Embolized mechanical aortic valve leaflet causing infrarenal aortic stenosis and claudication.

Leaflet escape from mechanical heart valves is a rare but potentially fatal complication of prosthetic valve replacement. Historically, the incompetent valve is replaced emergently and the escaped leaflet is subsequently retrieved from its settlement in a distal vessel. If it is not retrieved, the fragment can increase the risk of infection, thrombosis, and migration. We report a case of a mechanical aortic valve leaflet that embolized during valve reoperation and caused occlusive aortic disease found 2 years later. This case emphasizes the importance of locating leaflet fragments after they are noticed missing.

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are a significant source of morbidity and mortality. This study sought to determine whether implementation of the Institute for Healthcare Improvement (IHI) Central Line Bundle would reduce the incidence of CLABSIs. METHODS: The IHI Central Line Bundle was implemented in a surgical intensive care unit. Patient demographics and the rate of CLABSIs per 1,000 catheter days were compared between the pre- and postintervention groups. Contemporaneous infection rates in an adjacent ICU were measured. RESULTS: Baseline demographics were similar between the pre- and postintervention groups. The rate of CLABSIs per catheter days decreased from 19/3,784 to 3/1,870 after implementation of the IHI Bundle (1.60 vs 5.02 CLABSIs per 1,000 catheter days; rate ratio .32 [.08 to .99, P < .05]). There was no significant change in CLABSIs in the control ICU. CONCLUSIONS: Implementation of the IHI Central Line Bundle reduced the incidence of CLABSIs in our SICU by 68%, preventing 12 CLABSIs, 2.5 deaths, and saving $198,600 annually.

Blunt assault: 'million dollar baby'.

Contrasting reports exist in the literature regarding the management of patients with blunt assault to the head, neck, and face and more importantly for clearing the cervical spine. The purpose of our study was to determine the risk of cervical spine injuries after blunt assault to the head, neck, and face and its association with other injuries. We performed a retrospective case review of all blunt assault trauma admissions to the head, neck, and face at our Level I trauma center. We identified all patients who were assaulted with hands and feet and blunt instruments. A total of 3286 patients with blunt assault to the head, neck, and face were identified of whom 11 (0.003%) were found to have a cervical spine fracture or cervical spine subluxation. None of the patients had a cervical spinal cord injury. The 11 patients composed our study population with a mean age of 39 ± 7.8 years, 100 per cent were male, and the mean Injury Severity Score was 12 ± 7.9. Five (45%) patients required surgery for stabilization of the cervical spine. Mortality was reported in only one patient who had a C7 transverse process fracture. Cervical spine injury after blunt assault is rare but does occur and encompasses significant injuries requiring surgical intervention. However, these injuries are the result of direct blows to the cervical spine and we suggest that assaulted patients with no direct trauma to the neck do not require an exhaustive evaluation of the cervical spine.

Continuous noninvasive hemoglobin monitor from pulse ox: ready for prime time?

BACKGROUND: Advances in technology have allowed for continuous noninvasive hemoglobin monitoring (SpHb), which may enable earlier detection of hemorrhage and more efficient surgical and/or blood transfusion management. The use of SpHb has not been described in the trauma population. The purpose of the present study was to evaluate the accuracy of a SpHb measurement device in severely injured trauma patients. METHODS: We performed a prospective cohort analysis of severely injured trauma patients admitted to the intensive care unit (ICU) at our level I trauma center over a 6 month period. Serial IHb (invasive hemoglobin) levels and SpHb for the first 72 h were measured. Each SpHb measurement was matched with a corresponding IHb measurement. We defined normal Hgb as >8 mg/dL and low Hgb as <8 mg/dL. Data were then grouped based on Hgb level. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and Spearman correlation coefficient plot were calculated. RESULTS: A total of 23 trauma patients with 89 data pairs were reviewed. Eighty-six percent of the patients were male with a mean age of 32 years and a mean injury severity score (ISS) of 21.1 ± 14. Invasive hemoglobin had a range of 7.2-16.9 and SpHb had a range of 3.3-15.2. The average mean and difference between IHb and SpHb were 10.7 and 1, respectively. Continuous noninvasive hemoglobin measurement did not record data points 13.5% of the time. The Spearman correlation plot revealed a correlation of R = 0.670 (p < 0.001). After dichotomization with Hgb > 8, SpHb was found to have a sensitivity of 91%, PPV 96%, specificity 40%, NPV 20%, and an accuracy of 88%. CONCLUSIONS: The continuous noninvasive hemoglobin monitor does not appear to represent serum hemoglobin levels accurately in severely injured trauma patients. However, we were able to identify utility for this noninvasive tool when Hgb was dichotomized into normal or low levels.

