Trends in utilization of whole-body computed tomography in blunt trauma after MVC: Analysis of the Trauma Quality Improvement Program database.

BACKGROUND: The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma. METHODS: We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS). RESULTS: There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001). CONCLUSION: Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction. LEVEL OF EVIDENCE: Care management, Level IV.

Five-Year Management of Vascular Injuries of the Extremities in the "Real-World" Setting in Northeastern Greece: The Role of Iatrogenic Traumas.

BACKGROUND: Vascular trauma comprises a diagnostic and surgical challenge. Aim of this study was to present the vascular traumas treated in our Tertiary Hospital during the last 5 years. METHODS: We retrospectively reviewed the surgical records of our vascular department and documented the site and type of vascular injuries of the extremities along with the concurrence of musculoskeletal injuries. The type and outcome of surgical interventions were also recorded. RESULTS: Fifty-eight cases of vascular trauma were recorded (39 in the upper and 19 in the lower extremities). Overall, iatrogenic traumas accounted for 41.3% of cases. The arterial injuries of the upper limb were blunt and penetrating in 27% and 67%, respectively. The most affected artery in the upper limb was the radial artery (37.8%), followed by the ulnar artery (27%) and the brachial artery (24.3%). Orthopedic injuries were recorded in 19% of patients. Management involved simple revascularization, bypass operations, patch arterioplasty and endovascular management in 48.7%, 33.3%, 5.1%, and 5.1%, respectively. The most affected site in the lower extremity was the common femoral artery (36.8%) followed by the popliteal artery (21%). Bone fractures were reported in 5 cases (26.3%). The surgical management involved bypass, simple revascularization, patch arterioplasty in 42.1%, 26.3%, and 21%, respectively. Endovascular management was performed in 10.5%. CONCLUSIONS: A considerable percentage of iatrogenic vascular injuries was recorded, affecting both the upper and lower limbs. Despite the trend toward centralization of vascular services, a basic service of vascular surgery should be available in most sites to ensure that patients with vascular injuries receive fast and appropriate care.

Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis.

BACKGROUND: Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT. METHODS: A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project. RESULTS: In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model. CONCLUSIONS: ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient?

BACKGROUND: We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients. METHODS: We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated. RESULTS: Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis). CONCLUSION: Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary. SUMMARY: For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.

Focused assessment with sonography for trauma (FAST) identifies liver injury following cardiopulmonary resuscitation.

Liver trauma is a recognised rare complication of cardiopulmonary resuscitation (CPR) and may be difficult to detect. We report a case of intraperitoneal haemorrhage due to liver injury following CPR in a 50-year-old man admitted to the intensive care unit. The haemorrhage was diagnosed with focused assessment with sonography for trauma (FAST). FAST can rapidly and easily diagnose liver injury. FAST is recommended for excluding haemoperitoneum in patients who are haemodynamically unstable after resuscitation.

Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly.

BACKGROUND: Blunt head trauma accounts for a majority of pediatric trauma admissions. There is a growing subset of these patients with isolated skull fractures, but little evidence guiding their management. We hypothesized that inpatient neurological observation for pediatric patients with isolated skull fractures and normal neurological examinations is unnecessary and costly. METHODS: We performed a single center 10year retrospective review of all head traumas with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma. In each patient, we analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention. RESULTS: Seventy-one patients presented to our ED with acute isolated skull fractures, 56% were male and 44% were female. Their ages ranged from 1week to 12.4years old. The minority (22.5%) of patients were discharged from the ED following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation (p=0.7474, p=0.9670). No patients underwent repeat head imaging during their index admission. Repeat imaging was obtained in three previously admitted patients who returned to the ED. Cost analysis revealed a significant difference in total hospital costs between the groups, with an average increase in charges of $4,291.50 for admitted patients (p<0.0001). CONCLUSION: Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED without inpatient observation. This change in practice, additionally, would allow for huge health care dollar savings.

Aetiology, epidemiology and management strategies for blunt scrotal trauma.

