Risk of suicide after a concussion.

BACKGROUND: Head injuries have been associated with subsequent suicide among military personnel, but outcomes after a concussion in the community are uncertain. We assessed the long-term risk of suicide after concussions occurring on weekends or weekdays in the community. METHODS: We performed a longitudinal cohort analysis of adults with diagnosis of a concussion in Ontario, Canada, from Apr. 1, 1992, to Mar. 31, 2012 (a 20-yr period), excluding severe cases that resulted in hospital admission. The primary outcome was the long-term risk of suicide after a weekend or weekday concussion. RESULTS: We identified 235,110 patients with a concussion. Their mean age was 41 years, 52% were men, and most (86%) lived in an urban location. A total of 667 subsequent suicides occurred over a median follow-up of 9.3 years, equivalent to 31 deaths per 100,000 patients annually or 3 times the population norm. Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions (relative risk 1.36, 95% confidence interval 1.14-1.64). The increased risk applied regardless of patients' demographic characteristics, was independent of past psychiatric conditions, became accentuated with time and exceeded the risk among military personnel. Half of these patients had visited a physician in the last week of life. INTERPRETATION: Adults with a diagnosis of concussion had an increased long-term risk of suicide, particularly after concussions on weekends. Greater attention to the long-term care of patients after a concussion in the community might save lives because deaths from suicide can be prevented.

Physical rehabilitation of the critically ill trauma patient in the ICU.

OBJECTIVES: To 1) review the existing evidence for early mobilization of the critically ill patients in the ICU with polytrauma; 2) provide intensivists with an introduction to the biomechanics, physiology, and nomenclature of injuries; 3) summarize the evidence for early mobilization in each anatomic area; and 4) provide recommendations for the mobilization of these patients. DATA SOURCES: A literature search of the MEDLINE and EMBASE databases for articles published in English between 1980 and 2011. STUDY SELECTION: Studies pertaining to physical therapy and rehabilitation in trauma patients were selected. Articles were excluded if they dealt with pediatrics, geriatrics, burn injuries, isolated hand injuries, chronic (i.e., not acute) injuries, nontraumatic conditions, and pressure/decubitus ulcers, were in a language other than English, were published only in abstract form, were letters to the editor, were case reports, or were published prior to 1980. DATA EXTRACTION: Reviewers extracted data and summarized results according to anatomical areas. DATA SYNTHESIS: Of 1,411 titles and abstracts, 103 met inclusion criteria. We found no articles specifically addressing the rehabilitation of polytrauma patients in the ICU setting or patients with polytrauma in general. We summarized the articles addressing the role of mobilization for specific injuries and treatments. We used this evidence, in combination with biologic rationale and physician and surgeon experience and expertise, to summarize the important considerations when providing physical therapy to these patients in the ICU setting. CONCLUSIONS: There is a paucity of evidence addressing the role of early mobilization of ICU patients with polytrauma and patients with polytrauma in general. Evidence for the beneficial role of early mobilization of specific injuries exists. Important considerations when applying a strategy of early physical therapy and mobilization to this distinctive patient group are summarized.

Reducing time-to-treatment decreases mortality of trauma patients with acute subdural hematoma.

OBJECTIVES: To determine if reducing prehospital time and time-to-craniotomy is associated with decreased mortality in trauma patients with acute subdural hematomas. BACKGROUND: Time-to-treatment is an important performance filter for trauma systems, yet very little evidence exists to support its use. Despite the biological rationale supporting the notion of the "Golden Hour" for trauma patients, no evidence exists to support it. Likewise, it remains controversial whether or not time-to-craniotomy is associated with survival in patients with subdural hematomas. Previous studies may have been affected by selection bias. METHODS: Retrospective cohort study of all trauma patients who arrived directly from the scene of injury. Study patients were all patients with acute subdural hematomas and without severe torso injuries, who required craniotomy at a Canadian level 1 trauma center from January 1 1996 to December 31 2007. The independent variables of interest were prehospital time and time-to-craniotomy. The primary outcome measure was in-hospital mortality. RESULTS: Of 12,105 trauma patients assessed, 149 patients met inclusion criteria. Overall, 40% (n = 60) patients died. On univariate analysis, there was a strong trend suggesting that patients arriving within the "Golden Hour after trauma" had decreased mortality (37% vs. 53%, P = 0.09). However, there was no difference in mortality for patients undergoing craniotomy within 4 hours and after 4 hours (42% vs. 36%, P = 0.4). On multivariate logistic regression, increased prehospital time was found to be associated with increased mortality (odds ratio 1.03 per minute, 95% CI 1.004-1.05, P = 0.024). Surprisingly, there was a trend showing that increased trauma room to craniotomy times were associated with lower mortality (odds ratio 0.995 per minute, 95% CI 0.99-1.0, P = 0.056). However, patients who quickly had their craniotomy seemed to have more severe neurological injury. CONCLUSION: Rapid transport of patients with traumatic subdural hematomas hospital is associated with decreased mortality.

