Epidemiology and association of neighbourhood marginalisation on violent knife assaults in Ontario: a population-based case-control study.

BACKGROUND: Violent knife assaults ('stabbings') are underappreciated as a source of morbidity and mortality. The two objectives of this study were to describe the epidemiology of stabbing injuries in the population of Ontario, Canada and to assess the associations between two measures of neighbourhood marginalisation-material deprivation and housing instability, and the risk of stabbing injury. METHODS: We conducted a population-based case-control study over 2004-18 using linked administrative data. Cases suffered a stabbing injury resulting in an emergency department visit, hospitalisation or death. Four age and sex-matched controls were matched to each case. Multivariate logistic regression was used to assess the associations between neighbourhood material deprivation as well as housing instability and the risk of injury. Mean annualised injury incidences were estimated using the number of cases identified divided by the total population of Ontario for that year. RESULTS: We identified 26 657 individuals with a stabbing injury, of which 724 (2.7%) were fatal. The mean annualised incidence was 13.4 per 100 000 (95% CI: 12.7 to 15.9). Victims were disproportionately young (median age 25 years; IQR: 20-37 years) males (84.1%), from large urban centres (77.5%), and in the lowest income quintile (39.3%). In multivariate models, neighbourhood material deprivation (OR 1.45, 95% CI: 1.43 to 1.47) and housing instability (OR 1.4, 95% CI: 1.22 to 1.26) were associated with risk of injury. CONCLUSIONS: Stabbing injuries are a substantial public health problem that affects individuals of all ages and demographics but disproportionately affects younger men in urban settings. There is a weak association between residence in marginalised neighbourhoods and the risk of stabbing injury. Future studies should aim to better understand the nature of this association and consider opportunities for public health interventions to reduce the burden of violent knife injuries.

Prophylactic removal of a migratory missile from the cerebral ventricles: case report.

BACKGROUND AND IMPORTANCE: Nonpowder firearm injuries to the head pose major health risks, with retained fragments potentially causing harmful sequelae that require neurosurgical intervention. CLINICAL PRESENTATION: We report the case of 2-year-old girl who sustained an accidental gunshot wound to the head. She sustained a penetrating ballistic intracranial injury caused by a BB shot from a rifle. At presentation, she was neurologically intact with a punctate laceration on her left forehead. Head CT demonstrated a small depressed left frontal skull fracture, a small intracerebral hematoma, and a 5-mm metallic bullet fragment in the deep left frontal lobe near the frontal horn of the left lateral ventricle. She was admitted to the hospital and managed nonoperatively with levetiracetam and intravenous antibiotics, and discharged home in good condition. Follow-up CT in 1 week showed slight migration of the metallic bullet fragment to the left, placing it at the anterior horn of the lateral ventricle. Six weeks later, follow-up CT showed migration of the bullet to the temporal horn of the left lateral ventricle. Intraventricular migration of the bullet raised concern that it could move further to obstruct the foramen of Monro or cerebral aqueduct. Therefore, we removed the bullet through a small left temporal craniotomy with image guidance using a microsurgical approach through a translucent tube. CONCLUSION: The authors discuss the rationale and technique for removing a nonpowder firearm bullet that has migrated within the cerebral ventricles.

Anterior approach for a stab wound with penetrating rebar injury causing incomplete cauda equina syndrome in lumbosacral spine lesion: a case report and literature review.

PURPOSE: To report a unique case of incomplete CES following a rebar penetrating injury in perineal region with retro-pulsed fragment, which was treated with anterior approach and discuss suitable surgical approach. METHODS: Incomplete cauda equina syndrome caused by non-missile penetrating injury is extremely rare. A 26-year-old male patient presented incomplete cauda equina syndrome due to a penetrating rebar wound from his perineal region to the lumbosacral spine. Computed tomography demonstrated a bony fragment broken from S1 body compressing into the spinal canal. RESULTS: By anterior approach, we performed partial corpectomy of L5, decompression by retrieving the bony fragment and L5-S1 interbody fusion. The patient had a significant recovery, and no clinical complication was found after over 2-year follow-up. CONCLUSION: It is challenging to determine the optimal strategy of surgical treatment for penetrating spinal injuries with retained foreign bodies, here we suggest an anterior approach situation that has the advantage of being able to effectively perform decompression and prevent iatrogenic damages of thecal sac and nerve rootlets.

