Comparison between Injury Severity Score (ISS) and New Injury Severity Score (NISS) in predicting mortality of thoracic trauma in a tertiary hospital

INTRODUCTION

measuring the severity of traumatic injuries is crucial for predicting clinical outcomes. Whereas the Injury Severity Score (ISS) has limitations in assigning scores to injuries at the same site, the New Injury Severity Score (NISS) corrects for this problem by taking into account the three most severe injuries regardless of the region of the body. This study seeks to comprehend the clinical and epidemiological profile of trauma patients while comparing the effectiveness of scales for predicting mortality.

METHODS

a descriptive, observational and retrospective study using records of patients who underwent thoracotomy at the Hospital das Clínicas of the Federal University of Triângulo Mineiro between 2000 and 2019. Demographic data, mechanisms of injury, affected organs, length of stay and mortality were analyzed. Injury severity was assessed using the ISS and NISS, and statistical analyses were conducted using MedCalc and SigmaPlot.

RESULTS

101 patients were assessed, on average 29.6 years old, 86.13% of whom were men. The average duration of hospitalization was 10.9 days and the mortality rate was 28.7%. The ROC curve analysis revealed a sensitivity of 68.97%, specificity of 80.56% and area under the curve of 0.837 for the ISS, and 58.62%, 94.44% and 0.855 for the NISS, respectively. The Youden index was 0.49 for the ISS and 0.53 for the NISS.

CONCLUSION

the study demonstrated comparable efficacy of NISS and ISS in predicting mortality. These findings hold significance in the hospital setting. Professionals must be familiar with these scales to utilize them competently for each patient.

Limiting thoracic CT: a rule for use during initial pediatric trauma evaluation

BACKGROUND

Despite increases in imaging guidelines for other body-regions during initial trauma assessment and the demonstrated utility of chest radiographs (CXR), guidelines for use of thoracic computed-tomography (TCT) are lacking. We hypothesized that TCT utilization had not decreased relative to other protocolized CTs, and mechanism and CXR could together predict significant injury independent of TCT.

METHODS

We performed a retrospective review of blunt trauma patients ≤18 y.o. (2007-2015) at two level-1 trauma centers who received chest imaging. Baseline characteristics and incidences of body region-specific CT were compared. Injury mechanism, intrathoracic pathology, and interventions among other data were examined (significance: p<0.05).

RESULTS

Although other body-region CT incidence decreased (p<0.05), TCT incidence did not change (p=0.65). Of the 2951 patients, 567 had both CXR and TCT, 933 received TCT-only, and 1451 had CXR-only. TCT altered management in 17 patients: 2 operations, 1 stent-placement, 1 medical management, 9 thoracostomy tube placements, and 4 negative diagnostic workups. All clinically significant changes were predicted by vehicle-related mechanism and abnormal CXR findings.

CONCLUSIONS

TCT utilization has not decreased over time. All meaningful interventions were predicted by CXR and mechanism of injury. We propose a rule, for prospective validation, reserving TCT for patients with abnormal CXR findings and severe vehicle-related trauma.

LEVEL OF EVIDENCE

Diagnostic study, Level III.

Exposure to 100% Oxygen Abolishes the Impairment of Fracture Healing after Thoracic Trauma

In polytrauma patients a thoracic trauma is one of the most critical injuries and an important trigger of post-traumatic inflammation. About 50% of patients with thoracic trauma are additionally affected by bone fractures. The risk for fracture malunion is considerably increased in such patients, the pathomechanisms being poorly understood. Thoracic trauma causes regional alveolar hypoxia and, subsequently, hypoxemia, which in turn triggers local and systemic inflammation. Therefore, we aimed to unravel the role of oxygen in impaired bone regeneration after thoracic trauma. We hypothesized that short-term breathing of 100% oxygen in the early post-traumatic phase ameliorates inflammation and improves bone regeneration. Mice underwent a femur osteotomy alone or combined with blunt chest trauma 100% oxygen was administered immediately after trauma for two separate 3 hour intervals. Arterial blood gas tensions, microcirculatory perfusion and oxygenation were assessed at 3, 9 and 24 hours after injury. Inflammatory cytokines and markers of oxidative/nitrosative stress were measured in plasma, lung and fracture hematoma. Bone healing was assessed on day 7, 14 and 21. Thoracic trauma induced pulmonary and systemic inflammation and impaired bone healing. Short-term exposure to 100% oxygen in the acute post-traumatic phase significantly attenuated systemic and local inflammatory responses and improved fracture healing without provoking toxic side effects, suggesting that hyperoxia could induce anti-inflammatory and pro-regenerative effects after severe injury. These results suggest that breathing of 100% oxygen in the acute post-traumatic phase might reduce the risk of poorly healing fractures in severely injured patients.

