Is it time for firearm injury to be a separate activation criteria in children? An assessment of penetrating pediatric trauma using need for surgeon presence.

BACKGROUND: Penetrating injury independently predicts the need for surgeon presence (NSP) upon arrival. Penetrating injury is often used as a trauma triage indicator, however, it includes a wide range of specific mechanisms of injury. We sought to compare firearm-related and non-firearm related pediatric penetrating injuries with respect to NSP, ISS and mortality. METHODS: Patients <18 from the 2016 National Trauma Quality Improvement Program Database were included. Penetrating injury was identified and grouped using ICD-10 mechanism codes into firearm and non-firearm related injury. NSP, ISS, and mortality were compared between the two groups. RESULTS: A total of 1715 (4.2%) patients with penetrating injury were; 832 firearm-related and 883 non-firearm. No deaths occurred among the non-firearm group compared to 94 (11.3%) among firearm-related patients. Among non-firearm patients, 22.7% had a NSP indicator compared to 51.2% of patients injured by a firearm. CONCLUSION: There is a significantly higher proportion of severe injury and mortality with firearm penetrating injury when compared to non-firearm pediatric penetrating injury. Consideration should be given to dividing it into firearm and non-firearm penetrating injury.

Assessment of surgical wounds in the home health patient: definitions and accuracy with OASIS-C.

The number of surgical patients receiving home care continues to grow as hospitals discharge patients sooner. Home health clinicians must gain knowledge of the wound healing stages and surgical wound classification to collect accurate data in the Outcome and Assessment Information Set-C (OASIS-C). This article provides the information clinicians need to accurately assess surgical wounds and implement best practices for improving surgical wounds in the home health patient.

Closure of minor wounds with tissue adhesive.

This article provides basic information on safe and effective wound closure using tissue adhesive. Although it is intended for staff who are new to emergency care, it can be used by more experienced staff as a refresher or teaching aid.

A clinically relevant wound assessment method to monitor healing progression.

One of the most important principles of wound management is periodic assessment and documentation of wound healing. Documentation of healing progress over time allows providers to assess the effectiveness of care to maximize healing. Several methods to determine wound healing progress currently exist and include dimensional, visual, and physiological assessments. However, because existing tools often require correlation of subjective assessments, are time-consuming, and may not consider that wound healing occurs from the "bottom up," a more objective and quicker approach to monitor healing progression was pursued. The purpose of this case study is to describe a once pen-and-paper tool that has now been computerized (the Barber Measuring Tool) that builds a graphical representation of a patient's individual wound healing progress to facilitate clinical decisions regarding the patient's plan of care. The tool, which is currently used for all wound patients in the author's facility, calculates wound volume using a simple formula and tracks this measurement as a percent of baseline over time in the patient's chart. Although formal research to establish validity and reliability of this tool has yet to be conducted, the tool has been used with more than 400 patients and has provided an accurate representation of healing progress. Studies to support proliferating use of this tool are warranted.

Outcomes and costs of penetrating trauma injury in England and Wales.

BACKGROUND: Penetrating trauma injury is generally associated with higher short-term mortality than blunt trauma, and results in substantial societal costs given the young age of those typically injured. Little information exists on the patient and treatment characteristics for penetrating trauma in England and Wales, and the acute outcomes and costs of care have not been documented and analysed in detail. METHODS: Using the Trauma Audit Research Network (TARN) database, we examined patient records for persons aged 18+ years hospitalised for penetrating trauma injury between January 2000 and December 2005. Patients were stratified by injury severity score (ISS). RESULTS: 1365 patients were identified; 16% with ISS 1-8, 50% ISS 9-15, 15% ISS 16-24, 16% ISS 25-34, and 4% with ISS 35-75. The median age was 30 years and 91% of patients were men. Over 90% of the injuries occurred in alleged assaults. Stabbings were the most common cause of injury (73%), followed by shootings (19%). Forty-seven percent were admitted to critical care for a median length of stay of 2 days; median total hospital length of stay was 7 days. Sixty-nine percent of patients underwent at least one surgical procedure. Eight percent of the patients died before discharge, with a mean time to death of 1.6 days (S.D. 4.0). Mortality ranged from 0% among patients with ISS 1-8 to 55% in patients with ISS>34. The mean hospital cost per patient was pound 7983, ranging from pound 6035 in patients with ISS 9-15 to pound 16,438 among patients with ISS>34. Costs varied significantly by ISS, hospital mortality, cause and body region of injury. CONCLUSION: The acute treatment costs of penetrating trauma injury in England and Wales vary by patient, injury and treatment characteristics. Measures designed to reduce the incidence and severity of penetrating trauma may result in significant hospital cost savings.

Nail gun injuries among construction workers.