Prothrombin complex concentrate: an effective therapy in reversing the coagulopathy of traumatic brain injury.

BACKGROUND: Coagulopathy in patients with traumatic brain injury (TBI) is a well-studied concept. Prothrombin complex concentrate (PCC) has been shown to be an effective treatment modality for correction of TBI coagulopathy. However, its use and effectiveness compared with recombinant factor VII (rFVIIa) in TBI has not been established. The purpose of this study was to compare PCC and rFVIIa for the correction of TBI coagulopathy. METHODS: All patients with a TBI and an induced or acquired coagulopathy whom received rFVIIa or PCC at our Level I trauma center during a 4-year period were reviewed. Data collected included demographics, changes in international normalized ratio and blood products transfusion, craniotomy rates, and time to neurosurgical intervention, thromboembolic complications, and mortality differences. RESULTS: The study was composed of 85 TBI patients, of whom 64 patients received PCC while 21 patients received rFVIIa. PCC group were more likely to be on coumadin (44% vs. 14%, p = 0.01). There was a significant decline in packed red blood cell transfusion and fresh frozen plasma after PCC administration (p < 0.01). There was no statistically significant difference in the craniotomy rate (28% vs. 10 %, p = 0.1) or the mean time to intervention between the two groups (201 [33] vs. 230 [10], p = 0.9). Mortality rates were lower in the PCC group compared with rFVIIa (67% vs. 47%, p = 0.02). Subsequent thromboembolic event was seen in one patient on rFVIIa. Mean cost of treatment per patient on PCC was $1,007 compared with $5,757 for rFVIIa (p < 0.01). CONCLUSION: PCC is safe and effective for treating coagulopathy in TBI patients, while reducing costs and resource use. PCC should be considered as an effective therapy to treat both acquired and induced coagulopathy in TBI with or without prehospital coumadin use. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Incidence, risk factors, and outcomes for atrial arrhythmias in trauma patients.

The purpose of this study is to determine the incidence, risk factors, and outcomes after the development of an atrial arrhythmia (AA) in trauma patients admitted to the intensive care unit (ICU). We performed a retrospective study of more than 7 years of trauma patients admitted to the ICU at an urban, academic Level I trauma center. Patients with AA, defined as atrial fibrillation, atrial flutter, or paroxysmal supraventricular tachycardia, were compared with patients without AA. Groups were compared by univariate and multivariate analysis. Three thousand, four hundred and ninety-nine trauma patients were admitted to the ICU during the study period and 210 (6%) developed an AA. AA patients were more likely to sustain blunt trauma, were older, more often female, more severely injured, and sustained more head injuries. The only independent risk factor for developing an AA was age > 55 years (odds ratio = 4.6, P < 0.01). Mortality was higher in the AA group (33% vs. 14%, P < 0.01) and AA was an independent risk factor for mortality (odds ratio = 1.7, P = 0.01). Twenty-eight per cent (n = 59) of AA patients received beta-blockers in the postinjury period, and these patients had lower mortality (22% vs. 37%, P = 0.04). AA occurs in 6 per cent of trauma patients admitted to the ICU. Developing an AA is an independent risk factor for mortality after trauma. Beta-blocker therapy was associated with decreased mortality in trauma patients with AA.