OBJECTIVES: To describe our experience of all patients presenting to a tertiary referral centre over a 3 year time period with blunt scrotal trauma and to describe a methodical approach for managing this group of patients. METHODS: A retrospective analysis was performed on all patients presenting to the Emergency Department (ED) of a level 1 trauma centre with blunt scrotal trauma from 2010 to 2013 inclusive. Inclusion criteria included a recent history of blunt scrotal trauma with associated pain and/or swelling of the affected testis on clinical examination. RESULTS: Twenty-seven male patients with a median age of 19 (range 8-65) years were included and all but 1 patient underwent scrotal ultrasonography upon presentation. Sixteen patients (59%) presented with scrotal trauma secondary to a sports related injury. Fifteen patients were managed conservatively and of the 12 who underwent urgent exploration 9 had a testicular rupture, including 1 who had an emergency orchidectomy due to a completely shattered testis. Four patients had >30% of the testis replaced by necrotic tissue/haematoma; of which 2 ultimately underwent orchidectomy and insertion of testicular prosthesis. CONCLUSION: Our findings demonstrate that the necessity for scrotal protection in sports that predispose to scrotal trauma should be reviewed. We also demonstrate the importance of scrotal ultrasonography for determining an appropriate management strategy (i.e., conservative versus surgical treatment) in this young patient cohort.

Epidemiological features and management of complex neck trauma from an ENT surgeon's perspective.

OBJECTIVES: The aim of this study is to present a clear picture of the epidemiological aspects pertaining to the cases of neck trauma addressing to the ENT Emergency Room, as well as to display the complexity of the diagnostic and therapeutic management employed in two important Romanian ENTDepartments - "Sfantul Spiridon" Hospital Iasi and SfantaMaria Hospital Bucharest MATERIAL AND METHODS: We conducted a retrospective study on 538 patients with neck trauma that were referred to the abovementioned ENT Departments between March 2009 ­ March 2011, selecting 27 cases with forensic implications. RESULTS: In terms of aetiological mechanism, the most frequentneck injuries in our study were penetrating neck injuries due to assault or self-mutilation with white weapons (knives, razor blades, forks, glass) - 56%, followed by blunt trauma cases due to car accident, strangulation or accidental fall ­ 44%. The most important clinical findings recorded at admission were polytraumas (24.14%), hematomas, fractures, subcutaneous emphysema or skin perforation with visceral damages(representing each 13.8%) and tissue rip (10.34%), important bleedings (6.89%), as well as perforation of neck organs(3.45%). The most frequent postoperative complications were postoperative pharyngo-cutaneous fistula (7.4%) and laryngotrachealstenosis (7.4%). There were also 3 other patients with long-term complications, such as acute mediastinitis (3.4%)recurrential paralysis with Gerhardt's syndrome (3.4%) and dysphagia (3.4%).

Large animal-related injury requiring hospital admission: injury pattern disparities.

BACKGROUND: Due to the infrequent occurrence of large animal-related injury (LARI) in many areas, their significance as a public health problem could be overlooked. The purpose of this study was to examine the demographics and injury disparities associated with LARI. METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Survey from 2001 was used to construct a cohort of patients admitted after LARI. Patients were stratified by age, gender, race, and median household income of patient's zip code. Where available total hospital charges were converted to cost using the hospital's cost-to-charge ratio. To determine variables associated with injury type, univariable and multivariable logistic regression analysis were used. RESULTS: 2424 LARI admissions were identified within the database. The largest proportion of admitted patients were female (53.8%), Caucasian (64.6%), and from areas with median income >$45,000 (41.8%). Average hospital cost was $5062. Overall, the most common injuries were rib fractures (15.2%), vertebral fractures (11.6%) and haemo-pneumothorax (9%). Multivariable logistic regression analysis revealed that age disparities with older patients receiving more rib fractures, haemo-pneumothorax, vertebral fractures, and pelvic fractures. Skull fractures and head injuries are disproportionately seen in younger patients. Gender disparities were also present, with females more likely to have vertebral fractures but less likely to have rib fractures and heart and lung injuries. CONCLUSIONS: Disparities based on age and gender are associated with hospital admission for LARI in the United States. These admissions have a significant impact on the healthcare system with nationwide cost estimates of nearly $60 million. These findings represent potential areas for targeted prevention efforts.