Penetrating colored pencil injury with Clostridium bifermentans pre-septal cellulitis: case report, literature review, and treatment algorithm.

The incidence of penetrating orbital injuries from writing instruments continues to rise in the pediatric population. Such injuries can cause significant visual morbidity and have a lifelong psychosocial impact. While the description of graphite pencil-related orbital trauma management is well demonstrated with over 40 reported cases, a lack of consistent management protocol for colored pencil-related injuries. Here, we report an inadvertent penetrating orbital colored pencil injury with progressive mechanical ptosis and pre-septal cellulitis necessitating urgent orbitotomy, debridement, and washout to reduce inflammatory and infectious burden. The wooden body serves as a nidus for polymicrobial infection, and the unique composition of colored pencil cores may lead to inflammatory processes that require vigilant multidisciplinary surgical and medical management reflected in our literature review.

Iatrogenic needle penetrating injury of cervical spinal cord: a case of fatal therapeutic complication.

A 52-year-old woman with of neck pain underwent percutaneous neck injection of local anesthetic and a corticosteroid without image guidance. She collapsed asystolic during the procedure was resuscitated and then died after 2 weeks in the intensive care unit with hypoxic encephalopathy. Complete postmortem examination included additional posterior neck dissection and cervical spinal cord removal with intact dura mater. The entire cervical spinal cord with the dura and leptomeninges was embedded in an oriented sequence of several paraffin blocks. Serial sections of each selected blocks were then studied to locate a putative puncture site. Serial sections from the third and fourth cervical levels (C3-C4) were stained with luxol fast blue-hematoxylin-eosin, iron stain, trichrome stain, and immunostained for b-amyloid precursor protein, and CD68. Histological examination revealed a linear needle track with a subacute healing reaction. The path included the dorsal spinal dura, arachnoid, and the left dorsal column. Clinicopathological correlation and the cause of death are discussed. Careful planning, dissection, sampling, and oriented serial sectioning with immunostaining were key points to document the injuries and understand this case.

Evaluating the Regional Differences in Pediatric Injury Patterns During the COVID-19 Pandemic.

INTRODUCTION: Reports of pediatric injury patterns during the COVID-19 pandemic are conflicting and lack the granularity to explore differences across regions. We hypothesized there would be considerable variation in injury patterns across pediatric trauma centers in the United States. MATERIALS AND METHODS: A multicenter, retrospective study evaluating patients <18 y old with traumatic injuries meeting National Trauma Data Bank criteria was performed. Patients injured after stay-at-home orders through September 2020 ("COVID" cohort) were compared to "Historical" controls from an averaged period of equivalent dates in 2016-2019. Differences in injury type, intent, and mechanism were explored at the site level. RESULTS: 47,385 pediatric trauma patients were included. Overall trauma volume increased during the COVID cohort compared to the Historical (COVID 7068 patients versus Historical 5891 patients); however, some sites demonstrated a decrease in overall trauma of 25% while others had an increase of over 33%. Bicycle injuries increased at every site, with a range in percent change from 24% to 135% increase. Although the greatest net increase was due to blunt injuries, there was a greater relative increase in penetrating injuries at 7/9 sites, with a range in percent change from a 110% increase to a 69% decrease. CONCLUSIONS: There was considerable discrepancy in pediatric injury patterns at the individual site level, perhaps suggesting a variable impact of the specific sociopolitical climate and pandemic policies of each catchment area. Investigation of the unique response of the community during times of stress at pediatric trauma centers is warranted to be better prepared for future environmental stressors.

Wound size and location affect the prognosis of penetrating ocular injury.