Swan-Ganz catheter use in trauma patients can be reduced without negatively affecting outcomes.

OBJECTIVE: The use of pulmonary artery catheter (PAC) is controversial. The purpose of this study was to document the changing pattern of PAC use and to determine its effect on outcome. METHODS: The use of PAC was analyzed in patients ≥16 years old admitted to the surgical intensive care unit (SICU) over a 9-year period starting in 2000. Patients with SICU length of stay exceeding 30 days were excluded. For the evaluation of PAC's effect on outcome, PAC and no-PAC patients were matched utilizing propensity scores. RESULTS: During the 9-year study period, a total of 5,192 trauma patients were admitted to the SICU. Of these, 426 (8.2%) were <16 years old, and 174 (3.4%) had a SICU length of stay that exceeded 30 days. For the remaining 4,592 patients, the mean ± SD age was 39.5 ± 18.8 years, and the mean ISS was 19.9 ± 12.4. PAC was utilized in 19.5% (n = 896) of all the patients admitted to the SICU. The trend for PAC use decreased significantly over the years (P value for trend <0.001), from 38.6% in the year 2000 to 4.2% in the year 2008. This decrease was noted in all age and injury severity groups of patients. The overall mortality, however, remained at the same levels (P value for trend = 0.111). Patients managed with a PAC were significantly older, more severely injured, more frequently injured by a blunt mechanism, and were admitted more often in a hypotensive or comatose status. In the early part of the study, the PAC was utilized on the first day and for 4.1 days on average. In the later part of the study, however, the PAC was used on the second day and for a shorter period of time (3 days on average, P < 0.001). In the matched study population, patients in the PAC group had almost twofold higher odds for death, when compared to the no-PAC group [34.2% vs. 22.5%, Odds Ratio (95% CI): 1.78 (1.42, 2.26), P < 0.001]. Patients younger than 50 years of age who had an ISS ≥16 had worse outcome when managed with a PAC, whereas patients aged 30-69 years with an ISS <16 had a higher survival. The overall complication rate was fivefold higher in patients receiving a PAC [46.3% vs. 14.2%, Odds Ratio (95% CI): 5.22 (4.04, 6.74), P < 0.001]. CONCLUSION: The use of PAC has decreased almost 10-fold over the last decade at our institution. The PAC is being used later during the ICU course and for a shorter period of time. In a matched population, the use of PAC is associated with a significantly higher mortality and complication rate, but the reason for this association remains uncertain. The use of PAC is invasive and is associated with known complications and financial costs. While the use of PAC maybe useful in a select population, routine and widespread use of the PAC should be avoided.

Automobile versus pedestrian injuries: does gender matter?

BACKGROUND: Automobile vs. pedestrian (AVP) injuries cause substantial morbidity and mortality. Gender may be an important factor in determining the anatomic distribution and severity of these injuries. The objective of this study was to examine the effect of gender on the nature and severity of automobile vs. pedestrian injuries and the outcome. METHODS: Trauma registry study that included all AVP pedestrian injuries admitted during a 14-year period to a Level I trauma center. The following variables were included in an Excel (Microsoft Corporation, Redmond, WA) file for the purpose of this study: age, gender, body area Abbreviated Injury Score, Injury Severity Score, specific fractures (pelvic, spine, femur, tibia), survival, and intensive care unit (ICU) and hospital length of stay. RESULTS: The study population included 6965 patients, 67.3% of whom were male. Overall, 20.7% were in the age group < 15 years, 60.5% in the age group 15-55 years, 7.6% in the age group 56-65 years, and 11.1% in the age group > 65 years. Pelvic fractures were significantly more common in females than males (20.7% vs. 11.4%, respectively, p < 0.0001). This difference was present in all age groups, but especially in the groups 56-65 years (28.5% vs. 12.3%, respectively, p < 0.0001) and > 65 years (32.5% vs. 15.7%, respectively, p < 0.0001). Males in the age group 15-55 years were significantly more likely to suffer tibia fractures (31.8% vs. 25.7%, respectively, p < 0.001). Multivariate analysis showed no difference in survival or ICU stay between the two genders, but there was a significantly longer hospital stay in males 15-65 years. CONCLUSIONS: Gender plays a significant role in the incidence of pelvic and tibial fractures but has no effect on survival or ICU stay, but male patients in the age group 15-65 years had a significantly longer hospital stay.