Effect of weight, height and BMI on injury outcome in side impact crashes without airbag deployment

A comprehensive analysis is performed to evaluate the effect of weight, height and body mass index (BMI) of occupants on side impact injuries at different body regions. The accident dataset for this study is based on the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) for accident year 2000-08. The mean BMI values for driver and front passenger are estimated from all types of crashes using NASS database, which clearly indicates that mean BMI has been increasing over the years in the USA. To study the effect of BMI in side impact injuries, BMI was split into three groups namely (1) thin (BMI<21), (2) normal (BMI 24-27), (3) obese (BMI>30). For more clear identification of the effect of BMI in side impact injuries, a minimum gap of three BMI is set in between each adjacent BMI groups. Car model years from MY1995-1999 to MY2000-2008 are chosen in order to identify the degree of influence of older and newer generation of cars in side impact injuries. Impact locations particularly side-front (F), side-center (P) and side-distributed (Y) are chosen for this analysis. Direction of force (DOF) considered for both near side and far side occupants are 8 o'clock, 9 o'clock, 10 o'clock and 2 o'clock, 3 o'clock and 4 o'clock respectively. Age <60 years is also one of the constraints imposed on data selection to minimize the effect of bone strength on the occurrence of occupant injuries. AIS2+ and AIS3+ injury risk in all body regions have been plotted for the selected three BMI groups of occupant, delta-V 0-60kmph, two sets (old and new) of car model years. The analysis is carried with three approaches: (a) injury risk percentage based on simple graphical method with respect to a single variable, (b) injury distribution method where the injuries are marked on the respective anatomical locations and (c) logistic regression, a statistical method, considers all the related variables together. Lower extremity injury risk appears to be high for thin BMI group. It is found that BMI does not have much influence on head injuries but it is influenced more by the height of the occupant. Results of logistic analysis suggest that BMI, height and weight may have significant contribution towards side impact injuries across different body regions.

Comparing the effects of age, BMI and gender on severe injury (AIS 3+) in motor-vehicle crashes

BACKGROUND

The effects of age, body mass index (BMI) and gender on motor vehicle crash (MVC) injuries are not well understood and current prevention efforts do not effectively address variability in occupant characteristics.

OBJECTIVES

(1) Characterize the effects of age, BMI and gender on serious-to-fatal MVC injury. (2) Identify the crash modes and body regions where the effects of occupant characteristics on the numbers of occupants with injury is largest, and thereby aid in prioritizing the need for human surrogates that represent different types of occupant characteristics and adaptive restraint systems that consider these characteristics.

METHODS

Multivariate logistic regression was used to model the effects of occupant characteristics (age, BMI, gender), vehicle and crash characteristics on serious-to-fatal injuries (AIS 3+) by body region and crash mode using the 2000-2010 National Automotive Sampling System (NASS-CDS) dataset. Logistic regression models were applied to weighted crash data to estimate the change in the number of annual injured occupants with AIS 3+ injury that would occur if occupant characteristics were limited to their 5th percentiles (age≤17 years old, BMI≤19kg/m(2)) or male gender.

