Prospective evaluation of selective nonoperative management of torso gunshot wounds: when is it safe to discharge?

BACKGROUND: Selective nonoperative management (NOM) has been increasingly used for torso gunshot wounds (GSWs). The optimal observation time required to exclude a hollow viscus injury is not clear. The purpose of this study was to determine the safe period of observation before discharge. METHODS: All patients aged 16 years and older sustaining a torso GSW undergoing a trial of NOM were prospectively enrolled (January 2009 to January 2011). Patient demographics, initial computed tomography (CT) results, time to failure of NOM, operative procedures, and outcomes were collected. Failure of NOM was defined as the need for operation. RESULTS: A total of 270 patients sustained a GSW to the torso. Of those, 25 patients (9.3%) died in the emergency department and were excluded leaving 245 patients available for the analysis. Mean age was 26.5 years ± 9.9 years (16-62 years), 92.7% (227) were men, and mean Injury Severity Score scale was 13.8 ± 11.3 (1-45). Overall, 115 patients (46.9%) underwent immediate exploratory laparotomy based on clinical criteria (72.2% had peritonitis, 27.8% hypotension, 10.4% unevaluable, and 4.3% evisceration), and 130 patients (53.1%) underwent evaluation with CT for possible NOM. Of those, 39 patients (30.0%) had a positive CT and were subsequently operated on. All had significant intra-abdominal injuries requiring surgical management. A total of 91 patients (70.0%) underwent a trial of NOM (47 had equivocal CT findings and 44 had a negative examination). Of these, 8 patients (8.8%) failed NOM and underwent laparotomy (all had equivocal CT scans). Two patients had a nontherapeutic laparotomy; the remainder had stomach (50.0%), colon (25.5%), and rectal (12.5%) injuries. The mean time from admission to development of clinical or laboratory signs of NOM failure was 2 hours:43 minutes ± 2 hours:23 minutes (0 hour:31 minutes-6 hours:58 minutes). All patients failed within 24 hours of admission. CONCLUSION: In the initial evaluation of patients sustaining a GSW to the torso, clinical examination is essential for identifying those who will require emergency operation. For those undergoing a trial of NOM, all failures occurred within 24 hours of hospital admission, setting a minimum required observation period before discharge.

Effect of age on cervical spine injury in pediatric population: a National Trauma Data Bank review.

BACKGROUND: The objective of this study was to characterize the incidence, risk factors, and patterns of cervical spine injury (CSI) in different pediatric developmental ages. METHODS: A retrospective review of the National Trauma Data Bank was conducted for the period of January 2002 through December 2006 to identify pediatric patients admitted following blunt trauma. Patients were stratified into 4 developmental age groups: infants/toddlers (age 0-3 years), preschool/young children (age 4-9 years), preadolescents (age 10-13 years), and adolescents (age 14-17 years). Patients with a CSI were identified by the International Classification of Diseases, Ninth Revision codes. Demographics, clinical injury data, level of CSI, and outcomes were abstracted and analyzed. RESULTS: A total of 240,647 patients met the inclusion criteria. Of these, 1.3% (n = 3,035) sustained a CSI. The incidence of CSI in the stratified age groups was 0.4% in infants/toddlers, 0.4% in preschool/young children, 0.8% in preadolescents, and 2.6% in adolescents. The level of CSI (upper [C1-C4] vs lower [C5-C7]) according to the age groups was as follows: infants and toddlers, 70% vs 25%; preschool/young children, 74% vs 17%; preadolescents, 52% vs 37%; and adolescents, 40% vs 45%, respectively. The adjusted risk for CSI increased 2-fold in preadolescents and 5-fold in adolescents. CONCLUSION: The incidence of pediatric CSI increases in a stepwise fashion after 9 years of age. We noted an increase in lower CSI and a decrease in upper CSI after the age of 9 years. The incidence of upper CSI compared with lower CSI was higher in preadolescents (52% vs 37%) and almost equal in adolescents (40% vs 45%).

Sex-related differences in childhood and adolescent self-inflicted injuries: a National Trauma Databank review.

BACKGROUND: Recent reports have demonstrated increasing lethality among young women after inflicted injuries (SII). The aim of this study was to examine sex differences in the methods and outcomes of childhood and adolescent SII. METHODS: The National Trauma Databank (v 7.0) was used to identify all patients 18 years or younger who sustained a SII. Demographic data, clinical data, and outcomes were compared between male and female patients. RESULTS: During the study period, a total of 1853 (61.1%) male and 1182 (38.9%) female patients sustained a SII. The most common SII mechanism in male patients was gunshot wound (32.1% vs 6.8%, P < .001); in female patients, poisoning (45.6% vs 9.6%, P < .001). For younger patients (<12 years) hanging was the most common method for both male and female patients (36.5% and 29.2%, respectively). The most lethal method in both male and female patients was gunshot wound (32.3% and 38.0%, respectively). This was followed by hanging which had a high rate of lethality particularly in male adolescents 14 years or younger (36.5% and 33.2% for males <12 years and 12-14 years, respectively). CONCLUSION: Self-inflicted injuries in childhood and adolescence show distinct sex differences primarily with regard to mechanism. Males favor shooting; females, poisoning; younger ages, hanging. Gunshot wound and hanging were the 2 most lethal methods of self-inflicted injury.