Complications following renal trauma.

OBJECTIVES: To evaluate and compare the incidence and type of kidney-related complications among different modes of management for kidney injuries. DESIGN: Trauma registry and medical record review study. SETTING: Level I trauma center in Los Angeles, California. PATIENTS: All patients with renal trauma injuries treated from January 1, 1993, through December 31, 2006. MAIN OUTCOME MEASURES: Severity of kidney injury, method of renal treatment, and kidney-related complications. RESULTS: During the study period, 889 patients had kidney injuries, 227 of whom (25.5%) had severe kidney injuries. In 568 patients (63.9%), the kidney was not explored; 173 patients (19.5%) underwent total nephrectomy, 53 (6.0%) underwent partial nephrectomy, and 95 (10.7%) underwent kidney repair. Of the 227 patients with severe kidney injuries, 89 (39.2%) received no exploration, 105 (46.3%) underwent total nephrectomy, 25 (11.0%) underwent partial nephrectomy, and 8 (3.5%) underwent nephrorrhaphy. The overall incidence of kidney-related complications excluding renal failure was 5.2%. The kidney repair group was significantly more likely to develop local kidney-related complications than the total nephrectomy, partial nephrectomy, and no kidney exploration groups, even though the nephrorrhaphy group had less severe kidney injuries. Patients with minor or moderate kidney injuries who underwent kidney exploration had more than twice the local complication rate than patients with no kidney exploration (7.1% vs 3.3%, P = .05). CONCLUSIONS: Selective nonoperative management is safe for blunt and penetrating kidney injuries. Patients managed with nephrorrhaphy are at higher risk for local kidney-related complications than other therapeutic modalities. Patients with minor or moderate kidney injuries treated with exploration of the kidney are more likely to develop local complications than those treated without exploration.

Does the use of pulmonary artery catheters increase the number of organs available for transplantation?

Aggressive donor management, including the placement of a pulmonary artery catheter (PAC) to monitor hemodynamic status and tissue perfusion, has been associated with a significant increase in the number of organs recovered for transplantation. Nonetheless, there has been growing scrutiny over the use of PACs because of their known complications and lack of therapeutic effect. The purpose of this study is to evaluate the use of PACs in the management of organ donors. The records of all patients who successfully donated organs between January 1, 2002 and December 31, 2005 were reviewed. A total of 96 patients underwent successful organ donation during the four-yr study period. Of these, 49 (51.0%) were managed with a PAC. Compared with donors managed without a PAC, there were significantly more hearts recovered from donors managed with a PAC (71.4% vs. 44.7%; p = 0.0079) with no difference in the daily administration of fluids and vasopressors between the two groups. The management of organ donors with a PAC can help maximize cardiac procurement.

Traumatic suicide attempts at a level I trauma center.