Sturdivan's formula revisited: MRI assessment of anterior chest wall thickness for injury risk prediction of blunt ballistic impact trauma.

BACKGROUND: The thickness and composition of the chest wall are important quantities in multiparametric trauma models for the assessment of injury severity due to blunt ballistic chest impact. While ballistic parameters of non-penetrating projectiles can routinely be measured with high accuracy, data on the thickness of the anterior chest wall is unreliable. Therefore, it is the aim of this work to provide data on the thickness and composition of the anterior chest wall based on MRI examinations of healthy volunteers and to compare these measurements with different empirical estimation rules for the chest wall thickness. METHODS: The study encompassed consecutive male patients from an ongoing population-based cohort study. Each subject underwent standardized whole-body MRI (1.5Tesla). Thickness of total chest wall (CWT) and of adipose tissue (AT) were measured by two independent readers at ten anatomic locations on two cross-sectional planes over the centre of the left ventricle and over the tracheal bifurcation. For each subject, chest wall thickness was estimated based on ten different empirical estimation rules and percent errors were calculated. RESULTS: The study encompassed 250 male volunteers (average age 55.5 years, range 21-84 years, SD 13.6 years). Mean intraclass correlation coefficient of the two readers was 0.90 (range 0.59-1.0, SD 0.08). Average CWT was 31.2mm (range 17.3-51.6mm, SD 5.8mm) while average thickness of AT was 13.1mm (range 3.6-26.7mm, SD 4.6mm). Relative adiposity was 0.41 on average (range 0.19-0.61, SD 0.09). There was significant correlation between CWT and body weight and between CWT and body mass index. Sturdivan's approximation formula showed strong correlation with the measured values (percent error 3.58%, SD 16.26%). CONCLUSION: In this population, Sturdivan's equation formula which is based on the individual's body weight provides valid approximation values for the chest wall thickness and may be used for the optimal design of protective devices and personal body armor as well as for the development of anthropomorphic based test methodologies.

Blunt Criterion trauma model for head and chest injury risk assessment of cal. 380 R and cal. 22 long blank cartridge actuated gundog retrieval devices.

BACKGROUND: Blunt ballistic impact trauma is a current research topic due to the widespread use of kinetic energy munitions in law enforcement. In the civilian setting, an automatic dummy launcher has recently been identified as source of blunt impact trauma. However, there is no data on the injury risk of conventional dummy launchers. It is the aim of this investigation to predict potential impact injury to the human head and chest on the basis of the Blunt Criterion which is an energy based blunt trauma model to assess vulnerability to blunt weapons, projectile impacts, and behind-armor-exposures. METHODS: Based on experimentally investigated kinetic parameters, the injury risk of two commercially available gundog retrieval devices (Waidwerk Telebock, Germany; Turner Richards, United Kingdom) was assessed using the Blunt Criterion trauma model for blunt ballistic impact trauma to the head and chest. RESULTS: Assessing chest impact, the Blunt Criterion values for both shooting devices were higher than the critical Blunt Criterion value of 0.37, which represents a 50% risk of sustaining a thoracic skeletal injury of AIS 2 (moderate injury) or AIS 3 (serious injury). The maximum Blunt Criterion value (1.106) was higher than the Blunt Criterion value corresponding to AIS 4 (severe injury). With regard to the impact injury risk to the head, both devices surpass by far the critical Blunt Criterion value of 1.61, which represents a 50% risk of skull fracture. Highest Blunt Criterion values were measured for the Turner Richards Launcher (2.884) corresponding to a risk of skull fracture of higher than 80%. CONCLUSION: Even though the classification as non-guns by legal authorities might implicate harmlessness, the Blunt Criterion trauma model illustrates the hazardous potential of these shooting devices. The Blunt Criterion trauma model links the laboratory findings to the impact injury patterns of the head and chest that might be expected.

Biomechanical assessment of brain dynamic responses due to blast pressure waves.

