[Epidemiological analysis of the morbidity from suppurative-septic infections in a trauma center and orthopedic hospital]

Organizational measures, surgical techniques and surgical activity have proved to affect the morbidity rate of suppurative septic infections. Gram-negative bacilli have been shown to cause suppurative septic infections mostly as the result of superinfection.

Ineffectiveness of the trauma score and the CRAMS scale for accurately triaging patients to trauma centers

Both the Trauma Score (TS) and the CRAMS scale have been advocated for field triage of trauma victims to trauma centers. To determine which scale best serves this purpose, both scores were calculated by computer for 5,130 trauma cases in our statewide computer file of ambulance rescue runs from 1981 through 1983. A total of 3,231 patients (63%) were treated in the ED and released; 1,857 (36.2%) were admitted to the hospital (202 of whom were transferred directly from the ED to the operating room [OR] for immediate operation); and 42 (0.8%) were DOA or died in the ED. Major trauma was defined as a TS of 12 or less or a CRAMS scale of 8 or less. Both scales correctly identified as major trauma all patients who were DOA or died in the ED. The TS identified as major trauma more patients admitted to the hospital than did the CRAMS scale (33% vs 21%; P less than .0001). The TS identified as major trauma more patients transferred from the ED to the OR than did the CRAMS scale (37% vs 21%; P less than .002). Both scales failed to identify as major trauma almost two out of three patients brought directly from the ED to the OR. The paramedics', or emergency medical technicians' qualitative judgements about injury severity, reflected in their coding injuries as life- or limb-threatening, was almost as good (more than 90% sensitive and specific) as either score (100% sensitive and specific) in identifying patients who died, and was better in identifying patients sent from the ED to the OR.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of critically injured patients treated at Level I trauma centers versus full-service community hospitals

Critically injured patients were identified by a CRAMS (circulation, respiration, abdomen, motor, speech) score of 6 or less while still in the field. They were prospectively followed as they received their care at the nearest medical facility according to the then-existing district Emergency Medical Services protocols. Those cared for by Level I trauma centers had a significantly reduced mortality rate compared to those treated at the other large full-service community hospitals. The commitment to Level I trauma care improves outcome of the critically injured, and field triage of the critically injured patient to these centers is indicated.

Evaluation of possible patient survival in a mock airplane disaster

A mock disaster at Orange County's John Wayne Airport provided a basis for examining correct triage of patients and their arrival time for definitive care. The ability to triage critically injured patients in a timely fashion was found to be only slightly better than chance routing. For most of the seriously and critically injured patients, it took more than 1.5 hours to reach the hospital. Advanced life support with intravenous fluid resuscitation available on the scene would probably reduce the mortality of possible disaster victims by 50 percent. These problems are presently being addressed. In future disaster exercises, the present type of evaluation could be used to judge improvement in possible patient triage and survival.

[1 year of traumatologic activity in the Emergency Orthopedic Unit of the G. Pini Institute (statistical data)]

The Authors have considered one year's traumatological activity in the G. Pini Institute's S.T.U. by drawing some statistical results. The data refer to the traumas ambulatorium-treated and to all those which required hospitalization during 1979. The total of the traumas surveyed in 1979 is 33335 of which 1812 required urgent hospitalization (5.44%). Previous statistics show 6679 patients in 1961 and 3209 in 1956. We can realize how these figures have increased in a few years (and in this abstract the different kinds of traumas are also highlighted) without any adjustment to the existing structures and equipment which are completely insufficient.

Advances in the management of closed head injury

The management of closed head injury has improved recently. Mortality rates for severe trauma are lower and outcomes are more favorable. Advances are related to improved diagnostic tools, such as computerized tomography scanning, aggressive supportive care, standardized evaluation criteria, and program-oriented rehabilitation. Further progress depends on sophisticated triage, including delivery of the patient to an experienced head-injury unit, as well as successful manipulation of cellular and subcellular processes to maintain brain homeostasis. Recent developments in the pathophysiology, diagnosis, and treatment of closed head injury are reviewed, and promising research avenues are discussed.