BACKGROUND: The purpose of this study is to characterize traumatic suicide attempts (TSA) by age, gender, race, and mechanism of injury. METHODS: This is a retrospective review of TSA patients (identified by E-codes) admitted to our urban, level I trauma center from 1992 through 2005. Mechanisms of TSA included jump from height, firearm (gunshot wound [GSW]), cutting or piercing instrument (stab wound [SW]), and motor vehicle (MV)-related. Patients were categorized in groups by age in years (< 18, 18-35, 36-54, 55-69, ≥ 70). RESULTS: A total of 876 TSA patients were identified; 83% were male, with a mean age of 35 years and a mean Injury Severity Score of 10. The most common mechanism was SW (39%), followed by jump (26%), GSW (21%), and MV-related (13%). Primary mechanism of TSA varied by age (p < 0.0001), with GSW most common in those patients aged < 18 years (64%) and ≥ 70 years (44%), and SW most common in all other age groups. Overall, 16% of TSAs were successful. The adjusted odds ratio (AOR) for mortality for age 70+ vs. age 36-54 was 12.4 (95% confidence interval [CI] 2.3-78, p = 0.005), and the AOR for mortality from GSW vs. SW was 9.8 (95% CI 2.6-44, p = 0.001). CONCLUSIONS: The most common mechanism for TSA was SW, although GSW was the most effective. The mechanism of choice for TSA depends on age, with the extremes of age more commonly choosing a firearm. Age and method of TSA are significant contributing factors to success of suicide attempts.

Prognostic significance of lower extremity long bone fractures after automobile versus pedestrian injuries.

BACKGROUND: Fractures of the tibia and femur are common after automobile versus pedestrian (AVP) injuries. This study evaluates the effect of age on the type of fracture and the incidence and type of associated injuries. METHODS: All patients involved in an AVP crash from January 1, 1995, through June 30, 2006, were included in the study. Variables obtained from our trauma registry included age, gender, Injury Severity Score, Abbreviated Injury Scale, intra-abdominal and spine injuries, and mortality. Patients were divided into three age groups for analysis: younger than 15 years, 15 years to 55 years, and older than 55 years. The incidence and type of associated injuries were assessed according to the presence or absence of fractures of the tibia only, femur only, or combined femur and tibia fractures. RESULTS: A total of 6,652 patients had AVP crashes and 1,936 (29%) had tibia or femur fractures (tibia, 20%; femur, 7%; tibia/femur, 3%). The incidence of tibia fractures increased with age ranging from 13% in those younger than 15 years to 25% in those older than 55 (p < 0.001). Combined tibia and femur fractures were also more common in adults and isolated femur fractures were more common in children. Hollow viscus injury was 1.8% in those with lower extremity fractures and 0.9% in those without (p = 0.0013). Mortality was 10% in those with fractures and 6% in those without (p < 0.0001) and was 20% in those with tibia and femur fractures. CONCLUSIONS: Age affects the incidence and type of lower extremity fractures after AVP injuries. The presence of lower extremity fracture is associated with a higher incidence of chest, spine, and intra-abdominal injuries. It is advisable that all patients with lower extremity fractures after AVP injuries be evaluated by a surgeon familiar with these injury patterns.

Elevated serum pancreatic enzyme levels after hemorrhagic shock predict organ failure and death.

BACKGROUND: Intraluminal pancreatic enzymes have been shown in animal models to be associated with multiple organ failure after hemorrhagic shock, independent of pancreatitis. The translocation of these enzymes into the circulation may serve as a marker of hemorrhagic shock-induced gut ischemia in critically injured trauma patients. We hypothesized that serum amylase and lipase would be significantly elevated in patients presenting in hemorrhagic shock and in those who develop organ failure. METHODS: : Review of a prospective database at a level-1 trauma center from 2000 to 2005. Two thousand seven hundred eleven critically injured trauma patients without pancreatic injuries were evaluated for shock (systolic pressure <90 mm Hg in the emergency department), massive transfusion (10 units of packed red blood cells within the first 24 hours), and organ failure (standard criteria for acute pulmonary, cardiovascular, renal, and hepatic system failure were used). Serum levels >2 times the upper limit of normal for amylase (30-130 U/L) and lipase (7-60 U/L) were defined as elevated. Univariate analyses were performed with the Pearson's chi, and binary logistic regression was used to determine significant risk factors for organ failure. Results with a p value <0.05 were considered significant and are reported. RESULTS: : Patients with elevated amylase (n = 481, 18%) were more likely to present in shock (16% vs. 8%), require massive transfusion (19% vs. 9%), develop organ failure (34% vs. 16%), and die (23% vs. 13%). Patients with elevated lipase (n = 288, 11%) were more likely to require massive transfusion (18% vs. 10%) and develop organ failure (43% vs. 16%). Independent predictors of organ failure were age (odds ratio [OR] = 1.016), Injury Severity Score (OR = 1.02), massive transfusion (OR = 3.1), elevated amylase (OR = 1.9), and elevated lipase (OR = 3.2). Elevated amylase was also an independent predictor of mortality (OR = 1.3). CONCLUSIONS: : Serum levels of pancreatic enzymes are elevated in patients who present in shock or require a massive transfusion and are independent predictors of organ failure. Whether these elevations are caused by ischemic pancreatitis or the translocation of intraluminal enteric pancreatic enzymes is uncertain and future studies are needed. Trauma patients with elevated pancreatic enzymes in the absence of a pancreatic injury have an increased risk of morbidity and mortality.