Surgical experience at the Canadian-led Role 3 Multinational Medical Unit in Kandahar, Afghanistan.

INTRODUCTION: The purpose of this study was to document the surgical experience of the Role 3 Multinational Medical Unit (R3MMU) at Kandahar Airfield Base while Canada was the lead nation for the facility. This study will help inform on future staffing, training, and deployment issues of field hospitals on military missions. METHODS: From February 2, 2006, to October 15, 2009, the Canadian Forces Health Services served as the lead nation for the R3MMU. We retrospectively reviewed the electronic and the actual operative database during this timeframe to assess surgical workload, types of surgical procedures performed, and the involved anatomic regions of the surgical procedures. RESULTS: During this timeframe, there were 6,735 operative procedures performed on 4,434 patients. The majority of our patients were Afghan nationals, with Afghan civilians representing 34.8%, Afghan National Security Forces 31.6%, and North Atlantic Treaty Organization forces 25.3%. The number of operative procedures by specialty were 3,329 in orthopedic surgery (49.4%), 2,053 general surgery (30.5%), 930 oral maxillofacial surgery (13.8%), and 272 neurosurgery (6%). The most frequently operated on body region was the soft tissue, followed by the extremities and then the abdomen. Thoracic operations were very infrequent. CONCLUSION: Our operative data were slightly different from historical controls. Hopefully, this data will help with planning for future deployments of field hospitals on military missions.

Needle decompression for tension pneumothorax in Tactical Combat Casualty Care: do catheters placed in the midaxillary line kink more often than those in the midclavicular line?

BACKGROUND: Tactical Combat Casualty Care (TCCC) is a system of prehospital trauma care designed for the combat environment. Needle decompression (ND) is a critical TCCC intervention, because previous data suggest that up to 33% of all preventable deaths on the battlefield result from tension pneumothoraces. There has recently been increased interest in performing ND at the fifth intercostal space in the midaxillary line to prevent complications associated with landmarking second intercostal space in the midclavicular line site. We developed a model to assess whether catheters placed in the midaxillary line for decompressing tension pneumothoraces are more prone to kinking than those placed in the midclavicular line because of adducted arms during military transport. METHODS: To simulate ND, we secured segments of porcine chest walls over volunteer soldiers' chests and placed 14-gauge, 1.5-inch angiocatheters through the porcine wall segments which were affixed to either the midaxillary or midclavicular location on the volunteers. We then assessed for occlusion and kinking by flow of normal saline (NS) through the angiocatheter in situ. The angiocatheter was then transduced using standard arterial line manometry, and the opening pressures required to initiate flow through the catheters were measured. The opening pressures were then converted to mm Hg. We also assessed for catheter occlusion after the physical manipulation of the patient, by simulated patient transport. RESULTS: We observed that there was a significant pressure difference required to achieve free flow through the in situ angiocatheter between the fifth intercostal space midaxillary line versus the second intercostal space midclavicular line site (13.1 ± 3.6 mm Hg vs. 7.9 ± 1.8 mm Hg). CONCLUSIONS: This study suggests that the 14-gauge, 1.5-inch angiocatheter used for ND in the midaxillary line may partially and temporarily occlude in patients who will be transported on military stretchers. The pressure of 12.8 mm Hg has been documented in animal models as the pressure at which hemodynamic instability develops. This may contribute to the reaccumulation of tension pneumothoraces and ultimate patient deterioration in military transport.

Spinal injuries after improvised explosive device incidents: implications for Tactical Combat Casualty Care.

