Computed tomography in the initial evaluation of hemodynamically stable patients with blunt abdominal trauma: impact of severity of injury scale and technical factors on efficacy.

BACKGROUND: Although computed tomography is used widely in evaluating injuries from blunt abdominal trauma, grading of injuries does not reliably predict the need for intervention. Objective reporting is essential to evaluate accuracy and facilitate patient triage. We established and tested a five-point grading system for overall severity of injury. METHODS: A total of 392 computed tomographic trauma cases were objectively classified according to the type and severity of abdominal injuries, by two experienced radiologists. Interobserver variability between the original interpretation and the consensus of the film reviewers was evaluated. The computed tomographic grading system was measured against rate of admission, exploratory laparotomy, and further imaging. RESULTS: Patients with higher grades of injury on computed tomography were increasingly likely to have surgical management (odds ratio, 3.99; 95% confidence interval, 1.86-8.58; p < 0.0006), with sensitivity 100%, specificity 89.5% for level 2 injuries and higher. Although there was almost perfect agreement between the official interpretation and the reviewers' blinded consensus interpretation (raw agreement 84%, weighted kappa 0.86), indeterminate studies were reduced from 23% (16 of 67) to 12% (8 of 67) on review: these were more likely to have metallic or motion artifacts (5 of 16 vs. 1 of 51 p < 0.002). CONCLUSIONS: Standardizing reporting of injuries enhances accuracy, and grading eliminates equivocation. Diagnostic certainty in computed tomography of blunt abdominal trauma is reduced by motion and metallic artifacts.

Emergency department patients with assault injuries: previous injury and assault convictions.

STUDY OBJECTIVE: To compare the incidence of previous assault injury and assault conviction of patients presenting to the ED with assault injuries and the incidence of assault injury and conviction in nonassaulted control patients. METHODS: We conducted a retrospective, medical record-based case-control study of ED patients with assault injuries and matched controls presenting with medical and surgical problems unrelated to assault. The setting was the ED of a 900-bed teaching hospital and Level I trauma center in an urban area. Our subjects were 50 patients who presented as victims of blunt trauma, 50 patients who presented with penetrating trauma, and 100 control subjects matched by age, sex, and ZIP code who presented concurrently with nonassault complaints. RESULTS: The overall rate of previous assault injury was 35% and did not differ between cases and controls. Fifty-three patients had a history of criminal conviction, and 23 had a history of conviction for assault. Fewer patients presenting with assault injuries than controls had a history of conviction for assault (odds ratio [OR], .3; P < .02). Patients with penetrating injuries had the lowest incidence of assault conviction (OR, .13; P < .02). The subgroup of case subjects with criminal records had a higher rate of previous injury than those without records (P < .003). CONCLUSION: ED patients with assault injuries did not have a history of assault injuries exceeding that of controls and were less likely to have been convicted of assault. Violence-prevention programs should be directed toward a broader population of ED patients instead of narrowly focusing on victims of assault.

Epidemiology of firearm mortality and injury estimates: state of Connecticut, 1988-1993.

STUDY OBJECTIVES: To retrospectively determine the 6-year cumulative incidence rate of firearm mortality and estimate nonfatal firearm injuries in Connecticut. METHODS: Retrospective analysis of data originating from the Connecticut State Medical Examiner's Office and records from the Trauma Registry of one urban hospital. RESULTS: From January 1988 through December 1993, 1,625 Connecticut residents died from firearm-related injuries. The cumulative incidence rate was 49.4 deaths per 100,000 population during the 6-year study period. Rates peaked among 20- to 24-year-olds at 18.1 deaths per 100,000. Males outnumbered females more than eightfold. The ratio of nonfatal firearm injuries to firearm deaths was 7:1 for those shot by another, self-inflicted injuries were fatal in half of all cases. CONCLUSION: Analysis of firearm mortality data indicated that males in younger age categories were disproportionately affected. These rates combined with nonfatal injury projections demonstrate that firearms represent a significant public health threat to the population of Connecticut, reaching epidemic proportions among specific subpopulations. These results are consistent with those obtained from national studies.

