Torso trauma

Paediatric Blunt Torso Trauma: Injury mechanisms, patterns and outcomes among children requiring hospitalisation at the Sultan Qaboos University Hospital, Oman

OBJECTIVES

Trauma is the greatest cause of morbidity and mortality in paediatric/adolescent populations worldwide. This study aimed to describe trauma mechanisms, patterns and outcomes among children with blunt torso trauma admitted to the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman.

METHODS

This retrospective single-centre study involved all children ≤12 years old with blunt torso trauma admitted for paediatric surgical care at SQUH between January 2009 and December 2013. Medical records were analysed to collect demographic and clinical data.

RESULTS

A total of 70 children were admitted with blunt torso trauma during the study period, including 39 (55.7%) male patients. The mean age was 5.19 ± 2.66 years. Of the cohort, 35 children (50.0%) received their injuries after having been hit by cars as pedestrians, while 19 (27.1%) were injured by falls, 12 (17.1%) during car accidents as passengers and four (5.7%) by falling heavy objects. According to computed tomography scans, thoracic injuries were most common (65.7%), followed by abdominal injuries (42.9%). The most commonly involved solid organs were the liver (15.7%) and spleen (11.4%). The majority of the patients were managed conservatively (92.9%) with a good outcome (74.3%). The mortality rate was 7.1%. Most deaths were due to multisystem involvement.

CONCLUSION

Among children with blunt torso trauma admitted to SQUH, the main mechanism of injury was motor vehicle accidents. As a result, parental education and enforcement of infant car seat/child seat belt laws are recommended. Conservative management was the most successful approach.

Chest injuries based on medical rescue team data

Injuries are the leading cause of death before the age of 40 years, and the third most common incidence of death worldwide after cardiovascular diseases and cancer. THE AIM OF THE STUDY was to determine the number and type of chest injuries, based on EMS (Emergency Medical Service) documentation in the district of Otwock, with particular emphasis on patient age and gender at the time of injury.

MATERIAL AND METHODS

Analysis considered data obtained from medical rescue teams of Otwock County in 2009 concerning chest injuries.

RESULTS

The study group comprised 166 cases of chest injuries. Chest injuries were more often diagnosed in male patients. Most accidents occurred in the afternoon (between 1 and 6pm), and in the summer and winter seasons. Motor vehicle accidents and falls from heights were the most common cause of chest injuries, while the largest number of cases involved superficial chest injuries.

CONCLUSIONS

Chest injuries accounted for 12% of all medical rescue team interventions, due to injuries, most often connected with superficial contusions of the chest wall. Rib fractures are usually caused by blunt chest injuries, most often relating to the V-VIII ribs. Fractures of the I-III ribs are rare and are evidence of a significant injury. Due to the flexibility of the thoracic wall, fractures in children are less common, as compared to the adult population. Most chest injuries occur in the afternoon during increased patient activity.

Analytical review of 664 cases of penetrating buttock trauma

A comprehensive review of data has not yet been provided as penetrating injury to the buttock is not a common condition accounting for 2-3% of all penetrating injuries. The aim of the study is to provide the as yet lacking analytical review of the literature on penetrating trauma to the buttock, with appraisal of characteristics, features, outcomes, and patterns of major injuries. Based on these results we will provide an algorithm. Using a set of terms we searched the databases Pub Med, EMBASE, Cochran, and CINAHL for articles published in English between 1970 and 2010. We analysed cumulative data from prospective and retrospective studies, and case reports. The literature search revealed 36 relevant articles containing data on 664 patients. There was no grade A evidence found. The injury population mostly consists of young males (95.4%) with a high proportion missile injury (75.9%). Bleeding was found to be the key problem which mostly occurs from internal injury and results in shock in 10%. Overall mortality is 2.9% with significant adverse impact of visceral or vascular injury and shock (P < 0.001). The major injury pattern significantly varies between shot and stab injury with small bowel, colon, or rectum injuries leading in shot wounds, whilst vascular injury leads in stab wounds (P < 0.01). Laparotomy was required in 26.9% of patients. Wound infection, sepsis or multiorgan failure, small bowel fistula, ileus, rebleeding, focal neurologic deficit, and urinary tract infection were the most common complications. Sharp differences in injury pattern endorse an algorithm for differential therapy of penetrating buttock trauma. In conclusion, penetrating buttock trauma should be regarded as a life-threatening injury with impact beyond the pelvis until proven otherwise.