RESULTS

Limiting age was associated with a decrease in the total number of occupants with head [8396, 95% CI 6871-9070] and thorax injuries [17,961, 95% CI 15,960-18,859] across all crash modes, decreased occupants with spine [3843, 95% CI 3065-4242] and upper extremity [3578, 95% CI 1402-4439] injuries in frontal and rollover crashes and decreased abdominal [1368, 95% CI 1062-1417] and lower extremity [4584, 95% CI 4012-4995] injuries in frontal impacts. The age effect was modulated by gender with older females more likely to have thorax and upper extremity injuries than older males. Limiting BMI was associated with 2069 [95% CI 1107-2775] fewer thorax injuries in nearside crashes, and 5304 [95% CI 4279-5688] fewer lower extremity injuries in frontal crashes. Setting gender to male resulted in fewer occupants with head injuries in farside crashes [1999, 95% CI 844-2685] and fewer thorax [5618, 95% CI 4212-6272], upper [3804, 95% CI 1781-4803] and lower extremity [2791, 95% CI 2216-3256] injuries in frontal crashes. Results indicate that age provides the greater relative contribution to injury when compared to gender and BMI, especially for thorax and head injuries.

CONCLUSIONS

Restraint systems that account for the differential injury risks associated with age, BMI and gender could have a meaningful effect on injury in motor-vehicle crashes. Computational models of humans that represent older, high BMI, and female occupants are needed for use in simulations of particular types of crashes to develop these restraint systems.

[Diagnosis and treatment of cervicothoracic injuries]

It analyzed the diagnosis and treatment results of 123 patients with cervicothoracic injuries for 21 years. The frequency of cervicothoracic injuries among all patients with cervical injuries was 5.7%. Preoperative and postoperative diagnosis included radial and endoscopic methods. The complications rate was 43.6%. The most severe complications were observed in patients with delayed diagnosis of trachea and esophagus injuries.

Emergency management of blunt chest trauma in children: an evidence-based approach

Pediatric trauma is commonly encountered in the emergency department, and trauma to the head, chest, and abdomen may be a source of significant morbidity and mortality. As children have unique thoracic anatomical and physiological properties, they may present with diagnostic challenges that the emergency clinician must be aware of. This review examines the effects of blunt trauma to the pediatric chest, as well as its relevant etiologies and associated mortality. Diagnostic and treatment options for commonly encountered injuries such as pulmonary contusions, rib fractures, and pneumothoraces are examined. Additionally, this review discusses rarely encountered--yet highly lethal--chest wall injuries such as blunt cardiac injuries, commotio cordis, nonaccidental trauma, and aortic injuries.

[Medico-social characteristics of patients with septic complications after penetrating thoracic wounds]

232 cases of septic complications after penetrating thoracic injury were analyzed. All patients were divided into groups according to the injury mechanism and inhabitancy. Patients with medico-social deviations, as well as patients with hemocontact infections, mental insanity and social deviations were marked out. 75% of patients were reported to have any medico-social deviations. Among them the distributing was as follows: persons with no fixed abode (100%), women (91%), patients over 50 years (86.2%) and patients after knife thoracic injury (77.4%). Among patients with hemocontact infection the majority were incomers from the near-abroad countries (37%), victims of assault (20%) and patients aged 31-40 years (18.4%).

Fuzzy approach for reducing subjectivity in estimating occupational accident severity

Quantifying or, more generally, estimating the severity of the possible consequences of occupational accidents is a decisive step in any occupational risk assessment process. Because of the lack of historic information (accident data collection and recording are incipient and insufficient, particularly in construction) and the lack of practical tools in the construction industry, the estimation/quantification of occupational accident severity is a notably arbitrary process rather than a systematic and rigorous assessment. This work proposes several severity functions (based on a safety risk assessment) to represent biomechanical knowledge with the aim of determining the severity level of occupational accidents in the construction industry and, consequently, improving occupational risk assessment quality. We follow a fuzzy approach because it makes it possible to capture and represent imprecise knowledge in a simple and understandable way for users and specialists.

[Endovideosurgical interventions for thoracoabdominal wounds]

The authors presented results of examination and treatment of 1347 patients with different injuries of the chest and abdomen. Medico-diagnostic measures used in treatment of such kind of patients with rational application of endovideosurgical techniques such as thoraco- and laparoscopy are described which proved to be the final kind of operative treatment.