Identification and treatment of infections in multiply traumatized patients

Trauma is the leading cause of death among young adults, and infection is a leading complication in multiply traumatized patients. All antibiotic use and all infections among 1,009 patients admitted to the Maryland Institute for Emergency Medical Services Systems over a six-month period were reviewed. The vast majority of patients had sustained high-speed automobile trauma and had blunt injuries. All antibiotics were given by the infectious diseases consultants under predetermined protocols. During this time period, 175 infections and 76 bacteremias were identified. Thirty-three percent of the antibiotic use was for prophylaxis. Prophylactic antibiotics were used for open fractures, in which a cephalosporin was used; for abdominal trauma, in which an aminoglycoside and clindamycin or cefoxitin alone was used; and for penetrating open fractures of the oral cavity, in which penicillin was used. As therapy, the aminoglycosides were used in 25 percent, the cephalosporins in 21 percent, the penicillins in 39 percent, and other antibiotics in 15 percent of the cases. The organisms identified as causing infection were Staphylococcus aureus (25 percent), Escherichia coli (18 percent), Enterobacter species (17 percent), Pseudomonas species (12 percent), and Klebsiella species (11 percent). The sites of infections were primary bacteremia (11 percent), vascular lines (21 percent), the central nervous system (3 percent), the lower respiratory tract (13 percent), the paranasal sinuses (6 percent), the urinary tract (19 percent), surgical wounds (11 percent), the abdomen (7 percent), and other sites (9 percent). More than 82 percent of the infections that occurred were nosocomial in origin and were related to the various procedures used for monitoring and therapy in these critically ill patients. Infections of the abdominal cavity and the lower respiratory tract accounted for eight of the 10 infection-related deaths in these patients.

Emergency thoracotomy in an urban community hospital: initial cardiac rhythm as a new predictor of survival

Several authors have reviewed their experience with emergency thoracotomy in the university hospital setting. However, physicians in urban community hospitals are treating increasing numbers of patients who require emergency thoracotomy. To compare such experiences, the charts of all patients who underwent emergency thoracotomy in an urban community hospital during the years 1981 and 1982 were reviewed. In addition, the presenting cardiac rhythm was evaluated as a potential new prognosticator for survival in these patients. Forty-seven thoracotomies were performed during the two-year period. Thirty-nine (83%) were for penetrating trauma, of which 31 (66%) were for gunshot wounds and eight (17%) were for stab wounds. Eight patients (17%) underwent thoracotomy for blunt trauma. Of the 13 patients (28%) who survived and were discharged from the hospital, eight (17% of the total) had no neurological deficit. Twenty-five patients (53%) presented in sinus rhythm, 23 in sinus tachycardia, and two in normal sinus rhythm. All survivors beyond the operating room were in this group (P less than 0.001). Twenty-two patients (47%) presented in bradyasystolic rhythms, including bradycardia (four patients), agonal ventricular rhythm (five patients), ventricular fibrillation (three patients), and asystole (ten patients). None of these patients survived. The outcome data for community-hospital emergency thoracotomy are comparable with those of university centers where similar reviews were undertaken. The presenting cardiac rhythm is an accurate prognosticator of survival in patients undergoing emergency thoracotomy. Patients who present with sinus rhythms deserve aggressive resuscitation and emergency thoracotomy. Emergency thoracotomy does not improve the uniformly poor prognosis in patients presenting in bradyasystolic rhythms.

Endogenous opioid activity in clinical hemorrhagic shock

Plasma beta-endorphin, cortisol and total opioid-like activities were measured upon arrival at the hospital in ten patients with extensive trauma and in a state of shock and 11 patients with minor injury. Patients in a state of shock had significantly (p less than 0.01) higher mean plasma beta-endorphin immunoreactivity than patients with minor trauma (128.8 +/- 24.8 picomolars versus 31.7 +/- 5.6 picomolars). There were no significant intergroup differences in the mean plasma cortisol concentration (27.7 +/- 4.7 micrograms per deciliter versus 20.6 +/- 2.7 micrograms per deciliter) or opioid ligand activity (2.28 +/- 0.62 nanomolars versus 3.17 +/- 0.99 nanomolars). These data are consistent with the hypothesis that certain endogenous opioids may be physiopathologic factors in hemorrhagic shock but provide no proof of a cause and effect relationship.

