Splenic injury in side impact motor vehicle collisions: effect of occupant restraints.

BACKGROUND: Side impact motor vehicle collisions (MVCs) are associated with higher morbidity and mortality compared with other types of MVCs. The stiffness of the lateral aspect of the vehicle and restraint use may play a role. The purpose of this study was to evaluate the role of restraint use, vehicle size, and compartment intrusion on the incidence of splenic injury in side impact MVCs. METHODS: The National Automotive Sampling System was used to identify drivers involved in side impact collisions for the years 1996 to 1998. The incidence of splenic injury in these collisions was compared according to restraint use, vehicle size, and magnitude of vehicle crush. Information on the perceived cause of splenic injuries sustained in the MVC was also obtained from National Automotive Sampling System investigator records. RESULTS: Overall, among drivers involved in side impact MVCs, restraint use was associated with a significantly reduced rate of mortality (odds ratio [OR], 0.40; p < 0.0001) and splenic injury (OR, 0.76; p < 0.0001). Restrained drivers of small vehicles (<2,500 lb), however, had a higher incidence of splenic injury in both minimal (lateral intrusion < 30 cm) (OR, 60.1; p < 0.0001) and severe (lateral intrusion > 30 cm) (OR, 4.0; p < 0.0001) magnitudes of vehicle crush on the driver's side of the vehicle. For both midsize (2,500-3,000 lb) and large (>3,000 lb) vehicles, restraint use was associated with a lower risk of splenic injury regardless of the magnitude of crush. In nearly all cases of splenic injury, the left vehicle interior was the source of injury. CONCLUSION: Overall, restraint use is associated with lower rates of splenic injury and mortality in side impacts. Despite this fact, restrained drivers of small vehicles have a higher risk of splenic injury after lateral impact MVCs when compared with unrestrained drivers. Evaluation of the combined role of restraint use, crash, and injury patterns may provide novel insight regarding vehicle safety design features.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma.

OBJECTIVE: The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS: This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis. RESULTS: The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION: Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.