BACKGROUND: Ocular trauma is a leading cause of vision loss. Penetrating ocular injury is a major type of open globe injury(OGI), while its epidemiology and clinical characteristics are still uncertain. The aim of this study is to reveal the prevalence and prognostic factors of penetrating ocular injury in the Shandong province. METHODS: A retrospective study of penetrating ocular injury was performed at the Second Hospital of Shandong University, from January 2010 to December 2019. Demographic information, injury causes, ocular trauma types, and initial and final visual acuity(VA) were analyzed. To obtain more precise characteristics of penetrating injury, the eye global was divided into three zones and analyzed. RESULTS: Among 210 OGI, there are 83 penetrating injuries which account for 39.5% of all. In addition, the final VA of 59 penetrating injuries recovered to 0.1 or better, which possesses the highest frequency among OGI. In order to research the relationship between the wound location and the final VA, we took 74 cases of penetrating injuries without retina or optic nerve damage for analysis. Results show that 62 were male and 12 were female. The average age was 36.01 ± 14.15. The most frequent occupation is the worker followed by the peasant. Statistics show that there is an obvious deviation in the Ocular trauma score (OTS) predicting the final VA and the actual final VA in the 45-65 score group (p < 0.05). Results suggest that the commonest penetrating injury zone is zone III (32 cases, 43.8%). Zone III, which is farthest from the center of the visual axis, has the largest improvement of the final VA (p = 0.0001). On the contrary, there is no statistical difference in the visual improvement in zone I and zone I + II that involves the injury of the central visual axis. CONCLUSION: This study describes the epidemiology and clinical characteristics of patients hospitalized for penetrating ocular injury without retina damage in Shandong province. It can be concluded that larger size and closer location to the visual axis of damage are accompanied by worse prognosis improvement. The study provides a better understanding of the disease and enlightenment for the prediction of visual prognosis.

Intracranial penetrating injury by clothes fork in an infant: case report and review of the literature.

Nonmissile intracranial penetrating injury (IPI) in pediatric population is rare. Here, we report the exceedingly rare case of a 5-month-old infant sustained by a metallic clothes fork penetrating into his left forehead. The little baby was identified to carry a traumatic hemorrhagic shock, and a multidisciplinary team (MDT) was immediately established response for whole-course evaluation and decision-making. Computed tomography revealed that the clothes fork had impaled into the left frontal bone and brain parenchyma with about 3.2 cm inside the cranial vault. The infant underwent emergency surgery, and the clothes fork was removed jointly by MDT members under general anesthesia in the retrograde direction. His recovery was uneventful and was followed up 2 years without growth and developmental abnormality. As an extremely rare entity with distinct age-related characteristics, a MDT approach is a best choice and effective strategy to manage infant nonmissile IPI, including preoperative management, surgical treatment, and even following rehabilitation.

Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients.

INTRODUCTION: "Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma. METHODS: We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018. RESULTS: Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively. CONCLUSIONS: Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

Transoral penetrating upper cervical injury: a case report.

Transoral penetrating foreign body injury of the neck involving the cervical spine is a rare condition. We present an injury caused by transoral penetration of a broken piece of a wooden plank into the neck with injury to the upper cervical spine in a 31-year-old male patient. The foreign body was removed transorally with the patient making a full recovery under close observation and was discharged and followed up with no complications. This paper highlights the types of neck injuries, the key points to be considered in zone III neck injury in light of existing literature and a discussion on the management of these patients.

An Unusual Attack by a Blue Bull Resulting in Penetrating Horn Injuries.

Owing to multiple factors, human-wildlife interactions are increasing, and conflict can result in fatal injuries. A 21-y-old man was brought to the emergency department in critical condition with 2 puncture wounds over the thoracoabdominal region after a nilgai, or blue bull (Boselaphus tragocamelus), had gored him. The patient sustained double gastric perforation, which was managed laparoscopically and complicated by an abscess formation in the lesser sac 1 wk later, which required further surgical exploration. The operative culture showed growth of Klebsiella pneumoniae. Intravenous antibiotics were given as per the culture sensitivity report, and the patient improved. Many horn injuries are described as puncture lacerated wounds owing to the rugged nature of animal horns. However, in this case, the margins of the wound were regular and incision-like owing to the smooth and straight structure of blue bull horns. Early surgical exploration and monitoring of treatment progress are crucial in reducing morbidity in penetrating horn injuries.