Enteric absorption of ciprofloxacin during the immediate postoperative period.

We studied the enteric absorption of ciprofloxacin immediately following major abdominal surgery to determine if this drug could replace parenteral agents. Nine critically ill subjects received ciprofloxacin, 750 mg, every 12 h for 48 h via nasogastric tube. Drug concentrations were measured after the first and fourth doses. There was insignificant absorption after the initial dose, Cmax = 0.6 +/- 0.6 (mg/L) and AUC0-12 = 3.5 +/- 3.2 (mg.h/L). Unfortunately, serum ciprofloxacin concentrations were also minimally detectable in three of nine subjects after the fourth dose. Enteric absorption of ciprofloxacin, therefore, was erratic and unpredictable in critically ill patients following major abdominal surgery.

Detection of aortic tear in the acute trauma patient using MRI.

Traumatic aortic tears are life threatening and, therefore, need to be evaluated urgently. Typically, a thoracic aortogram is conducted; however, aortography occasionally demonstrates nonspecific abnormalities. These equivocal examinations can lead to unnecessary thoracotomies, or repeated angiography and catastrophic delays in aortic repair. We report a case in which magnetic resonance (MR) imaging was very useful in the diagnosis of aortic tear.

Prospective ultrasound evaluation of venous thrombosis in high-risk trauma patients.

UNLABELLED: To determine the incidence of venous thrombosis (VT), high-risk trauma patients were evaluated prospectively biweekly with Doppler ultrasound (US). Fifty-seven patients during an 8-month period met high-risk criteria for VT including age > 45 years, > 2 days bed rest, previous history of thromboembolism, spine fracture, coma, spinal cord injury, pelvic fracture, lower extremity injury, or femoral vein catheter. Doppler ultrasound showed 16 VTs in 12 patients. Venous thrombosis occurred despite prophylaxis (heparin or compression devices) in 9 of 12 patients. Iliac VT was noted in four patients, two of whom had no lower extremity VT. Upper extremity VT occurred in two patients who had received central venous catheters. CONCLUSIONS: (1) US surveillance may be valuable in high-risk trauma patients because VT is a common finding (21%), despite prophylactic measures. (2) Examination of the upper extremity and pelvic venous system appears to be important, since 33% (4 of 12) of our patients with VT developed thrombi isolated to these regions. These would not have been identified during routine lower extremity duplex studies.

Elderly patients in the emergency department.

Emergency department nursing care of the older individual requires a specific knowledge base to ensure optimal outcomes. Health-care resource utilization specific to elderly patients in the emergency department and selected common health problems that bring older people to the emergency department are described. Distinctions between normal age-related changes and disease signs and symptoms are explained to provide emergency department nurses with the requisite information to care for the elderly appropriately.

Clarification of the role of CT scan in the acute evaluation of blunt abdominal trauma.

We reviewed 100 patients sustaining blunt trauma whose initial evaluation included an abdominal computed tomographic scan (CT) to assess the role of this modality in managing these patients. Indications for CT scan were suspicion of abdominal injury based on mechanism of injury (46), tenderness (22), falling hematocrit (9), hematuria (5), pain (4), and hyperamylasemia (1). Thirty-four patients had abdominal injury, and four scans identified non-traumatic pathology; 66 patients had no evidence of abdominal injury. There were no additional abdominal injuries detected during the hospitalizations. Mechanism of injury was the only indication for CT scan in 20 patients, none of whom had evidence of abdominal injury. CT scan charges for these 20 patients accounted for 5.5% of the total hospital bill ($204,070). Hospital costs would have been reduced by $11,270 if these patients had been followed clinically. Fifteen patients with soft tissue contusions and normal CT scans were hospitalized less than 72 hours. Room and other hospital charges accounted for 38.5% of the hospital bill; these are costs that would have been saved if these patients had been discharged from the emergency service. Several conclusions can be made from this study. First, abdominal CT scan is a sensitive test for abdominal injury. Secondly, patients without objective signs of abdominal injury whose other injuries warrant admission allowing further observation should be followed clinically and do not need the additional expense of abdominal CT scan. Finally, mechanism of injury alone is not an indication for CT scan.