Sensitivity of the WorldSID 50th and ES-2re Thoraces to Loading Configuration

An ideal injury criterion should be predictive of the risk of injury across the range of loading conditions where it may be applied. The injury risk curve associated with this criterion should be applicable to all loading conditions. With respect to side impact, the injury risk curve should apply to pure lateral or oblique loading by rigid and padded walls, as well as airbags. Trosseille et al. (2009) reported that the number of fractured ribs was higher in pure lateral impact than in forward oblique interaction with an airbag. A good dummy criterion should be able to account for this difference. To evaluate various injury criteria with the WorldSID 50 th and ES-2re dummies, the dummies were exposed to the same airbag loadings as the PMHS. The criteria measured in the dummy tests were paired with the rib fractures from the PMHS tests. Regarding the effect of configuration, results of sled tests with the 50 th percentile WorldSID (Petitjean, 2009) and ES-2re (Kuppa, 2003) have been paired with injuries found in the PMHS tested in the same conditions. The relationships obtained were compared with the relationships established in the same way for the subjects loaded in the airbag tests. Comparing the lateral and oblique lateral loading conditions, both the WorldSID and the ES-2re exhibited differences in peak lateral deflection of their ribs that were consistent with the different number of rib fractures for PMHS subjected to these loading conditions. For each dummy, the risk of rib fractures could be assessed from one injury risk curve, regardless of the loading angle. Furthermore, the same injury risk curve can be used to assess the risk of rib fractures from sled tests and airbag loading. However, because the WorldSID deflection measurements differed in the rigid and padded sled tests, it is recommended that the dummy's sensitivity to padding be further assessed prior to adopting injury risk curves for WorldSID. Rib deflections of the ES- 2re were not sensitive to padding. Finally, VC should not be considered as a valid criterion to assess the risk of rib fractures.

[Classification of tangential (thoracoabdominal) gunshot wounds]

79 patients with gunshot bullet wounds of thorax and abdomen were observed. Thoracoabdominal wounds were observed in 37 cases, abdominothoracic wounds - in 35 cases. 7 cases of longitudinal non-penetrating thoracic and abdominal wounds were particularly investigated. The wound canal started in soft tissues of anterior thoracic wall and passed through the thick layers of anterior abdominal wall to the perineum. Lateral blow due to high kinetic energy of bullets caused severe damage of the ribs, lungs and abdominal organs without diaphragm lesions.

[Surgery of modern combat damage of breast]

The article presents an overall estimate of experience of surgical treatment of ballistic penetrating wounds of bosom of 1920 wounded in Afgan war (1979-1989) and 367 wounded during the armed conflict on Northern Caucasus (1994-1996). Ballistic penetrating wounds of bosom in modern military conflicts are characterized by high mortality on battle field, achieving 30%. In conditions of heavy wound the choice of optimum surgery tactics poses several difficulties, and due to it indications urgent thoracotomy are often increased. Multistage system of delivery of health care, used in Afgan war, during battle actions on the Northern Caucasus was changed to 2-stage system, where wounded persons during 1-2 hours were delivered to a specialist in multiprofile base hospital, placed in a combat zone. Effectuating of thoracocentesis with a closed drainage of pleural space stays the most popular and extended method of treatment ballistic penetrating wounds of bosom, used by 85% of wounded persons. Using of operative videothoracoscopia in 1995 during delivery of emergency specialized surgical medical care to wounded persons in forward base hospital leaded to decreasing of frequency of using of large thoracotomy to 2,4%. There was overviewed the modern conception of surgical treatment of patients, having bosom wounds.

Emergency evaluation, imaging, and classification of thoracolumbar injuries

Thoracolumbar injuries usually are the result of high-energy trauma and frequently are associated with multisystem concomitant injuries. Whenever a thoracolumbar injury is suspected, a prompt and thorough evaluation should be performed in the emergency department, using the guidelines of the American College of Surgeons and including full primary and secondary surveys as well as resuscitation. Protection of the spine and spinal cord is of paramount importance during the initial evaluation. A careful and complete neurologic examination is warranted as part of the secondary survey. Plain radiography, CT, and MRI studies are useful in diagnosing and classifying thoracolumbar injuries. At many trauma centers, CT has become the standard imaging technology for the initial evaluation of the spine. MRI is particularly accurate in detecting injury to the posterior ligamentous complex of the thoracolumbar spine. Classification and treatment of thoracolumbar injuries are controversial. The comprehensive, reproducible classification system of the Spine Trauma Study Group has prognostic significance and can guide treatment decisions. The Thoracolumbar Injury Classification and Severity scale classifies thoracolumbar injures based on three pivotal characteristics: the morphology of the injury, the integrity of the posterior ligamentous complex, and the patient's neurologic status. A total severity score is used in conjunction with the classification system to determine the treatment.