A Rare Case of Orbitocranial Penetrating Injury with Intracranial Wooden Foreign Body Residue.

Orbitocranial penetrating injuries (OPIs) caused by wooden foreign bodies (WFBs) are very rare and life threatening. Their diagnosis and treatment could be challenging for an ophthalmologist, requiring us to remain alert for possible intracranial extension. We present a case of a 52-year-old man with a residual wooden foreign body in the left frontal lobe. He had a notable history of trauma from a fall on a tree stump and surgical removal of a wooden foreign body from his left orbit 6 years ago. He was referred to us due to recurrent discharge from the eyelid wound. Wooden foreign body residue was successfully removed with a carefully planned craniotomy without complications. This case describes the clinical manifestation, radiographic features, and treatment of this rare trauma, with an emphasis on imaging diagnosis and multi-disciplinary management.

The usefulness of a trauma probability of survival model for forensic life-threatening danger assessments.

Clinical forensic medical examinations constitute an increasing proportion of our institution's tasks, and, concomitantly, the authorities are now requesting forensic life-threatening danger assessments based on our examinations. The aim of this retrospective study was to assess if a probability of survival (PS) trauma score could be useful for these forensic life-threatening danger assessments and to identify a cut-off PS score as a supporting tool for the forensic practice of assessing life-threatening danger. We compared a forensic database and a trauma database and identified 161 individuals (aged 15 years or older) who had both a forensic life-threatening danger assessment and a PS score. The life-threatening danger assessments comprised the following statements: was not in life-threatening danger (NLD); could have been in life-threatening danger (CLD); or was in life-threatening danger (LD). The inclusion period was 2012-2016. A statistically significant difference was found in the PS scores between NLD, CLD and LD (chi-square test: p < 0.0001). The usefulness of the PS score for categorizing life-threatening danger assessments was determined by a receiver-operator characteristic (ROC) curve. The area under the curve was 0.76 (95% CI, 0.69 to 0.84) and the ROC curve revealed that a cut-off PS score of 95.8 would appropriately identify LD. Therefore, a PS score below 95.8 would indicate life-threatening danger. We propose a further exploration of how the evidence-based PS score, including a cut-off value, might be implemented in clinical forensic medical statements to add to the scientific strength of these statements.

Life-threatening danger assessments of penetrating injuries in Eastern Danish clinical forensic medicine.

Clinical forensic assessments of injuries' life-threatening danger may have an impact on the legal aftermath following a violent assault. The pursuit of evidence-based guidelines should ensure a user-independent and reproducible forensic practice. However, does it? The aim of this study was to evaluate the forensic life-threatening danger assessments after a protocol implementation in 2016. The evaluation concerned usability and reproducibility of the protocol, and its influence on assessment severity. We analyzed the level of inter- and intra-rater agreement using 169 blinded, prior-protocol cases that were reassessed by two forensic specialists. We compared assessment made the year before and after protocol implementation (n = 262), and the forensic specialists' reassessments with the prior-protocol cases' original assessments (n = 169). Whether to make an assessment, the levels of agreement varied between weak agreement (inter-rater, Κ = 0.43; assessor 1, Κ = 0.57) and strong agreement (assessor 2, Κ = 0.90). Regarding severity, the levels of agreement varied between strong agreement (inter-rater, Κ = 0.87; assessor 1: Κ = 0.90) and almost perfect agreement (assessor 2: Κ = 0.94). The assessments were statistically significant redistributed after the implementation (chi-square test: p < 0.0001). The proportion of cases assessed as having not been in life-threatening danger increased from 9 to 43%, and moderate severity assessments decreased from 55 to 23%. Of the moderate severity assessments, 55% were reassessed as having not been in life-threatening danger. The protocol ensured independent and reproducible assessments when the forensic specialists agreed on making one. The protocol resulted in less severe assessments. Future studies should examine the reliability of the protocol and its consequences for legal aftermaths.

The rising burden of penetrating knife injuries.