Pneumatic nail guns greatly increase worker productivity and are extensively used in wood frame building construction, with especially high use in residential construction. One surveillance report of nail gun injuries in Washington State has been published; however, other literature consists largely of case reports and case series in trauma journals. The major objective of the current study was to investigate the occurrence of nail gun-associated injuries among construction workers and to identify preventable work-related factors associated with these injuries. Nail gun-related injuries occurring among a cohort of 13,347 carpenters in Ohio who worked union hours during the time period January 1, 1994, until September 30, 1997, were identified by matching the cohort with workers' compensation claims made to the Ohio Bureau of Workers' Compensation. We also analyzed workers' compensation claims for North Carolina Home Builders Association members for the period July 1996-November 1999 to identify nail gun-related injuries. Analyses included stratified analyses of claims by nature and body part injured, calculation of nail gun injury rates, and analyses of free text descriptions of injuries. Overall, nail gun injuries were responsible for 3.9 percent of workers' compensation claims with 8.3 percent to 25.5 percent of claims involving paid lost work time. The overall rate of nail gun injuries (cases per 200,000 work hours) was 0.33 in North Carolina and 0.26 in Ohio, reflecting the greater concentration of wood frame construction workers in the North Carolina population studied. Higher rates of injury were observed for carpenters in North Carolina and among residential carpenters in Ohio. The predominant body part injured was the hands/fingers, with 80 to 89 percent of injuries being nail punctures. Analyses of free text information for puncture injuries found approximately 70 percent of injuries to occur during the framing/sheathing stage of construction. Our data suggest that approximately 69 percent of puncture injuries may be due to an inadvertent gun discharge or misfire, preventable in large part by the use of sequential triggers. Worker training and education also are important components of nail gun injury prevention.

Technology-driven triage of abdominal trauma: the emerging era of nonoperative management.

Selective nonoperative management of blunt or penetrating abdominal trauma is safe, has eliminated the complications associated with nontherapeutic laparotomies, and is cost-effective. Appropriately selected investigations, such as focused abdominal sonography for trauma, diagnostic peritoneal lavage, spiral computed tomography (CT) scan, diagnostic laparoscopy, or thoracoscopy and angiography, play a critical role in the triage of patients. Future technological advances, such as improvement of the ultrasonic hardware and software that provide automated interpretation and the availability of portable CT scan machines in the emergency room, may improve the speed and accuracy of the initial evaluation. Improvement of the optical system of minilaparoscopes may allow reliable bedside laparoscopy for suspected diaphragmatic injuries.

Clinical assessment and arteriography for patients with penetrating extremity injuries: a review of 500 cases with the Veterans Affairs West Side Medical Center.

For patients suspected of having arterial injuries form penetrating trauma to the extremities, the decision to perform arteriography should be based on clinical criteria rather than "proximity" alone. In order to demonstrate the increased yield of arteriography resulting from appropriate patient selection, we reviewed the results of 500 arteriograms performed at the West Side Veterans Affairs Medical Center to exclude arterial injuries in symptomatic patients following penetrating trauma to their extremities. According to their clinical presentation, the patients were grouped into three different screening categories A, B, and C, which correspond respectively to "mild," "soft," and "hard" clinical signs and symptoms suggestive of arterial injury. All symptomatic patients injured by shotgun were included in category C due to the weapon's destructive power. The majority (318/500, 63.6%) of the 500 arteriograms were positive, and 102 of the positive studies identified major injuries that required surgical intervention. The remaining 216 identified injuries were minor or self-limiting. Increasing incidence of major injuries was found when comparing patients with mild (1.22%), soft (27.8%), and hard (60.0%) clinical signs and symptoms of arterial injury. These result suggest that arteriography, when combined with appropriate patient selection based on clinical examination, would be most effective in finding significant arterial injuries.

Clinical prospective injury severity scoring: when is it accurate?

The development of Condensed Abbreviated Injury Scaling (CAIS) charts (based on AIS-85) has allowed the development of a method to perform early prospective clinical injury scoring (ISS). This information, when available within hours of admission, has allowed an awareness of the magnitude of injuries and creates an appropriate atmosphere for clinical management. In addition, ISS may be used as a rough guide to length of stay and the cost of care for the trauma patient. Three hundred thirty-seven patients entering a Level I Trauma Center were prospectively scored on a daily basis to determine the relationship between time following admission and accuracy. Overall, 18 patients (4.9%) required subsequent changes in their Injury Severity Scores after 24 hours. Patients having severe injury (ISS greater than 16) from blunt trauma had a higher likelihood of having "delayed" diagnosis that resulted in a slightly higher ISS. Overall, the accuracy of this scoring technique was 95% at 24 hours, 98% at 72 hours, and 99% at 5 days.

Renal trauma: re-evaluation of the indications for radiographic assessment.

We studied prospectively 359 consecutive patients with blunt (306) or penetrating (53) renal trauma to refine the indications for radiographic evaluation. Various factors, including the degree of hematuria, presence of shock and associated injuries easily assessable at the time of initial evaluation, were correlated with the severity of renal injury to determine whether any combination of parameters will separate patients with renal contusions from those with significant renal injuries (minor and major lacerations, and vascular injuries). We identified 3 groups: group 1-85 patients with gross hematuria or microscopic hematuria and shock after blunt trauma (including all 23 with significant renal injuries), group 2-221 patients with microscopic hematuria but no shock after blunt trauma (all with renal contusions) and group 3-53 patients with penetrating trauma. No combination of parameters was able to predict a severe injury in group 3. Our data support radiographic evaluation in groups 1 and 3. However, because all patients in group 2 had renal contusions and experienced no complications from nonoperative management we believe that excretory urography, which is time-consuming and costly, can be avoided in patients with microscopic hematuria but no shock after blunt renal trauma.