A mechanized and integrated computational scheme is introduced to determine the human brain responses in an environment where the human head is exposed to explosions from trinitrotoluene (TNT), or other high-yield explosives, in military applications. The procedure is based on a three-dimensional (3-D) non-linear finite element method (FEM) that implements a simultaneous conduction of explosive detonation, shock wave propagation, blast-head interactions, and the confronting human head. The processes of blast propagation in the air and blast interaction with the head are modeled by an Arbitrary Lagrangian-Eulerian (ALE) multi-material FEM formulation, together with a penalty-based fluid/structure interaction (FSI) algorithm. Such a model has already been successfully validated against experimental data regarding air-free blast and plate-blast interactions. The human head model is a 3-D geometrically realistic configuration that has been previously validated against the brain intracranial pressure (ICP), as well as shear and principal strains under different impact loadings of cadaveric experimental tests of Hardy et al. [Hardy W. N., C. Foster, M. Mason, S. Chirag, J. Bishop, M. Bey, W. Anderst, and S. Tashman. A study of the response of the human cadaver head to impact. Proc. 51 ( st ) Stapp. Car Crash J. 17-80, 2007]. Different scenarios have been assumed to capture an appropriate picture of the brain response at a constant stand-off distance of nearly 80 cm from the core of the explosion, but exposed to different amounts of a highly explosive (HE) material such as TNT. The over-pressures at the vicinity of the head are in the range of about 2.4-8.7 atmosphere (atm), considering the reflected pressure from the head. The methodology provides brain ICP, maximum shear stresses and maximum principal strain within the milli-scale time frame of this highly dynamic phenomenon. While focusing on the two mechanical parameters of pressure, and also on the maximum shear stress and maximum principal strain to predict the brain injury, the research provides an assessment of the brain responses to different amounts of over-pressure. The research also demonstrates the ability to predict the ICP, as well as the stress and strain within the brain, due to such an event. The research cannot identify, however, the specific levels of ICP, stress and strain that necessarily lead to traumatic brain injury (TBI) because there is no access to experimental data regarding head-blast interactions.

Hybrid III ATD in inverted impacts: influence of impact angle on neck injury risk assessment.

The purpose of this paper is to present a protocol of inverted drop-tests using a 50th percentile Hybrid III Anthropomorphic Test Device (ATD) and investigate the influence of angle and velocity at impact on neck injury risk assessment. The tests were based on existing cadaveric experimental protocols for inverted seated positions. In this study selected ATD impact orientations were also assessed in both the sagittal and coronal planes. Twenty-six tests were performed at impact velocities from 1.4 to 3.1 m s(-1). The drop tests confirmed previously described behavior of the ATD in axial loading of its head/neck/thorax complex. They also showed a significant influence of the initial impact angle on neck injury criteria currently used by researchers in rollover crashworthiness tests. At 1.4 m s(-1), the peak upper neck axial force of 4350 N was reduced by an average 1760 +/- 80 N for configurations with 30 degrees initial impact angle in any plane, compared to a reference inverted vertical configuration. The N(ij) was also significantly influenced. For a given impact velocity, an out-of-both-planes initial configuration resulted in the highest combined outputs. Based on these results, similar dynamic conditions (intrusion velocity, impact duration) may result in significantly different loadings of the Hybrid III neck.

Outcomes and costs of blunt trauma in England and Wales.

BACKGROUND: Trauma represents an important public health concern in the United Kingdom, yet the acute costs of blunt trauma injury have not been documented and analysed in detail. Knowledge of the overall costs of trauma care, and the drivers of these costs, is a prerequisite for a cost-conscious approach to improvement in standards of trauma care, including evaluation of the cost-effectiveness of new healthcare technologies. METHODS: Using the Trauma Audit Research Network database, we examined patient records for persons aged 18 years and older hospitalised for blunt trauma between January 2000 and December 2005. Patients were stratified by the Injury Severity Score (ISS). RESULTS: A total of 35,564 patients were identified; 60% with an ISS of 0 to 9, 17% with an ISS of 10 to 16, 12% with an ISS of 17 to 25, and 11% with an ISS of 26 to 75. The median age was 46 years and 63% of patients were men. Falls were the most common cause of injury (50%), followed by road traffic collisions (33%). Twenty-nine percent of patients were admitted to critical care for a median length of stay of 4 days. The median total hospital length of stay was 9 days, and 69% of patients underwent at least one surgical procedure. Seven percent of the patients died before discharge, with the highest proportion of deaths among those in the ISS 26-75 group (32%). The mean hospital cost per person was 9,530 pounds sterling (+/- 11,872). Costs varied significantly by Glasgow Coma Score, ISS, age, cause of injury, type of injury, hospital mortality, grade and specialty of doctor seen in the accident and emergency department, and year of admission. CONCLUSION: The acute treatment costs of blunt trauma in England and Wales vary significantly by injury severity and survival, and public health initiatives that aim to reduce both the incidence and severity of blunt trauma are likely to produce significant savings in acute trauma care. The largest component of acute hospital cost is determined by the length of stay, and measures designed to reduce length of admissions are likely to be the most effective in reducing the costs of blunt trauma care.