INTRODUCTION: Knife crime remains an area of public health concern. In order to tackle this problem and reduce its burden, the epidemiology of penetrating knife injuries needs to be understood. The aim of this study is to analyse the pattern of knife injuries at a major trauma centre (MTC) in London. METHODS: An analysis of cases from the prospectively collected Trauma Audit and Research Network database of patients attending the emergency department with violent intentional knife injuries from January 2014 to December 2018 was performed. Registry data were analysed for mechanism of injury, number of stabbings, month/date/time of admission, patient demographics, anatomical pattern of injury, hospital length of stay, intervention, ethnicity, repeat victims and fatality. RESULTS: 1373 penetrating knife injuries activated the major trauma call representing 11.7% of all major trauma alerts. 44% occurred in the 16-25 years age group and 85.6% were male. 67.2% required hospital admission. 14.1% required surgery. 50.3% required intervention from multiple specialities. 39.4% had thoracic injuries and 25.8% abdominal injuries. Fatality rate was 0.9% (n=12). 3.6% were repeat victims. 26.8% were multiple stabbings. 5.2% were deliberate self-harm. 23.2% were of white ethnic background. Injury incidence peaked on a Saturday. A significant peak in injuries occurred between 22:00 and 00:00. CONCLUSION: This study shows an increase in the incidence of knife crime per year. These cases contribute approximately 12% of major trauma calls. Female assaults increased from 8.4% to 14.3%. Approximately 2/3 injuries occur in the thorax and abdomen with high frequencies at weekends and evenings. These facts can help allocate resources more efficiently.

Dynamic monitoring of cardiac foreign body by perioperative echocardiography: A case study.

Cardiac foreign bodies, especially those with sharp tips, may lead to unpredictable complications, such as penetrating cardiac injuries. Yet there have not been many reports of penetrating cardiac injuries caused by a needle that migrates from the neck to the heart. We herein present a review of such a case, focusing on the dynamic monitoring by perioperative echocardiography. The needle was represented on the monitor as a linear artifact that had penetrated through the ventricular wall and caused increasing pericardial effusion. Fortunately, the needle was successfully removed before it completely entered the right ventricular cavity. In this case, perioperative echocardiography played a significant role in clinical emergency decision making.

The role of tertiary neurosurgical intervention in non-missile penetrating injuries of the spine.

PURPOSE: The objective of the study was to determine whether all patients with spinal non-missile penetrating injuries (NMPIs) need to be managed at a tertiary neurosurgical centre. METHODS: A retrospective analysis of clinical, demographic, and imaging records was performed on all NMPI patients referred to the Department of Neurosurgery at Tygerberg Academic Hospital in Cape Town, South Africa, between 1 January 2016 and 31 December 2019. RESULTS: Ninety-six patients were identified (94 males and 2 females) with 35 cervical, 60 thoracic, and 1 lumbar spinal stab. Eighty-six had an incomplete spinal cord injury. Six patients presented with cerebrospinal fluid (CSF) leak, all of which resolved spontaneously. MRI was performed in nine patients. Six patients had retained blades, of which 5 were removed in the emergency room (ER). Surgery was performed in two patients (cervical intramedullary abscess and a retained blade). Two patients developed meningitis, and one an intramedullary abscess. Twenty-two patients had associated injuries (pneumothorax, bowel injury). The average length of stay was 17 days, with 81% being unchanged neurologically. The average time from discharge to leaving the hospital was 11 days. CONCLUSION: Early management of NMPI should include prophylactic antibiotics and wound debridement and X-ray imaging to exclude retained blades. Bowel and lung injury must be managed accordingly. Tertiary neurosurgical referral is not routinely necessary and is only warranted for deteriorating neurology, retained blades not removable in the ER, and respiratory failure secondary to spinal cord injury. Complications include meningitis and persistent CSF leak, which should be referred timeously.

Open globe injuries: Epidemiology, visual and surgical predictive variables, prognostic models, and economic cost analysis.