BACKGROUND: Tactical Combat Casualty Care aims to treat preventable causes of death on the battlefield but deemphasizes the importance of spinal immobilization in the prehospital tactical setting. However, improvised explosive devices (IEDs) now cause the majority of injuries to Canadian Forces (CF) members serving in Afghanistan. We hypothesize that IEDs are more frequently associated with spinal injuries than non-IED injuries and that spinal precautions are not being routinely employed on the battlefield. METHODS: We examined retrospectively a database of all CF soldiers who were wounded and arrived alive at the Role 3 Multinational Medical Unit in Kandahar, Afghanistan, from February 7, 2006, to October 14, 2009. We collected data on demographics, injury mechanism, anatomic injury descriptions, physiologic data on presentation, and prehospital interventions performed. Outcomes were incidence of any spinal injuries. RESULTS: Three hundred seventy-two CF soldiers were injured during the study period and met study criteria. Twenty-nine (8%) had spinal fractures identified. Of these, 41% (n = 12) were unstable, 31% (n = 9) stable, and 28% indeterminate. Most patients were injured by IEDs (n = 212, 57%). Patients injured by IEDs were more likely to have spinal injuries than those injured by non-IED-related mechanisms (10.4% vs. 2.3%; p < 0.01). IED victims were even more likely to have spinal injuries than patients suffering blunt trauma (10.4% vs. 6.7%; p = 0.02). Prehospital providers were less likely to immobilize the spine in IED victims compared with blunt trauma patients (10% [22 of 212] vs. 23.0% [17 of 74]; p < 0.05). CONCLUSIONS: IEDs are a common cause of stable and unstable spinal injuries in the Afghanistan conflict. Spinal immobilization is an underutilized intervention in the battlefield care of casualties in the conflict in Afghanistan. This may be a result of tactical limitations; however, current protocols should continue to emphasize the judicious use of immobilization in these patients.

Design and preliminary results of a pilot randomized controlled trial on a 1:1:1 transfusion strategy: the trauma formula-driven versus laboratory-guided study.

BACKGROUND: Retrospective reviews have recently shown an survival benefit for adopting a resuscitation strategy that transfuses plasma and platelets at a near 1:1 ratio with red blood cells (RBCs). However, a randomized controlled trial on the topic is lacking. We report on the design and preliminary results of our ongoing randomized control pilot trial (ClinicalTrial.gov NCT00945542). METHODS: This is a 2-year feasibility randomized control trial at a single tertiary trauma center. Bleeding trauma patients were randomized to either a laboratory-driven or a formula-driven (1 plasma:1 platelet:1 RBC) transfusion protocols. Feasibility was assessed by analyzing for ability to enroll patients, appropriate activation of transfusion protocols, time to transfusion of each type of blood product, laboratory turnaround time, ratio of blood products transfused, and wastage of blood products. RESULTS: From July 6, 2009, to May 31, 2010, n = 18 patients were randomized and included in the study. Issues that we noted were the need to do postrandomization exclusions, the need to have rapid and accurate predictors of massive bleeding to enroll patients quickly, and the need to have waived consent for study participation. As well, we noted that the logistics of administering 1:1:1 were formidable and required rapid access to thawed plasma. Similarly, challenges in the control arm of such a study included the turnaround time for obtaining laboratory results. CONCLUSION: Despite major challenges, our initial experience suggests that with an organized system, it is possible to prospectively randomize massively bleeding trauma patients. The accomplishment of high ratios of plasma to RBCs is challenging with current thawing methods and unavailability of thawed plasma in Canada. Longer shelf-life for plasma and faster plasma thawing microwaves should overcome some of these obstacles. For a laboratory-guided transfusion protocol, massive transfusion protocols should be in place with faster turnaround time for coagulation tests. Finally, further research on predictors of massive transfusion is needed.

Hypoperfusion in severely injured trauma patients is associated with reduced coagulation factor activity.