The impact of intoxication on the number of organs available for transplantation after brain death.

A significant number of head-injured trauma patients are likely to present with a positive toxicology. The purpose of this study is to investigate whether intoxication with substances such as cocaine, amphetamine, alcohol, and opiates on admission has any influence on the number of organs that are recovered after brain death in these patients. We conducted a retrospective review of all organ donor patients admitted to a Level I trauma center over a 4-year period (2002 to 2005). Patients with positive toxicology screens on admission were compared to counterparts with negative screens with regard to the number of organs harvested. There were 90 organ donor patients during the 4-year period. There were 63 (70%) patients to negative toxicology screens. The remaining 27 (30%) were found to be intoxicated with a variety of substances, including alcohol (18%), cocaine (4%), amphetamines (9%), benzodiazepines (4%), opiates (4%), and polysubstances (10%). A comparison of total organs and individual organs donated by both intoxicated and nonintoxicated patients showed no overall statistical difference in the number or type of organs donated between the two groups. Thus, the prospect of organ procurement should not be overlooked in intoxicated patients.

What is the significance of thrombocytosis in patients with trauma?

BACKGROUND: The incidence and risk factors for the development of thrombocytosis after trauma have not been well established. Although it has been suggested that the occurrence of this sequela may be associated with adverse events, there are also limited data regarding outcomes of patients developing posttraumatic thrombocytosis. The objective of this study was to determine the incidence of, risk factors for, and sequela of posttraumatic thrombocytosis. METHODS: A retrospective review of all trauma intensive care unit (ICU) admissions between July 1998 and December 2005 identified patients with early (< or = 7 days), late, and no thrombocytosis. Bivariate analysis was used to compare the clinical and demographic characteristics with outcomes between the three patient groups. RESULTS: A total of 3,484 patients were admitted to the ICU during the 7-year study period. After exclusions, the study population consisted of 3,286 patients. The overall incidence of thrombocytosis was 18.7%; early thrombocytosis was found in 72 patients, and late thrombocytosis was identified in 542 patients. All complications examined were significantly higher in patients with thrombocytosis. Overall, the venous thromboembolic rate was 2.4%; for patients with thrombocytosis it was 4.6% compared with 1.9% in patients without thrombocytosis. Overall mortality was 15.4%, but was significantly lower in patients with thrombocytosis (3.8% vs. 18.1%, p < 0.0001). Independent risk factors for the development of thrombocytosis included obesity, laparotomy, blunt injury, Injury Severity Score > 16, mechanical ventilation, Chest Abbreviated Injury Score > 3, and tachycardia. CONCLUSION: Thrombocytosis is a common finding among patients with trauma admitted to the ICU. The occurrence of both early and late thrombocytosis is associated with significantly higher rates of complications, particularly venous thromboembolism. However, patients developing posttraumatic thrombocytosis may have a significantly lower mortality compared with those without this sequela of injury.

Outcomes of blunt assault at a level I trauma center.