Effects of shoulder belt limit forces on adult thoracic protection in frontal collisions

Three-point restraint systems have been installed in vehicles since the early 1960s. However, it wasn't until the automatic protection rule became effective for 1987 Model Year vehicles that manufacturers began installing 3-point restraints with force-limiting shoulder belts and frontal airbags for the driver and right front passenger. This was the first time that all vehicle manufacturers had to certify that their cars would meet the 50th percentile, adult male protection requirements in the 48 km/h frontal, rigid-barrier test specified in FMVSS 208. To assess the effectiveness of these certified 3-point restraint systems, a search was done of the 1988-2005 NASS data for 3-point belted, front outboard-seated, adult occupants in passenger vehicles that were equipped with airbags and that were involved in frontal, towaway collisions. These data showed that i) half of the occupants with AIS > or = 3 chest injuries were in collisions with a DeltaV < or = 40 km/h; ii) for older occupants (50+ years), half experienced their chest injuries at DeltaVs < or = 34 km/h; and iii) the chest injury rate for the older occupants was more than double that of the younger occupants. An analysis was done to estimate the effectiveness of various levels of shoulder belt limit loads in reducing chest injuries to older occupants. The result of the analysis indicated that a 2.5 kN shoulder belt limit load would substantially reduce shoulder belt-induced AIS > or = 3 chest injuries in 99 percent of frontal collisions to all adult, front outboard seated occupants whose normalized bone strengths are greater than 0.4.

Prognostic analysis of patients with blunt chest trauma admitted to an intensive care unit

BACKGROUND/PURPOSE

Predictors of mortality in blunt chest trauma patients have mostly been studied by univariate analysis. This study used multivariate analysis to identify the independent predictors in these patients admitted to a surgical intensive care unit (SICU).

METHODS

One hundred and twenty-seven blunt thoracic trauma patients consecutively admitted to a SICU were enrolled and evaluated by quantified injury severity scores including Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), Therapeutic Intervention Scoring System (TISS) and Injury Severity Score (ISS). Incidence of thoracic and extrathoracic injuries, transfusion and resuscitation volumes, PaO2/FIO2 ratio and the presence of shock were also evaluated.

RESULTS

In the univariate analysis, clinical characteristics of survivors (n = 113) and non-survivors (n = 14) at admission were similar regarding age, gender, incidence of intrathoracic injuries and extrathoracic injuries and ISS. The following variables were higher for non-survivors: APACHE II score, 19 +/- 6 vs.12 +/- 6 (p = 0.002); TISS points, 39 +/- 13 vs. 29 +/- 15 (p = 0.019); the presence of shock, 93% vs. 42% (p < 0.001). Non-survivors also had lower GCS, 8 +/- 5 vs.14 +/- 3 (p < 0.001), and PaO2/FIO2 ratio, 211 +/- 124 vs. 340 +/- 145 (p = 0.002). Of the shock patients, they had significantly higher volumes of blood transfusions and fluid resuscitations (p < 0.001) and a higher incidence of abdominal injuries (p = 0.031) and mortality rate (p < 0.001) than non-shock patients. Multivariate logistic regression analysis identified three independent risk factors of mortality: GCS (adjusted odds ratio [OR], 0.76; 95% confidence interval [CI], 0.64-0.89; p = 0.001), PaO2/FIO2 ratio (adjusted OR, 0.75; 95% CI, 0.58-0.98; p = 0.036) and shock (adjusted OR, 3.8; 95% CI, 1.24-11.69; p = 0.020).

CONCLUSION

Blunt chest trauma was usually associated with injuries of other organ systems, especially of the abdomen and head. Besides a decreased PaO2/FIO2, a lower GCS and a presence of shock were also independent prognostic predictors of mortality for these patients admitted to the ICU.