Nonoperative management of adult blunt splenic trauma. Criteria for successful outcome.

Nonoperative management of blunt splenic trauma in adults is controversial despite numerous reports advocating this mode of therapy. Blunt splenic trauma is frequently managed without operation at our institution and, to define criteria that may predict a successful outcome, a retrospective review (1980 to 1988) of all adult splenic injuries was undertaken. Splenic injuries were documented by scintillation studies, CAT scanning, or at laparotomy. Sixty of 252 (24%) splenic injuries were initially treated without operation, which included bed rest, ICU monitoring, frequent physical exams, nasogastric tube, serial hematocrits, and follow-up splenic imaging. Five patients (5 of 60) failed nonoperative management and required interval laparotomy. Reasons for failure included blood loss greater than four units, enlarging splenic defect, or increasing peritoneal signs. Parameters predicting a successful outcome were localized trauma to the left flank or abdomen, hemodynamic stability, transfusion requirements less than four units, rapid return of GI function, age less than 60 years, and early resolution of splenic defects on imaging studies. No morbidity or deaths resulted from delayed operative intervention. In carefully selected adult patients, blunt splenic trauma may be successfully managed without operation.

Blunt hollow viscus injuries of the digestive tract: a poorly recognized phenomenon.

A review of records from admission to the trauma center at Yale-New Haven Hospital for a five year period (July 1981 through June 1986) revealed 41 blunt hollow viscus injuries in 31 patients. Organs injured included small intestine (18), large intestine (14), duodenum (6), stomach (2), and gall bladder (1). The most accurate predictors of blunt hollow viscus injury were peritoneal lavage (91%, n = 14) and abdominal tenderness (50%). Seventeen patients underwent early celiotomy with morbidity and mortality rates of 16% each. Nonetheless, 13 patients had delay in diagnosis with substantially higher morbidity (46%) and mortality (31%). Blunt hollow viscus injuries are uncommon, are difficult to diagnose, and can lead to major morbidity and mortality when diagnosis is delayed.

Cardiac contusion. The effect on operative management of the patient with trauma injuries.

Sixty-four patients with cardiac contusion documented by electrocardiographic changes and creatine kinase MB fraction assay following blunt chest injury were reviewed to assess the impact of cardiac contusion on subsequent management. Fifty-eight patients had elevated creatine kinase MB levels; 35 patients had electrocardiographic abnormalities, including ST-segment and T-wave changes (25), premature ventricular contraction (ten), right bundle-branch block (nine), atrioventricular block (three), atrial fibrillation (three), and premature atrial contraction (two). Thirty patients underwent general anesthesia. There were only four perioperative complications: ventricular ectopy, ventricular fibrillation, nodal rhythm, and pulmonary edema. There were no deaths attributable to cardiac contusion. In summary, patients with blunt trauma who have sustained a cardiac contusion can undergo elective operation with a low incidence of complication. In the emergency setting, however, hemodynamic monitoring for early detection of arrhythmias is indicated.

Impact of a trauma service on trauma care in a university hospital.

This study describes the experience in a major university hospital for a year before and a year after the institution of a trauma service. Demographic data and severity of injury were similar before and after the trauma service was instituted. Nonetheless, mortality for all trauma patients admitted to an intensive care unit decreased somewhat (from 16.1 to 11.8 percent) in the second period of study. When outcome for trauma patients admitted to the surgical intensive care unit was examined, the differences was more impressive, with a reduction in mortality from 27 percent to 6.1 percent. This reduction seemed to be due largely to a decrease in the number of patients who died from sepsis, multiple organ failure, or both. We suggest that trauma care can be significantly improved by an organized approach to the care of the multiply injured patient. A powerful argument can be made for organizing care of injured patients in major hospitals along the lines of a dedicated trauma service.