Traumatic cardiac arrest: scope of paramedic services

The challenge of the 1960s to ambulance care provision was the stimulus for the emergence of prehospital advanced life support (ALS) being provided by paramedic personnel. While services for cardiac disease have been accepted, paramedic activities for the trauma victim continue to be a concern for many trauma surgeons. The capability and success rate of treatment, and the time spent at the scene and during transport to the hospital have raised questions about the overall need for paramedic services. Our study period was from January 1, 1981, to December 31, 1982, and it covered 95 clinically dead trauma victims who were first seen and subsequently treated by paramedics working in a medically controlled emergency medical services system. Endotracheal intubation was successful in 81 of the patients (85%). Esophageal obturator airway use was viewed as unsuccessful intubation. Intravenous (IV) access utilizing 16-gauge angiocaths was placed successfully by a peripheral or jugular vein in 70 patients (74%). Thirty-three patients averaged 860 mL volume infusion (30 to 3,000 mL). Average scene time was 22 minutes. Scene time of patients with unsuccessful IV and endotracheal intubation was 14 minutes (P = .07). Fourteen patients (14.7%) were admitted to the operating room or intensive care unit. Only three of the study group (3.2%) survived.

Empirical development and evaluation of prehospital trauma triage instruments

The field identification of the patients who should be taken to trauma centers is a major problem of trauma care. This study appears to be the first to use multivariate analysis to systematically design a field triage instrument and to evaluate its performance in terms of a meaningful and plausible criterion for which patients ought to be treated at trauma centers. Four new triage instruments were created and their performance compared to that of two existing measures, the Trauma Score and the CRAMS scale. The new measures appear to perform better than the best of existing instruments tested, although independent validation is necessary. The one purely physiologic instrument tested appeared to be inferior to instruments that included anatomic and historic as well as physiologic indices. Simple checklists performed approximately as well as weighted scales. No instrument was found to be high in both sensitivity and positive accuracy.

A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck

Over-all, the results of this review suggest that mandatory exploration for penetrating wounds of the neck may be safely supplanted by selective management. The basis for this conclusion includes: 1, most neck wounds were not associated with significant injury; 2, routine exploration did not obviate the possibility of missed injuries; 3, negative findings at exploration were associated with a number of complications; 4, hospital stay for patients with negative neck exploration results was similar to those with positive exploration findings, and 5, it appears that selective management should not increase the need for special diagnostic studies. Patients with clearly positive clinical findings indicating visceral neck injury should undergo operative exploration. Those with a negative clinical examination should be closely observed. Contrast roentgenographic and other special studies should be reserved for those with equivocal clinical findings or who have a change in clinical status under observation.

Blunt liver trauma at the Sunnybrook Regional Trauma Unit

Between June 1, 1976 and Mar. 31, 1983, the Sunnybrook Medical Centre Regional Trauma Unit in Toronto, Ont., admitted 145 patients with liver trauma; of these, 141 (97%) had sustained blunt liver trauma. Of 113 patients who underwent open peritoneal lavage, 112 had a true-positive lavage. Resuscitation was successful in 137 patients and 134 of these underwent laparotomy. Seventy-nine (59%) of the 134 patients required only minor surgical treatment; the other 55 (41%) required major surgical procedures. The overall mortality was 32% (47 of 145). Eight patients died during resuscitation but only one of them died of liver hemorrhage. Of the 39 patients who died after admission, the cause of death was head injury in 22, while 6 died of liver hemorrhage and 11 of other causes. Overall, liver hemorrhage was the cause of death in 15% of cases (7 of 47).

Analysis of peritoneal lavage parameters in blunt abdominal trauma

Peritoneal lavage is the most valuable diagnostic modality presently available for the evaluation of patients with blunt abdominal trauma. A retrospective review of 523 patients who underwent open peritoneal lavage for blunt abdominal trauma over a 3 1/2-year period revealed serious intra-abdominal pathology in 83% of patients undergoing laparotomy with RBC lavage counts in the range of 20,000 to 100,000 cells/mm3, a level considered by many authors to be negative or indeterminate. Two patients with isolated small bowel perforations had an elevated amylase level as the only measured abnormality. The data indicate that the standard guidelines for RBC positivity (positive count greater than 100,000 cells/mm3 and indeterminate count 50,000 to 100,000 cells/mm3) result in missed intraperitoneal injuries in a large percentage of patients and therefore require reevaluation. Lavage amylase determinations, previously stated to be costly and of insignificant yield, should be performed on patients whose lavage would otherwise be considered negative by RBC and WBC counts.

Prospective evaluation of the CRAMS scale for triaging major trauma

In order to effectively implement a community-wide trauma system, a mechanism of field triage is required. This process of triage should be simple to use and should accurately identify patients who are in need of level I trauma facility care. It should also allow the less critically injured to be cared for at the local hospital of their choice or at the nearest community hospital. The CRAMS (Circulation, Respiration, Abdomen, Motor, Speech) scale was prospectively studied as a potential triage tool by using it to score patients in the field and then comparing their scores to their emergency room dispositions and final outcomes. The CRAMS scale was easy to apply and accurately identified both the critically injured who should be triaged to a Level I center and the less critically injured who can be adequately cared for by Level II and III centers.