[Principles of reanimation in managing thoracic injuries]

<zakljucak> Bez obzira na tezinu povreda grudnog kosa vecini povredjenih moze se pomoci ako se povrede prepoznaju na vreme i ako se, pre svega, na vreme preduzmu reanimacijske mere i pruzi odgovarajuca prva pomoc. Primenom reanimacijskih mera stvaraju se uslovi za ocuvanje vitalnih funkcija povredjenih i primenu ostalih vidova lecenja. Tako shvacen koncept zbrinjavanja povreda grudnog kosa predstavlja kontinuiran i dinamican proces u toku koga se stalno preplicu inicijalni pregled, procena stanja povredjenog, primena reanimacijskih mera i hirursko lecenje, uz stalnu procenu efekta reanimacije i preduzetog lecenja.

Overview of Thoracic Trauma in the United States

Most patients with injuries to the chest (approximately 75%) can usually be managed expectantly with simple tube thoracostomy and volume resuscitation [1,11,21-24]. As a result, initial care of these patients is usually straightforward and often performed adequately by emergency room physicians and general surgeons. Tertiary care of these patients is often multidisciplinary in nature, however, and communication with the thoracic surgeon is essential to minimize mortality and long-term morbidity. Improvement in the understanding of the underlying molecular physiologic mechanisms involved in the various traumatic pathologic processes, and the advancement of diagnostic techniques, minimally invasive approaches, and pharmacologic therapy, all continue to contribute to decreasing the morbidity and mortality of these critically injured patients.

Correlation between crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study

BACKGROUND

The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis.

METHODS

A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed.

RESULTS

Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred.

CONCLUSION

The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.

Appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making

BACKGROUND

Current techniques for assessment of chest trauma rely on clinical diagnoses or scoring systems. However, there is no generally accepted standard for early judgement of the severity of these injuries, especially in regards to related complications. This drawback may have a significant impact on the management of skeletal injuries, which are frequently associated with chest trauma. However, no convincing conclusions can be determined until standardization of the degrees of chest trauma is achieved. We investigated the role of early clinical and radiologic assessment techniques on outcome in patients with blunt multiple trauma and thoracic injuries and developed a new scoring system for early evaluation of chest trauma.

METHODS

A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS] > or = 18) patients admitted to our unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISS > or = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated.

RESULTS

A total of 1,495 patients fulfilled the inclusion criteria. Patients' medical records and chest radiographs were reevaluated between May 1, 1998, and June 1, 1999. The association between rib fractures and chest-related death was low (> three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (> three ribs bilateral, mortality 40.9%, odds ratio 3.43). Injuries to the lung parenchyma, as determined by plain radiography, were associated with chest-related death, especially if the injuries were bilateral or associated with hemopneumothorax (lung contusion unilateral, mortality 25.2%, odds ratio 1.82; lung contusion bilateral + hemopneumothorax, mortality 53.3%, odds ratio 5.1). When plain anteroposterior chest radiographs were used, the diagnostic rate of rib fractures (< or = three ribs) increased slightly, from 77.1% to 97.3% during the first 24 hours of admission. In contrast, pulmonary contusions were often not diagnosed until 24 hours after admission (47.3% at admission, 92.4% at 24 h, p = 0.002). A new composite scoring system (thoracic trauma severity score) was developed that combines several variables: injuries to the chest wall, intrathoracic lesions, injuries involving the pleura, admission PaO2/FIO2 ratio, and patient age. The receiver operating characteristic curve demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693).

CONCLUSION

Radiographically determined injuries to the lung parenchyma have a closer association with adverse outcome than chest-wall injuries but are often not diagnosed until 24 hours after injury. Therefore, clinical decision making, such as about the choice of surgery for long bone fractures, may be flawed if this information is used alone. A new thoracic trauma severity score may serve as an additional tool to improve the accuracy of the prediction of thoracic trauma-related complications.

Validation of an outcome prediction model for critically ill trauma patients without head injury

BACKGROUND

The Acute Physiology and Chronic Health Evaluation (APACHE) II system is inaccurate in predicting the risk of death in trauma patients, especially those without head injury. Using multivariate analysis of the APACHE II system in a development set, a new predictive equation was modeled. The four variables that were independently associated with mortality were PaO2/FiO2 ratio, mean arterial pressure, temperature, and the need for inotropic support. This model was tested prospectively in an independent validation set of 300 patients.

METHODS

Risk of death was calculated using the APACHE II system with the diagnostic category of multiple trauma and weighting for operative intervention as required. The new model was similarly assessed using the four predictor variables and their beta-coefficients for each mechanism of injury and the entire group. The predicted risk of death derived by both models was compared with the observed mortality rate. Discrimination was calculated using a 2 x 2 decision matrix with a decision threshold of r = 0.5 and receiver operating characteristic curves. Calibration was assessed graphically and by statistical correlation.