BACKGROUND: Recent studies have shown that acute traumatic coagulopathy is associated with hypoperfusion, increased plasma levels of soluble thrombomodulin, and decreased levels of protein C but with no change in factor VII activity. These findings led to the hypothesis that acute traumatic coagulopathy is primarily due to systemic anticoagulation, by activated protein C, rather than decreases in serine protease activity. This study was designed to examine the effect of hypoperfusion secondary to traumatic injury on the activity of coagulation factors. METHODS: Post hoc analysis of prospectively collected data on severely injured adult trauma patients presenting to a single trauma center within 120 minutes of injury. Venous blood was analyzed for activity of factors II, V, VII, VIII, IX, X, and XI. Base deficit from arterial blood samples was used as a marker of hypoperfusion. RESULTS: Seventy-one patients were identified. The activity of factors II, V, VII, IX, X, and XI correlated negatively with base deficit, and after stratification into three groups, based on the severity of hypoperfusion, a statistically significant dose-related reduction in the activity of factors II, VII, IX, X, and XI was observed. Hypoperfusion is also associated with marked reductions in factor V activity levels, but these appear to be relatively independent of the degree of hypoperfusion. The activity of factor VIII did not correlate with base deficit. CONCLUSIONS: Hypoperfusion in trauma patients is associated with a moderate, dose-dependent reduction in the activity of coagulation factors II, VII, IX, X, and XI, and a more marked reduction in factor V activity, which is relatively independent of the severity of shock. These findings suggest that the mechanisms underlying decreased factor V activity--which could be due to activated protein C mediated cleavage, thus providing a possible link between the proposed thrombomodulin/thrombin-APC pathway and the serine proteases of the coagulation cascade--and the reductions in factors II, VII, IX, X, and XI may differ. Preservation of coagulation factor activity in the majority of normally and moderately hypoperfused patients suggests that aggressive administration of plasma is probably only indicated in severely hypoperfused patients. Markers of hypoperfusion, such as base deficit, might be better and more readily available predictors of who require coagulation support than international normalized ratio or activated partial thromboplastin time.

Causes of death in Canadian Forces members deployed to Afghanistan and implications on tactical combat casualty care provision.

BACKGROUND: As part of its contribution to the Global War on Terror and North Atlantic Treaty Organization's International Security Assistance Force, the Canadian Forces deployed to Kandahar, Afghanistan, in 2006. We have studied the causes of deaths sustained by the Canadian Forces during the first 28 months of this mission. The purpose of this study was to identify potential areas for improving battlefield trauma care. METHODS: We analyzed autopsy reports of Canadian soldiers killed in Afghanistan between January 2006 and April 2008. Demographic characteristics, injury data, location of death within the chain of evacuation, and cause of death were determined. We also determined whether the death was potentially preventable using both explicit review and implicit review by a panel of trauma surgeons. RESULTS: During the study period, 73 Canadian Forces members died in Afghanistan. Their mean age was 29 (+/-7) years and 98% were male. The predominant mechanism of injury was explosive blast, resulting in 81% of overall deaths during the study period. Gunshot wounds and nonblast-related motor vehicle collisions were the second and third leading mechanisms of injury causing death. The mean Injury Severity Score was 57 (+/-24) for the 63 study patients analyzed. The most common cause of death was hemorrhage (38%), followed by neurologic injury (33%) and blast injuries (16%). Three deaths were deemed potentially preventable on explicit review, but implicit review only categorized two deaths as being potentially preventable. CONCLUSIONS: The majority of combat-related deaths occurred in the field (92%). Very few deaths were potentially preventable with current Tactical Combat Casualty interventions. Our panel review identified several interventions that are not currently part of Tactical Combat Casualty that may prevent future battlefield deaths.

Clotting factor deficiency in early trauma-associated coagulopathy.

BACKGROUND: Coagulopathic bleeding is a leading cause of in-hospital death after injury. A recently proposed transfusion strategy calls for early and aggressive frozen plasma transfusion to bleeding trauma patients, thus addressing trauma-associated coagulopathy (TAC) by transfusing clotting factors (CFs). This strategy may dramatically improve survival of bleeding trauma patients. However, other studies suggest that early TAC occurs by protein C activation and is independent of CF deficiency. This study investigated whether CF deficiency is associated with early TAC. METHODS: This is a prospective observational cohort study of severely traumatized patients (Injury Severity Score ≥ 16) admitted shortly after injury, receiving minimal fluids and no prehospital blood. Blood was assayed for CF levels, thromboelastography, and routine coagulation tests. Critical CF deficiency was defined as ≤ 30% activity of any CF. RESULTS: Of 110 patients, 22 (20%) had critical CF deficiency: critically low factor V level was evident in all these patients. International normalized ratio, activated prothrombin time, and, thromboelastography were abnormal in 32%, 36%, and 35%, respectively, of patients with any critically low CF. Patients with critical CF deficiency suffered more severe injuries, were more acidotic, received more blood transfusions, and showed a trend toward higher mortality (32% vs. 18%, p = 0.23). Computational modeling showed coagulopathic patients had pronounced delays and quantitative deficits in generating thrombin. CONCLUSIONS: Twenty percent of all severely injured patients had critical CF deficiency on admission, particularly of factor V. The observed factor V deficit aligns with current understanding of the mechanisms underlying early TAC. Critical deficiency of factor V impairs thrombin generation and profoundly affects hemostasis.