BACKGROUND: Physical assault is common in trauma patients. Penetrating injuries resulting from interpersonal violence have been well described in literature, but there have been few studies examining the injury patterns due to assaults with hands and feet or blunt instruments. METHODS: The Trauma Registry of an American College of Surgeons Level I center was queried for all patients with an E-code diagnosis of assault by hands and feet or blunt instrument for the period of January 1, 1992 to September 30, 2005. Demographic and injury pattern data were analyzed. Univariate and multivariable analysis was performed to identify independent predictors of mortality. RESULTS: There were 3,286 patients identified (89.7% male) with a mean age of 36 years +/- 13 years and mean injury severity score of 8 +/- 7. Overall, 65 (2.0%) patients required laparotomy, 10 (0.3%) required craniectomy, and 1 (0.03%) patient required thoracotomy. Traumatic brain injury was present in 66.5% (2,184). Mortality was 2.4% (80). Patients older than 55 years were more likely to be severely injured (injury severity score > or = 16) (23.4% vs. 14.6%, p < 0.001) and were more likely to die of injuries (4.8% vs. 2.1%, p < 0.05). Nineteen (0.6%) patients had documented fractures of the cervical spine and cervical spinal cord injury was not observed in any patient. CONCLUSIONS: Injuries due to assault rarely require operative intervention and have a low risk of cervical spine or cord injuries. However, many result in traumatic brain injury. Patients older than 55 years tend to be more severely injured and at higher risk of mortality.

The role of routine spinal imaging and immobilisation in asymptomatic patients after gunshot wounds.

BACKGROUND: The role of routine dedicated spinal imaging and immobilisation following gunshot wounds (GSW) to the head, neck or torso has been debated. The purpose of this study was to determine the incidence of spinal column injury requiring stabilisation in evaluable patients following gunshot injury. METHODS: A retrospective study from of a Level I trauma centre from January 1995 to December 2004. All patients with GSW to the head, neck or torso and bony spinal column injury underwent medical record review to determine injury type, presentation, presence of concomitant spinal cord injury, treatment and outcome. RESULTS: A total of 4204 patients sustaining GSW to the head, neck or torso were identified. Complete medical records were available for the 327 (7.8%) patients with bony spinal column injury. Among these patients, 173 (52.9%) sustained spinal cord injury. Two patients (0.6%) with GSW to the torso and bony spinal column injury required operative spinal intervention. The indication for operative intervention in both cases was removal of a foreign body or bony fragment for decompression of the spinal canal. None of the 4204 patients sustaining GSW to the head, neck or torso demonstrated spinal instability requiring operative intervention, and only 2/327 (0.6%) required any form of operative intervention for decompression. CONCLUSION: Spinal instability following GSW with spine injury is very rare. Routine spinal imaging and immobilisation is unwarranted in examinable patients without symptoms consistent with spinal injury following GSW to the head, neck or torso.

Methamphetamines in trauma: effect on injury patterns and outcome.

BACKGROUND: The association of methamphetamine exposure and outcomes after trauma is not known. METHODS: This study included trauma patients who underwent alcohol and illicit drug screening. Patients who had a screen positive for Methamphetamine only [METH (+)] were compared with patients with a completely negative screen for illicit drugs or alcohol [TOX (-)]. Patients with polysubstance or alcohol abuse were excluded. Logistic regression was used to determine whether METH (+) status was independently associated with injury patterns or outcomes. Associations were further evaluated by patient matching with respect to age, gender, mechanism, injured body area abbreviated injury scores, and injury severity. RESULTS: There were 5,372 patients eligible where 526 (9.8%) were METH (+). On multivariate analysis, the METH (+) group had a significantly higher adjusted rate of intensive care unit (ICU) admission but there was no difference in mortality or complications or ICU stay. On matching, there was no difference in mortality (11.1% vs. 10.9%, p = 0.87), complication rate (5.6% vs. 4.2%, p = 0.40), and lengths of ICU and hospital stay but the METH (+) group had a higher rate of laparotomy. CONCLUSION: Patients exposed to Methamphetamines do not have increased mortality or complications or lengths of ICU and hospital stay. However, they are more likely to require admission to the ICU.