[The assessment of clinical evaluation and treatment results of high-energy blunt polytrauma patients]. / Dideles energijos buka trauma patyrusiu pacientu klinikinio tyrimo duomenu ir gydymo rezultatu ivertinimas.

UNLABELLED: The aim of this study was to evaluate the mechanism of high-energy blunt trauma, age and gender of patients, severity of regional and multiple injury, ventilation time, length of stay in intensive care unit and in-hospital stay, in-hospital complications, and treatment outcome. MATERIALS AND METHODS: Data on 159 patients with severe multiple injuries, meeting inclusion criteria, were collected prospectively and evaluated retrospectively. RESULTS: The mean age of multiple trauma patients was 43.9+/-1.4 years; males were injured 2.5 times more often than females (P<0.001). More than half (66.7%) of patients were 17-64-year-old males. Majority (83%) of all patients were injured in motor vehicle crashes, and 52.2% of these patients were pedestrians. The mean Injury Severity Score was 29.5+/-0.8, and severe (Abbreviated Injury Scale score of 3 and more) injuries of extremities, head, and chest made up 69.1% of all injuries. The mean ventilation time, mean length of stay in intensive care unit, and mean in-hospital stay were 5.5+/-0.7, 7.0+/-0.8, and 23.6+/-1.6 days, respectively. Acute lung complications were the most common (25.2%). Systemic inflammatory response syndrome developed in 7.5% of patients, and sepsis in 3.8% of patients. More than one-fifth (20.8%) of polytrauma patients died. CONCLUSIONS: Working-age male pedestrians (17-64 years old) made up two-thirds of all polytrauma patients. Severe injuries of extremities, head, and chest were present in 69.1% of all cases. Lung complications were the most common.

A review of traumatic airway injuries: potential implications for airway assessment and management.

BACKGROUND: Obtaining a patent airway can be difficult in patients with traumatic airway injuries (TAI). There is a paucity of data available about the incidence of airway compromise and techniques used in these patients. METHODS: Charts review of all patients with TAI treated in a Regional Trauma Center from July 1989 to June 2005. RESULTS: One hundred and four patients were identified as TAI in the study period (incidence of 0.4% for blunt and 4.5% for penetrating trauma). Sixty-eighty patients were victims of penetrating trauma (ISS: 24+/-10; mortality: 16%). Thirty-six patients were blunt trauma victims (ISS: 33+/-16; mortality: 36%). Overall, 65% of the patients received a definitive airway (DA) in the pre-hospital setting or at the initial hospital assessment. Alternative techniques for obtaining DA including wound tracheal tube, surgical airway and intubation under fiberoptic bronchoscopy were used in 30% of the patients. Among 24 deaths, 10 were considered primarily due to the airway injury. Twelve patients presented with thoracic TAI with nine deaths in this subgroup. CONCLUSIONS: Overall, the incidence of TAI is low. Blunt trauma TAI is less common, and these patients have a different clinical presentation, higher ISS and mortality than the penetrating TAI group. Early assessment of airways is crucial and DA was required in 2/3 of the patients with TAI. Lower airway injuries have higher mortality than upper airway injuries. Even though most patients died as a result of other injuries, causative factors of death included difficulty in obtaining DA and ventilation/oxygenation problems.

The accuracy of focused assessment with sonography in trauma (FAST) in blunt trauma patients: experience of an Australian major trauma service.