The natural history of trauma-related coagulopathy: implications for treatment.

BACKGROUND: Hemorrhage is a leading cause of death in trauma patients and coagulopathy is a significant contributor. Although the exact mechanisms of trauma-associated coagulopathy (TAC) are incompletely understood, hemostatic resuscitation strategies have been developed to treat TAC. Our study sought to identify which trauma patients develop TAC and the factors associated with its development, to describe the natural history of TAC, and to identify patients with TAC who may not require hemostatic resuscitation. METHODS: Patients with early coagulopathy (International Normalized Ratio >1.3) who were admitted directly from the scene within 1 hour of injury were identified in our institutional trauma registry. We analyzed these data for the presence of TAC, predictors of early and delayed TAC, and evolution of TAC during the first 24 hours of admission. RESULTS: Of 2,473 patients, 290 (12%) had early TAC (International Normalized Ratio >1.3) and 271 (11%) developed delayed TAC. Multivariate analysis identified female gender (odds ratio [OR] 1.25 [1.11-1.41]), lower pH (OR 0.08 [0.015-0.47]), lower hemoglobin (OR 0.96 [0.95-0.97]), lower temperature (OR 0.82 [0.70-0.95]), and blunt mechanism (OR 0.49 [0.33-0.71]) as factors significantly associated with development of early TAC. Progression of early TAC occurred in 64%, and these patients had more severe abdominal injury and received more emergency room crystalloid. Of patients with early TAC who did not receive fresh frozen plasma, only 49% developed worsening coagulopathy. Patients with isolated intracranial hemorrhage had higher rates of bleeding progression (75% vs. 20%, p < 0.005) in the presence of early TAC. CONCLUSIONS: TAC may appear in an early or delayed form and its presence and progression are associated with a number of identifiable factors. Although TAC commonly progresses, it also resolves spontaneously in many patients. Further research is required to identify which patients with TAC require hemostatic treatment, although those with intracranial hemorrhages seem to warrant aggressive therapy.

Disseminated intravascular coagulopathy in the first 24 hours after trauma: the association between ISTH score and anatomopathologic evidence.

BACKGROUND: Recent studies questioned "classical" concepts in trauma care, including whether disseminated intravascular coagulation (DIC) occurs in trauma. The knowledge on trauma DIC is limited to few studies built on diagnosing DIC with laboratory-based scores. This study explores whether DIC diagnosed by the well-established ISTH (International Society for Thrombosis and Hemostasis) score is corroborated by anatomopathologic findings. METHODS: Prospective observational cohort study of severely injured (ISS ≥ 16) patients. DIC was diagnosed by the ISTH score throughout the first 24 hours after trauma. All organs surgically removed within 24 hours of trauma were reviewed by two independent pathologists. All autopsy reports were reviewed. RESULTS: Of 423 patients enrolled, ∼11% had "overt DIC" and 85% had "suggestive of non-overt DIC" scores throughout the 24 hours after trauma. "Overt DIC" patients had higher mortality and worse bleeding, receiving more blood and plasma transfusions. One hundred and sixteen patients underwent surgery within 24 hours of trauma, and all 40 excised organs were reviewed by two pathologists. Twenty-seven autopsies reports were reviewed. No anatomopathologic evidence of DIC was identified in the first 24 hours, even after additional histochemical staining. d-dimer was universally elevated after trauma. Common DIC features: platelet count, fibrinogen, clotting time, and factor VIII drop were mostly absent. CONCLUSIONS: d-dimer has a disproportional participation in trauma DIC scores. Within 24 hours of trauma, most severely injured patients have DIC scores "suggestive for" or of "overt DIC" but no anatomopathologic evidence of DIC. Considering pathologic findings as the gold standard diagnosis, then DIC is exceptionally uncommon and the ISTH score should not be used for trauma.

Controlled blast exposure during forced explosive entry training and mild traumatic brain injury.