[Classification of mechanical injuries of the chest]

The authors propose morpho-functional and medico-strategy classification of mechanical injuries of the chest. In addition to traditional principles, special attention is given to concurrency, plurality, possible shocks, domination of the injuries as one of the basic concepts of wound dystrophy. The proposed classifications of mechanical injuries of the chest substantially supplement traditional principles, allow not only correct and full diagnosing and decision on the most rational strategy of treatment of patients with combined traumas, but also give a complex of reliable criteria for a scientific generalization of the results of clinical investigations.

Chest injury in victims of Bam earthquake

OBJECTIVE

To analyze the data of trauma patients with thoracic injury in the earthquake of Bam admitted to hospitals of Tehran University of Medical Science (TUMS) for better understanding the type and consequence of thoracic injuries in a major earthquake.

METHODS

After Bam earthquake registering 6.5 on the Richter scale, 526 trauma patients were admitted to hospitals of TUMS. Among them, 53 patients sustained thoracic injury.

RESULTS

This group was composed of 21 females (39.6%) and 32 males (60.4%). Fifteen patients (28.3%) had isolated chest injuries. Rib fracture (36.4%) was the most common injury in our patients and haemo/pneumothorax (25.5%) followed. Superficial injury was the most common accompanying injury. Multiple-trauma patients with chest injury had higher injury severity score (ISS) versus patients with isolated chest injury (P=0.003).

CONCLUSIONS

Chest wall injuries and haemo/pneumothorax comprise a considerable number of injuries in survival victims of earthquakes. Consequently, the majority of these patients can be treated with observation or tube thoracostomy. We should train and equip the health workers and members of rescue teams to treat and manage these patients in the field.

Classification and management of chest trauma

OBJECTIVE

To classify the predominant pattern of injuries following blunt and penetrating chest trauma and to assess the adequacy of treatment strategies, complications and mortality associated with such injuries.

DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

Surgical Unit I, Holy Family Hospital, Rawalpindi, from December 2000 to December 2003.

PATIENTS AND METHODS

One hundred consecutive patients with thoracic trauma either blunt or penetrating, admitted in the ward were evaluated. Their injuries were classified, treatment strategies outlined and complications and mortality were documented on a specially-designed proforma.

RESULTS

Out of the 100 patients presenting in emergency, 44% presented with blunt and 56% with penetrating trauma. Pneumothorax was detected in 39% of the patients, hemopneumothorax in 29%, hemothorax in 12%, flail chest in 9 %. Two had involvement of the heart and major vessels, 4 % had injury to the diaphragm and 5 % had multiple trauma. During treatment, 3% of all the patients were managed conservatively, 83% of patients required chest intubations, 6% needed ventilatory support and 8 % required thoracotomy. Complications were experienced in 28% of the patients of which 9% had pneumonias, 14% empyema and 5 % suffered from wound infections. The overall mortality was 7 %.

CONCLUSION

This series showed the pattern of injuries following blunt and penetrating chest trauma. Furthermore, it was found that chest intubation and simple resuscitation was adequate for majority of the cases.

[Shotgun injuries--epidemiological and clinical aspects]

Shotgun injuries constitute an increasing surgical problem as they frequently lead to severe trauma disease and even to death. These injuries are mainly diagnosed in young people and are localized in limbs. Human life is in danger in case of shotgun injuries of the head (CNS), abdominal and thoracic cavities. Prognosis is worse in multiple shotgun lesions. The dominating cause of death in shotgun victims is hemorrhagic shock. Patient's life is potentially in a real danger and necessitates precise diagnostic and therapeutic management in the early stages following shotgun trauma, in the operating room and in the postoperative phase.

The Evaluation of Casualties from Operation Iraqi Freedom on Return to the Continental United States from March to June 2003

BACKGROUND

Most seriously wounded US Army casualties from the Iraqi theater of operations come through Walter Reed Army Medical Center on their return to the United States. General surgery and orthopaedic surgery services have developed a multidisciplinary team approach to triage and treatment of incoming casualties.

STUDY DESIGN

Prospective database of returning casualties to Walter Reed Army Medical Center from Operation Iraqi Freedom (OIF) from March 1 to July 1, 2003.