Self-inflicted gunshot wounds: lethality of method versus intent

The authors studied 30 patients treated at an urban trauma center for self-inflicted gunshot wounds, most or all of which would have been fatal without emergency treatment. About half the patients had used alcohol or drugs immediately before wounding themselves, and slightly more than half had experienced interpersonal conflict just before the incident. Thirteen of the 30 were women. Only nine were given diagnoses of major depressive episode or dysthymia; none of the patients had written suicide notes. These data indicate that the reported demographic and clinical characteristics of impulsive, violent self-injury must be reexamined.

Acute spinal cord injury patients--who cares?

Pertinent aspects of the remarkable advances instituted and developed for the management of patients who have sustained serious spinal injuries are discussed in this communication, and the responsibilities of medical doctors and others who care for such patients is taken up in relation to some of the recent advances in our knowledge, both experimental, and clinical. There are new challenges in investigations and therapy to be considered, some of which are being somewhat precipitiously put into practice. In particular, early spinal operations, where certain closed or open reduction procedures are followed by some of the newer forms of vertebral column fixation, may cause complications. Also the apparent benefits from such techniques may not be achieved and a plea is made for careful well documented accounts to be assembled and where possible set out, using modern statistical methods, to be made by doctors treating such patients. The significance of a full understanding of the importance of modern rehabilitation techniques for spinal cord injury patients is stressed; and finally, the practical realisation of insurance claims and of possible medical litigation is mentioned.

Emergency department treatment of chest injuries

Injury to the chest accounts directly or indirectly for up to 50 per cent of deaths secondary to trauma. Eighty-five per cent of patients with chest injury may be managed by minor procedures available to the emergency physician. The indications for surgery in the remaining 15 per cent of patients with chest injury must be understood.

Impact of routine arteriography on management of penetrating neck injuries

We evaluated the impact of routine arteriography on the management of 105 patients with penetrating injuries to the neck and upper chest. Of 72 patients with bullet wounds and 33 with knife wounds, surgical exploration on an emergency basis was performed in three patients because of shock; the remaining 102 underwent aortic arch or selective arteriography. Surgical exploration was performed in 18 patients because of abnormal arteriograms and in 13 (10 with normal arteriograms) because of shock or suspected hemorrhage. Operative findings confirmed the angiographic interpretation in 26 of the 31 patients who were explored. The angiogram underestimated the arterial injury in two patients and failed to identify an associated venous injury in three. Seventy-two patients with negative arteriograms received expectant treatment without subsequent complications. Routine arteriography is integral to expeditious triage and accurate diagnosis of patients with brachiocephalic trauma. A negative study in almost 80% of patients permits safe nonoperative management, whereas a positive study allows the surgeon to plan his operative approach more judiciously. Endoscopic procedures are important adjuncts in selected patients.

Urban helicopter response to the scene of injury

Metropolitan Houston with a population of four million has the nation's poorest freeway system. Its two Level I trauma centers are adjacent within a centrally located freeway loop, therefore the city is ideally suited for a trauma scene helicopter transport service. During 1981 there were 577 flights to the scene of injury (blunt, 466; penetrating, 111). Flights were requested by 60 agencies (EMS, law enforcement, etc.). All flights were manned by a surgical resident and flight nurse. The flight distances ranged from 2 to 57 miles (average, 14.4). Three hundred six flights (53%) were within the city, including 59 (10.2%) within the freeway loop. In approximately one half of the flights, the initial responding EMS unit was a paramedic unit. The average time at the scene was 28 minutes. The overall mortality for trauma scene flights was 35.7% (206/577). Eighty-nine patients (15.1%) died at the scene and were not transported (initial median scene Trauma Score, 2). The mortality among transported patients was 24.0% (117/488). Twenty-nine patients died during attempted emergency-center resuscitation (initial median scene Trauma Score, 5). Eight-eight patients died after hospital admission (initial median scene Trauma Score, 10). Only 27 patients (5.5%) did not require hospitalization. Scene treatment (intubation, hyperventilation and, when appropriate, mannitol administration) was routinely initiated for patients with severe head injuries. Two hundred seventy-nine patients required cardiopulmonary resuscitation, tracheal intubation, chest-tube placement, or other invasive procedures. Based upon these resuscitative efforts and invasive procedures, a physician in attendance was deemed medically desirable for one half of the flights.(ABSTRACT TRUNCATED AT 250 WORDS)