UNLABELLED: Focused assessment with sonography for trauma (FAST) is a method for detecting haemoperitoneum in trauma patients on initial assessment in the Emergency Department. The aim of this paper is to present an Australian trauma centre's experience with FAST as a tool to screen for intraabdominal free fluid in patient's sustaining blunt truncal trauma. METHOD: Over a 63-month period, FAST scans were prospectively studied and compared with findings from a gold-standard investigation, either computed tomography (CT) or laparotomy. RESULTS: 463 FAST results were collected prospectively from 463 patients. 53 scans were excluded due to lack of a corresponding confirmatory gold-standard test. Overall sensitivity, specificity, positive and negative predictive values for FAST in detecting free fluid were 78%, 97%, 91%, 93%, respectively. Analysis of the credentialed operators demonstrated an improvement in accuracy (sensitivity 80%, specificity 100%, positive predictive value 100%, negative predictive value 94%). These findings are comparable with documented international experience. CONCLUSION: The study demonstrates that the use of non-radiologist performed FAST in the detection of free fluid is safe and accurate within an Australian Trauma Centre.

A simple fall in the elderly: not so simple.

BACKGROUND: The goal of this study was to evaluate the burden of falls in the elderly in a Canadian tertiary trauma center. METHODS: Patients admitted to Charles-LeMoyne Hospital with a low velocity fall (LVF) from April 1, 1993 to March 31, 2000 were individually reviewed. Elderly was defined as age 65 years and older. A region was considered to be injured if Abbreviated Injury Scale was greater than or equal to 2. RESULTS: There were 2,333 patients with LVF, 41.4% of all blunt trauma admissions. Median Injury Severity Score was 9 for elderly compared with 5 for young (p < 0.001). Injuries were significantly more frequent to head, face, thorax, and lower limbs in the elderly. Mortality (13.4% versus 0.9%; p < 0.001), length of stay (median = 15 versus 3 days; p < 0.001) and long-term care facility reference (19.3% versus 1.1%, p < 0.001) were significantly higher in the elderly. CONCLUSIONS: LVF is a frequent cause of admission for trauma in the elderly. Despite the apparent benign nature of the mechanism, LVF is associated with more severe injuries and worse outcome.

Blunt cardiac trauma caused by fatal falls from height: an autopsy-based assessment of the injury pattern.

BACKGROUND: Falls from height are contributing widely to population morbidity and mortality, especially in urban settings. The presence of blunt cardiac injuries can increase morbidity among these patients, leading even to death. Some clinical studies and case reports have been published on the subject, but a systematic autopsy-based approach to the subject is missing in the literature of recent decades. METHODS: This study reviewed 61 cases of fatal fall from height that were subjected to a full autopsy at the Institute of Legal Medicine, Hamburg, Germany, from 1998 to 2002. The autopsy protocols and available clinical information were evaluated for assessment of the cardiac injury pattern. RESULTS: Cardiac injuries were found in 33 cases (54%), all of which involved falls from heights exceeding 6 m. In 16 cases, the cardiac injuries were the cause of death or contributed to the fatal outcome. In five of these cases, the individuals possibly could have recovered from their trauma if their heart injury had been sufficiently diagnosed and adequately treated in time. The most frequent finding was pericardial tearing (45%). Tears caused by stretching of the epicardium in the area wherein the inferior vena cava leads into the right atrium and epicardial hematoma were present in 11 cases (33%). Endocardial tears of the atria were found in six cases (18%), and did not occur during falls from heights lower than 11 m. Transmural tears to the right atrium were present in 10 cases (39%), and to the left atrium in 6 cases (18%). These tears occurred with increasing frequency in relation to greater heights. When the heights were lower than 15 m, these tears were smaller than 1 cm in diameter, but when the heights exceeded 15 m, extensive irregular tears were observed. Sternal fractures were seen in 76% of all cases involving heart injuries. In 16% of these cases, the fractures were multiple. Only 18% of the cases without cardiac injuries had sternal fractures, and none of these was multiple. Thus, the presence of severe sternal fractures can be used as an indicator of possible cardiac trauma. CONCLUSIONS: A thorough cardiologic diagnosis should always be performed for patients who survive a fall from height. These patients should be transported to a unit capable of performing cardiopulmonary bypass, and explorative thoracotomy should be considered.