RESULTS

Of 294 casualties seen, 119 were triaged to inpatient status and treated within 1 hour of arrival; mean age 26.6 +/- 6.2 years (range 23 to 37). Time from original battlefield injury was a mean of 8 days (range 3 to 28 days). Forty-six (39%) sustained gunshot wounds, 37 (31%) sustained blast and shrapnel injuries, and 41 (34%) had blunt/motor vehicle collision mechanisms. There were a total of 184 wounded locations in these 119 casualties; of these, there were 29 head and neck, 25 chest, 20 abdomen, 74 lower extremity, and 36 upper extremity. Twenty-eight casualties (23%) required emergent surgical procedures on the night of arrival. Another 30 (25%) required an urgent surgical procedure within 48 hours of arrival.

CONCLUSIONS

Followup surgical procedures were urgently or emergently required in 43% of admitted battlefield casualties from OIF on transfer to Level V care in the continental United States. The injury pattern of wounds from this engagement is described. The Walter Reed Army Medical Center system of incoming battlefield casualty evaluation using multidisciplinary teams is successful in expediting care and ensuring evaluation of the full range of potential injuries.

Detection of alveolar epithelial injury by99mTc-DTPA radioaerosol inhalation lung scan following blunt chest trauma

DTPA clearance rate is a reliable index of alveolar epithelial permeability, and is a highly sensitive marker of pulmonary epithelial damage, even of mild degree. In this study, 99mTc-DTPA aerosol inhalation scintigraphy was used to assesss the pulmonary epithelial membrane permeability and to investigate the possible application of this permeability value as an indicator of early alveolar or interstitial changes in patients with blunt chest trauma. A total of 26 patients was chest trauma (4 female, 22 male, 31-80 yrs, mean age; 53+/-13 yrs) who were referred to the emergency department in our hospital participated in this tsudy. Technetium-99m diethylene triamine pentaacetic acid (DTPA) aerosol inhalation scintigraphy was performed on the first and thirtieth days after trauma. Clearance half times (T1/2) were calculated by placing a mono-exponential fit on the curves. Penetration index (PI) was calculated on the first-minute image. On the first day, mean T1/2 value of the whole lung was 63+/-19 minutes (min), and thirtieth day mean T1/2 value was 67+/-21 min. On the first day, mean PI values of the lung and 30th day mean PI value were 0.60+/-0.05, and 0.63+/-0.05, respectively. Significant changes were observed in radioaerosol clearance and penetration indices. Following chest trauma, clearance of 99mTc-DTPA increased owing to breakdown of the alveolar-capillary barrier. This increase in the epithelial permeability of the lung appears to be an early manifestation of lung disease that may lead to efficient therapy in the early phase.

[Traumatic lung injury]

Pulmonary injuries include a wide variety of clinical conditions. Most patients with blunt chest trauma can be managed with conservative treatment. Only about 10 to 15% of patients with severe chest injuries require major thoracotomy. Management of pulmonary contusion, pulmonary laceration, pneumothorax or hemothorax by oxygen inhalation, respirator assist and chest drainage can usually result in complete recovery. However, pulmonary injuries sometimes lapse into fatal condition if they are improperly treated. Open thoracotomy is required in cases with persistent massive air leakage or massive bleeding with the use of chest drainage. It is crucial to evaluate the extent and severity of the injuries based on chest X-ray and computed tomography (CT) findings for the proper initial treatment in patients with pulmonary injuries.

Multidetector Computed Tomography and Blunt Thoracoabdominal Trauma

Computed tomography has had an increasing role in the evaluation of patients after blunt trauma. Important findings in thoracic trauma include acute traumatic aortic injury, pneumothorax, hemothorax, pulmonary contusions and lacerations, mediastinal hematoma, and diaphragmatic rupture. The solid abdominal viscera may lacerate; infarct; or suffer vascular, ductal, or pyelocalyceal disruption. The bladder and intestines may rupture. In abdominal pelvic trauma, the direction of applied force often results in an identifiable constellation of injuries. This article reviews how multidetector computed tomography (MDCT) is used in the trauma patient. Technical advances of increased cephalocaudad coverage speed and improved z-axis resolution intrinsic to MDCT, together with effective contrast utilization, make MDCT invaluable in the setting of trauma.