BACKGROUND: Open globe injuries (OGI) represent a visually and economically devastating cause of vision loss. We examined the epidemiology, predictive variables, prognostic models, and economic cost of surgically managed OGI. METHODS: A retrospective tertiary centre study from 2008 to 2018 of 155 consecutive OGI in individuals aged 16 and older was performed. Medical records review, application of Ocular Trauma Score (OTS) and Classification and Regression Tree Analysis (CART) and cost analysis were undertaken. Key outcomes measured were visual acuity, number of operating theatre visits, prognostication using OTS and CART and estimated costs. RESULTS: Younger males at work with inadequate protective eyewear (89.1%) and falls in the elderly were overrepresented. Inferior visual outcomes were associated with a more severe OTS score, a larger injury zone, increasing age, the presence of retinal detachment, extraocular muscle involvement, intraocular foreign body, and globe rupture (R2  = 0.723, p < 0.001). Multiple operating theatre visits were required in the presence of retinal detachment, lens or orbit involvement, work-related injury, globe rupture, and a history of previous intraocular surgery (R2  = 0.0423, p < 0.001). Both OTS and CART prognosticated outcomes (p < 0.001). The OTS predicted for no vision (no light perception/enucleation/evisceration) and profound visual loss (worse than 6/120; specificity: both 100%, sensitivity: 88.2% and 88%) whereas the CART predicted for visual survival (light perception or better) and minimal-to-severe visual loss (6/120 or better; specificity: 88.5% and 81.7% , sensitivity: 97.7% and 100%). Estimated annual OGI cost for Australia was AUD48.1-60.5 million (USD37.3-47.0 million). CONCLUSIONS: The total cost of OGI is immense with young males and the elderly being disproportionately affected. Implementation of targeted government legislation and public health preventative measures may be cost-effective in ameliorating the significant burden.

Association Between Mode of Transportation and Outcomes in Penetrating Trauma Across Different Prehospital Time Intervals: A Matched Cohort Study.

BACKGROUND: National guidelines do not provide recommendations concerning optimal dispatch time for helicopter emergency medical services (HEMS) in the United States. OBJECTIVES: This study describes the association between mode of transport (ground vs. helicopter) and survival of patients with penetrating injury across different prehospital time intervals and proposes evidence-based time-related dispatch criteria for HEMS. METHODS: A retrospective matched cohort study was conducted using the 2015 National Trauma Data Bank. Adult patients (age ≥ 16 years) with penetrating injuries were included. Patients transported via HEMS were selected and matched (1 to 1) for 17 variables to patients transported by ground ambulance (GEMS). Bivariate analyses were conducted to compare characteristics and outcomes (survival to hospital discharge) of patients across different prehospital time intervals. RESULTS: Each group consisted of 949 patients. Overall survival rate was similar in both groups (90.6% for HEMS vs. 87.9% for GEMS, p = 0.054). Patients transported by HEMS had significantly higher survival compared with those transported by GEMS (92.5% for HEMS vs. 87.0% for GEMS, p = 0.002) in the 0-60-min time interval from dispatch to arrival to hospital, and more specifically, in the 31-60-min interval (92.2% vs. 85.2%, p = 0.001). No difference in survival between the two groups was observed in the shortest (0-30 min) or in the extended prehospital time intervals (>60 min). CONCLUSION: In adult patients with penetrating trauma, HEMS transport was associated with improved survival in a specific total prehospital time interval (31 to 60 min). This finding can help emergency medicine service administrators develop evidence-based HEMS dispatch criteria.

An unusual patterned injury from homicidal craniocerebral impalement with a metal chair leg.

A 26-year-old young man died shortly after he had suffered craniocerebral impalement from a metal chair leg during an affray at an airport bar. At autopsy a 25 mm diameter circular wound was present in the left parietal region with protruding brain tissue. Death was due to craniocerebral trauma from a penetrating injury to the head. Examination of the chair used in the assault showed a metal chair with smeared blood on the front right leg that matched the blood group of the decedent. The fatal wound had been inflicted by the assailant with the victim leaning forward while kneeling on the floor. The assault had produced an unusual circular patterned defect in the left parietal bone with dimensions corresponding to the chair leg. The location of the defect and the use of a chair leg were two very unusual features in this homicide.