BACKGROUND: There is a paucity of data regarding the pathophysiology and short- and long-term neurologic consequences of primary blast injury in humans. The purpose of this investigation was to test the feasibility of implementing a research protocol in the context of a forced explosive entry training course. METHODS: Instructors (n = 4) and students (n = 10) completing the Police Explosives Technicians-Forced Entry Instructors course were recruited to participate in the study. Participants underwent a physical examination, tests of postural stability and vestibular ataxia, and a neurocognitive battery 1 day before and 10 days following practical forced explosive entry exercises. RESULTS: The instructors reported significantly more blast exposures in their careers than the students (p < 0.05). Seventy-five percent of the instructors and 50% of the students reported a history of trauma to the head. A minority of the participants had deficits on cranial nerve, vestibular ataxia, and neurocognitive tests which did not change significantly postexposure. All the instructors and most of the students (90%) demonstrated postural stability deficits at baseline which did not change significantly postexposure. CONCLUSIONS: Studying the effects of blast exposure on the human brain in a controlled experimental setting is not possible. Forced explosive entry training courses afford an opportunity to begin examining this issue in real time in a controlled setting. This study underscores the importance of baseline testing of troops, of the consideration of subclinical implications of blast exposure, and of continued studies of the effects of blast exposures, including repeated exposures on the human brain.

The value of serum biomarkers in prediction models of outcome after mild traumatic brain injury.

BACKGROUND: To determine, using a civilian model of mild traumatic brain injury (TBI), the added value of biomarker sampling upon prognostication of outcome at 1 week and 6 weeks postinjury. METHODS: The Galveston Orientation and Amnesia test was administered, and blood samples for serum protein S100B and neuron-specific enolase (NSE) were collected from 141 emergency department patients within 4 hours of a suspected mild TBI (mTBI). The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was administered via telephone 3 days postinjury. Patients were assessed by a physician at 1 week (n = 113; 80%) and 6 weeks (n = 95; 67%) postinjury. Neurocognitive and postural stability measures were also administered at these follow-ups. RESULTS: Levels of S100B and NSE were found to be abnormally elevated in 49% and 65% of patients with TBI, respectively. Sixty-eight percent and 38% of the patients were considered impaired at 1 week and 6 weeks postinjury, respectively. Stepwise logistic regression modeling identified admission Galveston Orientation and Amnesia test score, S100B level, and RPQ score at day 3 postinjury to be predictive of poor outcome at 1 week postinjury (c-statistic 0.877); female gender, loss of consciousness, NSE level, and RPQ score at day 3 postinjury were predictive of poor outcome at 6 weeks postinjury (c-statistic 0.895). The discriminative power of the biomarkers alone was limited. CONCLUSIONS: Biomarkers, in conjunction with other readily available determinants of outcome assessed in the acute period after injury, add value in the early prognostication of patients with mTBI. Our findings are consistent with the notion that S100B and NSE point to biological mechanisms underlying poor outcome after mTBI.

Assessing response to changing plasma/red cell ratios in a bleeding trauma patient.

Recent military experience suggests that transfusing fresh frozen plasma and packed red cells in a 1:1 ratio may improve survival in exsanguinating trauma patients. We report the case of a single patient who required massive transfusion after suffering a single gunshot wound. Initially, the patient received FFP:PRBC in 1:2 ratio, but this did not correct laboratory parameters except for INR and clotting factor VII level, which were likely normalized by treatment with recombinant activated factor VII. After receiving FFP:PRBC in a 4:5 ratio, he continued to bleed and his coagulation profile showed no appreciable improvement. In the final phase, he received FFP:PRBC in a 7:5 ratio and his laboratory parameters of coagulopathy normalized, except for factor V level which was improved. He also clinically stopped bleeding.

The cost of providing health care to injured soldiers in war.

