patients.ConclusionsMost civilian low-velocity duodenal gunshot injuries treated with simple primary repair result in overall morbidity, mortality, and duodenum-related complication rates comparable to those in reports where more complex surgical procedures were employed. Primary repair is also applicable for most combined pancreatic and duodenal gunshot injuries.

Ethanol Intoxication Is Associated with a Lower Incidence of Admission Coagulopathy in Severe Traumatic Brain Injury Patients

The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury (sTBI)-associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. Patients admitted to the surgical intensive care unit from June 2005 through December 2008 following sTBI, defined as a head Abbreviated Injury Scale (AIS) score ≥3, were retrospectively identified. Patients with a chest, abdomen, or extremity AIS score >3 were excluded to minimize the impact of extracranial injuries. Criteria for sTBI-associated coagulopathy included thrombocytopenia and/or elevated International Normalized Ratio (INR) and/or prolonged activated partial thromboplastin time (aPTT). The incidence of admission coagulopathy, in-hospital complications, and mortality were compared between patients who were ETOH positive [ETOH (+)] and ETOH negative [ETOH (-)]. During the study period, there were 439 patients with ETOH levels available for analysis. Overall, 46.5% (n=204) of these patients were ETOH (+), while 53.5% (n=235) were ETOH (-). Coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (-) counterparts (5.4% versus 15.3%; adjusted p<0.001). In the forward logistic regression analysis, a positive ETOH level proved to be an independent protective factor for admission coagulopathy [OR (95% CI)=0.24 (0.10,0.54; p=0.001]. ETOH (+) patients had a significantly lower in-hospital mortality rate than ETOH (-) patients [9.8% versus 16.6%; adjusted p=0.011; adjusted OR (95% CI)=0.39 (0.19,0.81)]. For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality. Further research to establish the pathophysiologic mechanisms underlying any potential beneficial effect of ETOH on the coagulation system following sTBI is warranted.

Skateboard-Related Injuries: Not to be Taken Lightly. A National Trauma Databank Analysis

BACKGROUND With the increasing popularity of skateboarding, trauma centers are experiencing increased number of skateboard injuries. The incidence and type of injuries and the effect of age on these variables are poorly described in the literature. METHODS Data from National Trauma Databank during a 5-year period was used for this study. Injury Severity Score (ISS), injured body area, specific injuries, and outcomes were calculated according to age groups (younger than 10 years, 10-16 years, and older than 16 years). RESULTS During the study period, there were 2,270 admissions due to skateboard-related injuries (0.1% of all trauma admissions). There were 187 patients (8%) younger than 10 years, 1,314 patients (58%) 10 years to 16 years, and 769 patients (34%) older than 16 years. The overall mortality was 1.1% and ranged from 0% in the age group younger than 10 years to 0.3% in the group 10 years to 16 years and 2.6% in the group older than 16 years (p < 0.001). The incidence of severe trauma (Injury Severity Score ≥ 16) in the three age groups was 5.4%, 13.5%, and 23.7%, respectively (p < 0.001). The incidence of traumatic brain injury in the three age groups was 24.1%, 32.6%, and 45.5%, respectively (p < 0.001). The younger age group (younger than 10 years) was significantly more likely to suffer femur fractures and less likely to suffer tibia fractures than the older age groups. Helmets and use of a skateboard park were significant factors protecting against head injury. CONCLUSION Skateboard-related injuries are associated with a high incidence of traumatic brain injury and long bone fractures. Age plays an important role in the anatomic distribution of injuries, injury severity, and outcomes. Our findings demonstrate that helmet utilization and designated skateboard areas significantly reduce the incidence of serious head injuries.

The Model for End-stage Liver Disease Score An Independent Prognostic Factor of Mortality in Injured Cirrhotic Patients

OBJECTIVE To examine the ability of the model for end-stage liver disease (MELD) score to predict the risk of mortality in trauma patients with cirrhosis. Although cirrhosis is associated with poor outcomes after injury, the relative effect of the severity of the cirrhosis on outcomes is unclear. The MELD score is a prospectively developed and validated scoring system, which is associated with increasing severity of hepatic dysfunction and risk of death in patients with chronic liver disease. DESIGN Retrospective review. The MELD score for each patient was calculated from the international normalized ratio, the serum creatinine level, and the serum total bilirubin level obtained from the patient at admission to the level 1 trauma center. The association of MELD score with mortality was assessed using logistic regression analysis. SETTING Level 1 trauma center. PATIENTS Cirrhotic patients with trauma admitted to the level 1 trauma center during the period from January 2003 to December 2009. MAIN OUTCOME MEASURE Mortality. RESULTS During the 7-year study period, 285 injured cirrhotic patients were admitted. The mean (SD) age was 50.0 (10.5) years, and the mean (SD) MELD score was 11.7 (4.8) (range, 6-28). Overall, patients who died had a significantly higher mean (SD) MELD score than did survivors (14.1 [5.4] vs 11.2 [4.6]; P < .001). The MELD score and the injury severity score were statistically significant risk factors that were independently associated with mortality in this group of patients (the area under the curve for the model was 0.944; cumulative R(2) = 0.545). Each unit increase in the MELD score was associated with an 18% increase in the odds for mortality (adjusted odds ratio, 1.18 [95% confidence interval, 1.08-1.29]; P < .001). CONCLUSION The MELD score is a simple objective tool for risk stratification in cirrhotic patients who have sustained injury.