Maximum survival in pediatric trauma: the ideal system

One hundred consecutive pediatric trauma deaths (0.01-18 yrs) were analyzed for their survival potential in an optimally functioning EMS/Trauma system in Mobile, Alabama (1980-1982). Thorough evaluation of all phases of care by paramedic run sheets, ER records, hospital records, and autopsy reports, revealed that 47/100 victims could have never survived due to the extreme nature of their injuries, and 53/100 victims had the potential of surviving if the EMS/Trauma system functioned optimally. Errors in care were identified in those cases deemed potentially salvageable. Identification phase errors were found in 79% of potentially salvageable victims. Field treatment errors occurred in 36%, transport errors in 23%, and definitive care errors in 17% of those considered to be potentially salvageable. By evaluating where in an EMS/Trauma system errors occur and then by correcting those errors, it should be possible to minimize the mortality rate in pediatric trauma.

Shock trauma

Trauma - accidental or intentional injury - is a major health and social problem. It is still the chief cause of death in people between the ages of 1 and 38 years. In the United States, the mortality due to trauma between the ages of 15 and 24 years increased by 13% from 1960 to 1978. During the same period, the mortality for people aged 25 to 64 years declined by 16%. Murders have increased from 8464 in 1960, to 26 000 in 1982. The overall death rate of American teenagers and young adults is 50% higher than that of their counterparts in Britain, Sweden and Japan. Trauma affects young, productive citizens, and the estimated costs for death, disability and loss of productivity exceed $230 million a day. The most tragic statistic is that at least 40% of the deaths are needless and preventable if better treatment and prevention programs were available. Trauma deaths that might be prevented are those due to motor vehicle accidents, homicide, burns, and alcohol and drug abuse. In this paper suggestions for prevention are made. They include improved crash worthiness of motor vehicles, revocation of drunk drivers' licences, use of devices that limit drunk drivers, increased tax on alcohol and random breathalyser tests, and the use of seat belts and motorcycle helmets. Control of hand-guns and burn characteristics of cigarettes could also reduce deaths. The problems and issues in trauma care can be divided into two broad categories: system and professional. System problems include prehospital care, in-hospital care, rehabilitation and prevention. Professional problems include education, research, economics, and quality.(ABSTRACT TRUNCATED AT 250 WORDS)

Nosocomial Hemophilus pneumonia in patients with severe trauma

In recent years, there have been increasing reports of Hemophilus pneumonia in adults. With few exceptions, these reports described Hemophilus as a cause of community acquired pneumonia. In the past three years, however, we have seen 15 instances of nosocomial Hemophilus pneumonia in patients with trauma who are intubated. This represented 11 per cent of the incidences of pneumonia that we diagnosed in this time period. The average age of the patient was 36 years and most patients had been in motor vehicle accidents. Six had received antibiotics and nine, steroids prior to their infection. Of note is that all incidences of Hemophilus pneumonia occurred within 11 days of hospitalization. This suggested to us that although the infections were clearly nosocomial, the organisms were probably not hospital acquired. Nevertheless, Hemophilus should be considered a potential cause of early pneumonia in the patients with trauma who are intubated.

Assessing the influence of non-treatment variables in a study of outcome from severe head injuries

An evaluation was made of the impact of non-treatment variables on severely injured head trauma patients. The principal findings were: 1) severity of injury was the best predictor of outcome; 2) patient's age had a statistically significant but marginally useful impact on outcome; 3) a regression analysis showed that duration of transport, up to 4 hours, had no impact on outcome; 4) time from accident to intubation had a marginal impact on outcome; and 5) one-way analysis of variance showed that mode of transportation, whether helicopter, ambulance, or other means had no impact on outcome.