BACKGROUND: As the Global War on Terror progresses, the total health cost for treating wounded soldiers continues to rise. Although some reports have estimated the total cost of soldiers' health care, no study has attempted to rigorously quantify this amount. We sought to quantify the cost of providing health care to soldiers injured while on duty in a conflict area. METHODS: Retrospective study of all Canadian Forces (CF) soldiers injured in Afghanistan from February 7, 2006, to February 6, 2007. CF trauma registry was used to identify all injured Canadian soldiers and hospitalized at the military field hospital in Kandahar. Financial reports from the Canadian Forces Health Services were used to quantify the cost of providing care to these soldiers in Kandahar at Landstuhl Regional Medical Center and during evacuation back to Canada. Insurance claims paid (as of October 15, 2007) to a third-party insurer by the CF were used to quantify the charges and costs of health care in Canada. All dollar figures are in Canadian dollars. RESULTS: During the 1-year period, the CF spent more than $24.3 million to provide health care to 1,245 patients at its field hospital in Kandahar. One hundred twenty-seven of these patients were injured Canadian soldiers who required admission to the field hospital. A total of 93 soldiers required evacuation to Landstuhl Regional Medical Center, and of these, 75 required further care at the Canadian civilian hospitals. The CF spent approximately $2.5 million to provide trauma care in Kandahar to its 127 injured soldiers. Caring for 93 wounded soldiers at Landstuhl Regional medical center cost approximately $2.0 million. Air evacuation costs of 75 wounded soldiers back to Canada cost $3.9 million. The CF were charged approximately $2.4 million for further care in Canada for 75 severely wounded soldiers. The estimated actual cost of this care in Canada was $1.4 million. CONCLUSIONS: Estimating the financial cost to properly care for soldiers wounded on overseas duty in the conflict areas is critical for future planning and forecasting. We estimated on average, it costs approximately $20,000 to care for a wounded soldier at a field hospital who is subsequently returned to duty, $42,000 for the case of a wounded soldier treated at an out-of-theater regional referral hospital and subsequently returned to duty, and $113,000 to care for a wounded soldier who is repatriated and finally treated in Canada. Most of the costs are from establishing and staffing field hospitals in the conflict area and from evacuation costs.

Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma.

BACKGROUND: Intravenous contrast extravasation (CE) on computed tomography (CT) scan in blunt abdominal trauma is generally regarded as an indication for the need for invasive intervention (either angiography or laparotomy). More recently, improvements in CT scan technology have increased the sensitivity in detecting CE, and, thus, we postulate that not all patients with this finding require intervention. METHODS: This study is a retrospective review of all patients who underwent a CT scan for blunt abdominal trauma between January 1999 and September 2003. Patterns of injury, associated injuries, management, and outcomes were examined for patients with CE. RESULTS: Seventy of 1,435 patients (4.8%) demonstrated CE. Mean age was 44 years and mean Injury Severity Score was 39. The location of CE was intra-abdominal in 25, pelvis/retroperitoneum in 39, and both areas in 3 patients. Six patients received supportive treatment for nonsurvivable head injury and were excluded from further analysis. Overall, 30 (47%) patients underwent immediate intervention (angiography or laparotomy) and 34 (53%) were managed nonoperatively. Of those who had initial nonoperative management, overall seven (20.5%) underwent intervention, with the remainder being managed without intervention. The success for nonoperative management was greater for those with pelvic/retroperitoneal CE (4 of 7: 57%) than for intra-abdominal extravasation (23 of 27: 85%). CONCLUSION: Although evidence of CE may suggest significant vascular injury, our data suggest that not all patients require invasive intervention. Further studies are needed to better define criteria for nonoperative management in patients with CE identified on their initial CT scan.

Radiation dose from initial trauma assessment and resuscitation: review of the literature.

BACKGROUND: Trauma care benefits from the use of imaging technologies. Trauma patients and trauma team members are exposed to radiation during the continuum of care. Knowledge of exposure amounts and effects are important for trauma team members. METHODS: We performed a review of the published literature; keywords included "trauma," "patients," "trauma team members," "wounds," "injuries," "radiation," "exposure," "dose" and "computed tomography" (CT). We also reviewed the Board on Radiation Effects Research (BEIR VII) report, published in 2005 and 2006. RESULTS: We found no randomized controlled trials or studies. Relevant studies demonstrated that CT accounts for the single largest radiation exposure in trauma patients. Exposure to 100 mSv could result in a solid organ cancer or leukemia in 1 of 100 people. Trauma team members do not exceed the acceptable occupation radiation exposure determined by the National Council of Radiation Protection and Management. Modern imaging technologies such as 16- and 64-slice CT scanners may decrease radiation exposure. CONCLUSION: Multiple injured trauma patients receive a substantial dose of radiation. Radiation exposure is cumulative. The low individual risk of cancer becomes a greater public health issue when multiplied by a large number of examinations. Though CT scans are an invaluable resource and are becoming more easily accessible, they should not replace careful clinical examination and should be used only in appropriate patients.