Preinjury β-blockade is protective in isolated severe traumatic brain injury

BACKGROUND The purpose of this study was to investigate the effect of preinjury &bgr;-blockade in patients experiencing isolated severe traumatic brain injury (TBI). We hypothesized that &bgr;-blockade before TBI is associated with improved survival. METHODS The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between January 2007 and December 2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS) score of 3 or greater excluding all extracranial injuries AIS score of 3 or greater. Patient demographics, clinical characteristics on admission, injury profile, Injury Severity Score (ISS), AIS score, in-hospital morbidity, and &bgr;-blocker exposure were abstracted for analysis. The primary outcome evaluated was in-hospital mortality stratified by preinjury &bgr;-blockade exposure. RESULTS Overall, a total of 662 patients met the study criteria. Of these, 25% (n = 159) were exposed to &bgr;-blockade before their traumatic insult. When comparing the demographics and injury characteristics between the groups, the sole difference was age, with the &bgr;-blocked group being older (69 [12] years vs. 63 [13] years, p < 0.001). &bgr;-blocked patients had a higher rate of infectious complications (30% vs. 19%, p = 0.04), with no difference in cardiac or pulmonary complications between the cohorts. Patients exposed to &bgr;-blockade versus no &bgr;-blockade experienced 13% and 22% mortality, respectively (p = 0.01). Stepwise logistic regression predicted the absence of &bgr;-blockade exposure as a risk factor for mortality (odds ratio, 2.7; 95% confidence interval, 1.5–4.8; p = 0.002). After adjustment for significant differences between the groups, patients not exposed to &bgr;-blockade experienced twofold increased risk of mortality (adjusted odds ratio, 2.2; 95% confidence interval, 1.3–3.7; p = 0.004). CONCLUSION Preinjury &bgr;-blockade improves survival following isolated severe TBI. The role of prophylactic &bgr;-blockade and the timing of initiation of such therapy after TBI warrant further investigations. LEVEL OF EVIDENCE Therapeutic study, level III; prognostic study, level II.

Prehospital management and fluid resuscitation in hypotensive trauma patients admitted to Karolinska University Hospital in Stockholm.

INTRODUCTION Few previous studies have been conducted on the prehospital management of hypotensive trauma patients in Stockholm County. The aim of this study was to describe the prehospital management of hypotensive trauma patients admitted to the largest trauma center in Sweden, and to assess whether prehospital trauma life support (PHTLS) guidelines have been implemented regarding prehospital time intervals and fluid therapy. In addition, the effects of the age, type of injury, injury severity, prehospital time interval, blood pressure, and fluid therapy on outcome were investigated. METHODS This is a retrospective, descriptive study on consecutive, hypotensive trauma patients (systolic blood pressure < or = 90 mmHg on the scene of injury) admitted to Karolinska University Hospital in Stockholm, Sweden, during 2001-2003. The reported values are medians with interquartile ranges. Basic demographics, prehospital time intervals and interventions, injury severity scores (ISS), type and volumes of prehospital fluid resuscitation, and 30-day mortality were abstracted. The effects of the patients age, gender, prehospital time interval, type of injury, injury severity, on-scene and emergency department blood pressure, and resuscitation fluid volumes on mortality were analyzed using the exact logistic regression model. RESULTS In 102 (71 male) adult patients (age > or = 15 years) recruited, the median age was 35.5 years (range: 27-55 years) and 77 patients (75%) had suffered blunt injury. The predominant trauma mechanisms were falls between levels (24%) and motor vehicle crashes (22%) with an ISS of 28.5 (range: 16-50). The on-scene time interval was 19 minutes (range: 12-24 minutes). Fluid therapy was initiated at the scene of injury in the majority of patients (73%) regardless of the type of injury (77 blunt [75%] / 25 penetrating [25%]) or injury severity (ISS: 0-20; 21-40; 41-75). Age (odds ratio (OR) = 1.04), male gender (OR = 3.2), ISS 21-40 (OR = 13.6), and ISS >40 (OR = 43.6) were the significant factors affecting outcome in the exact logistic regression analysis. CONCLUSION The time interval at the scene of injury exceeded PHTLS guidelines. The vast majority of the hypotensive trauma patients were fluid-resuscitated on-scene regardless of the type, mechanism, or severity of injury. A predefined fluid resuscitation regimen is not employed in hypotensive trauma victims with different types of injuries. The outcome was worsened by male gender, progressive age, and ISS > 20 in the exact multiple regression analysis.