Cocaine use in trauma: effect on injuries and outcomes.

BACKGROUND: It has been reported that cocaine is associated with trauma patients at epidemic proportions. However, the injury patterns, complications, and mortality in cocaine test-positive trauma patients are not well known. METHODS: Retrospective review of all trauma patients with toxicology screen at a Level I trauma center between January 2002 and December 2005. A total of 1,096 patients were positive for cocaine but no other substances of abuse or alcohol. Nine hundred eighty-five patients of these cocaine test-positive patients were matched to a pool of 4,846 toxicology test-negative patients admitted during the same period with respect to age (< or = 18, 19-55, > 55 years), gender, mechanism (blunt, penetrating), Injury Severity Score (ISS < 16, 16-25, > 25), head Abbreviated Injury Score (AIS < 3, > or = 3), chest AIS (< 3, > or = 3), abdominal AIS (< 3, > or = 3), and extremity AIS (< 3, > or = 3). Matched pairs of binary outcomes were analyzed using McNemars, and continuous data were tested using the Wilcoxon signed-ranks test. RESULTS: The two groups had similar injury patterns and there was no difference in surgical procedures between cocaine test-positive and toxicology test-negative patients. Overall, there was no difference in mortality between the cocaine and test-negative patients (6.5% vs. 6.2%; p = 0.81), or between cocaine and test-negative patients with an ISS < 16 (1.4% vs. 1.5%; p = 1.00), ISS 16 to 25 (13% vs. 12%; p = 1.00), and ISS > 25 (59% vs. 54%; p = 0.70). The overall incidence of complications was 4% in cocaine patients and 3.6% in test-negative patients (p = 0.72), although the incidence of pneumonia was significantly higher in the cocaine test-positive patients (p = 0.04). CONCLUSION: Cocaine abuse in trauma patients is concerning. This study did not show a difference in mortality or length of intensive care unit stay between cocaine positive and negative patients. However, there was a significantly higher incidence of pneumonia in cocaine positive patients. Implementation of effective prevention strategies may help reduce cocaine related victims of trauma.

Cirrhosis and trauma are a lethal combination.

BACKGROUND: The objective of this study was to evaluate the risk of mortality and complications associated with cirrhosis in trauma patients. METHODS: This is an IRB-approved retrospective trauma registry study of patients admitted to an academic level 1 trauma center from 1997 to 2006. The following parameters were abstracted for analysis: age, gender, mechanism of injury, Abbreviated Injury Score, Injury Severity Score, Glasgow Coma Scale, mortality, and complications (ARDS, acute renal failure, pneumonia, intra-abdominal abscess, trauma-associated coagulopathy). Multivariable analysis was utilized to compare the mortality and complication rates between cirrhotic and noncirrhotic trauma patients. The subgroup of patients who underwent laparotomy was also analyzed. RESULTS: During the 10-year study period there were 36,038 trauma registry patients, of which 468 (1.3%) had a diagnosis of cirrhosis. The mortality in the cirrhotic group was 12% vs. 6% in the noncirrhotic group [adjusted odds ratio = 5.65 (95% CI = 3.72 - 8.41, p < 0.0001)]. ARDS, trauma-associated coagulopathy, and septic complications were significantly more common in the cirrhotic group. The overall severe complication rate in the two groups was 10 and 4%, respectively [adjusted odds ratio = 2.05 (95% CI = 1.45 - 2.84, p < 0.0001)]. For the subgroup of patients who underwent emergent abdominal exploration, the mortality rate increased to 40% compared with that of noncirrhotics at 15% [adjusted odds ratio = 4.35 (95% CI = 2.00 - 9.18, p = 0.0002)]. CONCLUSION: Cirrhosis is an independent risk factor for increased mortality and higher complication rate following trauma. Injured patients who undergo laparotomy are significantly more likely to die than noncirrhotic patients. Injured patients with cirrhosis warrant aggressive monitoring and treatment.