Duodenal trauma: experience of a trauma center

In the past decade 93 patients with duodenal injury were treated at a trauma center. By chart review, the age, sex, mechanism of injury, time to initial exploration (and the reason for delay), laboratory results, associated injury, extent of duodenal injury, operative repair, use of drains and tube decompression, morbidity, and cause of death were tabulated in order to improve management of these injuries. Of 87 patients surviving until the time of operative repair 73% required no repair (four) or primary closure (59). The remainder had either resection with primary anastomosis (ten), diverticulization (12), or pancreaticoduodenectomy (two). All patients with penetrating trauma were immediately explored. Patients with blunt trauma were explored on the basis of the judgment of house staff and faculty. Overall mortality was 18%. Significant morbidity occurred in 49% of survivors. This urban experience was heavily weighted toward penetrating injury. In this group early death usually resulted from associated vascular injuries. Blunt duodenal injury was less frequently associated with immediate exsanguination. Mortality associated with blunt duodenal injury was usually the result of delayed diagnosis. In blunt duodenal trauma peritoneal lavage is not diagnostic and may often be misleading; in this series 50% of lavages were false negatives. Blunt duodenal trauma, particularly when combined with pancreatic injury or delayed repair, was a lethal combination. A high index of suspicion and aggressive diagnostic evaluation (CT contrast study/amylase) in the emergency department is required in equivocal cases to avoid morbidity and mortality.

The effect of advanced life support and sophisticated hospital systems on motor vehicle mortality

A mileage population death index (MPDI) was devised to compare the death rate from motor vehicle trauma in Florida counties. The MPDI was defined as the average death rate per one hundred million miles driven divided by the population of the particular county X 10(5). The resultant MPDI was correlated with the presence in a county of basic life support only and advanced life support. In addition, counties with large metropolitan hospitals which might possibly classify as Level I institutions were compared with other counties. A low MPDI was found to be highly correlated with the presence of an ALS system (p = 0.001). Counties with hospitals which might qualify as Level I also had a significantly lower MPDI (p = 0.04). We conclude that the presence of advanced life support and a sophisticated hospital is correlated with a significantly lower motor vehicle mortality.

Undergraduate education in the accident unit

The present system of undergraduate education in trauma has evolved over the past 15 years. As with orthopaedic teaching in Oxford (Dickson, Houghton & Duthie, 1979) an intensive 4-week course is provided for small groups of students. The subject is covered by personal teaching illustrated by practical problems together with a basis of seminars and tutorials.

Trauma mortality in Orange County: the effect of implementation of a regional trauma system

One hundred eighteen deaths from motor vehicle accidents were reviewed retrospectively to evaluate the effect of implementation of a regional trauma system. Fifty-eight deaths occurring prior to implementation and 60 occurring after were reviewed by teams of four physicians. Following implementation the proportion of potentially salvageable deaths dropped from 34% (20/58) to 15% (9/60) (P less than .02). Seven of the nine potentially salvageable deaths occurred in 13 patients treated in non-trauma facilities (54%), while only two potentially salvageable deaths occurred in 47 patients treated in trauma facilities (4%) (P less than .0002). The median age of patients dying of trauma rose from 22 to 27 years (P less than .04); the median Injury Severity Score rose from 42.5 to 52.0 (P less than .03). The 1981 death rate for vehicular trauma dropped to 13.93 per 100,000 population compared to a projected rate of 15.72 (P less than .03); the 1982 rate dropped to 12.37 compared to a projected rate of 15.80 (P less than .02). Implementation of a regional trauma system has resulted in significant improvements in trauma care and a reduction in the death rate from vehicular trauma.

A postmortem review of trauma mortalities--a comparative study

Two hundred two mortalities from blunt trauma from the Coroner's Office of Ontario were reviewed and compared to 102 mortalities seen at the Regional Trauma Unit at Sunnybrook Medical Centre, Toronto, and its 36 referring hospitals (EMSS). Nonpreventable deaths due to head injury were defined and excluded from review. This left 103 mortalities from the Coroner's Office and 52 from the EMSS. The average postmortem I.S.S. of patients dying in the Trauma Unit was 53, compared to 33 in patients treated outside the EMSS. Of EMSS patients 5.8% had an I.S.S. below their LD50, with 53% below their LD50 in the reference group. This postmortem review shows the advantages of an organized system of trauma management.

[Prevention of venous thrombosis in surgery of the lower limbs. Various phases of an experience in a general traumatology service]

Intraoperative findings in traumatology reveal that any damage to a vein is initially plugged by a mural thrombus. This thrombus ensures spontaneous haemostasis and is therefore part of a physiological process. An extension of this initial clot is no longer physiological process. An extension of this initial clot is no longer physiological however and results in pathological thrombosis by stagnation. On the basis of these findings, a very specialized anticoagulant drug is required immediately after the accident. The actual choice of anticoagulant is of secondary importance.