RESULTS

The observed mortality rate was 28.3% and the predicted mortality risk was 27.4% for the model and 6.26% for APACHE II. The sensitivity and specificity of the model were 58.8 and 90.7%, and the sensitivity and specificity of APACHE II were 1.2 and 100%. The areas under the receiver operating characteristic curves were 0.84 and 0.78 for the model and the APACHE II system, respectively. Calibration of the model was superior within all deciles of risk (model, R2 = 0.93, p < 0.001; APACHE II, R2 = 0.82, p = 0.02).

CONCLUSION

The model accurately predicted the risk of death for the entire group. It is superior to the APACHE II system and is the highest reported sensitivity for 24-hour intensive care unit predictive models that have been applied to the critically injured.

The ongoing challenge of retroperitoneal vascular injuries

BACKGROUND

Retroperitoneal vascular injury remains one of the most frequent causes of death following abdominal trauma. A risk analysis of the association between potential outcome predictors and mortality following abdominal aorta and inferior vena cava injuries was performed.

METHODS

Eighty-nine patients sustaining abdominal aortic or inferior vena cava injury were concurrently evaluated for a 10-year period and retrospectively reviewed. A multiple logistic regression model evaluated the following variables:presence of shock on admission, base deficit (< -10 or > or = -10), classification by the organ injury scale (OIS), blood transfusion, crystalloid infusion, total infusion volume, associated injuries, site of injury, and presence of retroperitoneal tamponade.

RESULTS

Overall mortality for all injuries was 57%. Excluding all death on arrival (DOA) patients, the mortality rate decreased to 45.7%. Death following abdominal aortic injuries was significantly associated with free bleeding in the peritoneal cavity, acidosis, and an injury in the suprarenal location (OIS > 4). For inferior vena cava injuries and combined abdominal aortic and inferior vena cava injuries, death was associated with free bleeding, the suprarenal location (OIS = 4), and the presence of shock on admission as well.

CONCLUSIONS

Despite advances in transport and resuscitation, mortality of aortic and vena cava injuries remains unchanged. Shock on admission, bleeding without retroperitoneal tamponade, acidosis, and the suprarenal location each play a significant role in mortality. Immediate identification associated with a rapid surgical approach are the only factors that may improve survival of such devastating injuries.

Transaxial gunshot injuries

OBJECTIVE

To define the clinical characteristics of gunshot injuries across the truncal midline (transaxial injuries).

DESIGN

A retrospective case-control study

MATERIALS AND METHODS

Analysis of a consecutive series of 223 patients with gunshot injuries to the torso treated at one trauma center. Sixty-three patients with transaxial injuries were compared to 148 patients with unilateral bullet trajectories.

MAIN RESULTS

The incidence of cardiac (8%), vascular (17%), and spinal (29%) injuries and the mortality rate (29%) were significantly higher among the 63 patients with transaxial injuries compared with 148 patients with unilateral injuries. Initial operative access to the wrong visceral cavity (10%), missed injuries (14%), and early reoperations (19%) were also more common in the transaxial group.

CONCLUSIONS

A transaxial bullet trajectory identifies a distinct injury pattern associated with a high incidence of major visceral damage, intraoperative misadventures, and very high mortality.

Ventilatory management of pulmonary contusion patients

BACKGROUND

The goal of this study was to evaluate two modes of mechanical ventilation in patients with pulmonary contusion: pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV).

METHODS

One hundred and thirty-five patients with pulmonary contusion, defined as an infiltrate on admission chest x-ray and hypoxemia, were treated over 45 months; 59 patients who required more than 48 hours of mechanical ventilation were initially managed with VCV.

RESULTS

Twenty patients were converted from VCV to PCV when pulmonary function deteriorated. With PCV, peak inspiratory pressure decreased from 49 +/- 1 to 31 +/- 1 cm H2O, the alveolar-arterial oxygen difference decreased from 491 +/- 36 mm Hg to 300 +/- 36 mm Hg. These findings were significantly different (P < 0.05, by Student's paired t-test). Twenty patients managed with PCV had equivalent duration of mechanical ventilation and days in intensive care units to 39 patients with less pulmonary dysfunction managed with VCV. None of the 10 patients who died expired from pulmonary failure.

CONCLUSIONS

PCV is an alternative mode to VCV in patients with poorly compliant lungs after pulmonary contusion.

Pulmonary contusion. Evaluation and classification by computed tomography

In thoracic trauma, as in all of medicine, diagnosis precedes therapy. Over the past 5 years, we have liberally used chest CT examinations to improve diagnosis in the severely injured patient. This approach has significantly increased our diagnostic yield and permitted early diagnosis and treatment of unsuspected injuries. Confidence in our method of quantitation has helped us to assess the severity of pulmonary parenchymal injuries. Correlation of the CT findings with histologic study has changed our concept of pulmonary contusion from that of interstitial disease to that of pulmonary laceration with blood pneumonia.