Utility of plain film pelvic radiographs in blunt trauma patients in the emergency department.

The objective of this study was to evaluate the utility and sensitivity of routine pelvic radiographs (PXR) in the initial evaluation of blunt trauma patients. A retrospective review was performed. One hundred seventy-four patients with a pelvic fracture who had computed tomography (CT) and PXR were included (average age, 36.1; average Injury Severity Score, 16.3). Nine (5%) patients died. Five hundred twenty-one fractures were identified on CT. One hundred sixteen (22%) of these fractures were missed by PXR. Eighty-eight (51%) patients were underdiagnosed by PXR alone. The most common fractures missed by PXR were sacral and iliac fractures. Eight patients required angiograms, with four undergoing therapeutic pelvic embolization. Forty-seven (27%) patients were hypotensive or required a transfusion in the emergency department. These patients were more likely to require an angiogram (17% vs 0%, P < 0.0001) and were more likely to require embolization (9% vs 0%, P < 0.001). This study demonstrates that CT scan is highly sensitive in identifying and classifying pelvic fractures. PXR has a sensitivity of only 78 per cent for identification of pelvic fractures in the acute trauma patient. In hemodynamically stable patients who are going to undergo diagnostic CT scan, PXR is of little value. The greatest use of PXR may be as a screening tool in hemodynamically unstable patients and/or those that require transfusion to allow for early notification of the interventional radiology team.

Predictors of mortality and management of patients with traumatic inferior vena cava injuries.

The aim of this study was to determine factors that predict mortality in patients with traumatic inferior vena cava (IVC) injuries and to review the current management of this lethal injury. A 7-year retrospective review of all trauma patients with IVC injuries was performed. Factors associated with mortality were assessed by univariate analysis. Significant variables were included in a multivariate regression analysis model to determine independent predictors of mortality. Statistical significance was determined at P < or = 0.05. A literature review of traumatic IVC injuries was performed and compared with our institutional experience. Thirty-six IVC injuries were identified (mortality, 56%; mechanisms of injury, 28% blunt and 72% penetrating). There was no difference in mortality based on mechanism of injury. Injuries with closer proximity to the heart were associated with increased mortality (P < 0.001). Univariate analysis demonstrated that nonsurvivors had a higher injury severity scale, a lower systolic blood pressure in the emergency department, a lower Glasgow coma score (GCS), and were more likely to have thoracotomies performed in the emergency department or operating room. Multivariate analysis revealed that only GCS (P = 0.03) was an independent predictor of mortality. Typical factors predicting mortality were identified in our cohort of patients, including GCS. The mechanism of injury is not associated with survival outcome, although mortality is higher with injuries more proximal to the heart. The form of management by IVC level is reviewed in our patient population and compared with the literature.

Predictors of morbidity and mortality in patients with traumatic duodenal injuries.

The aim of our study is to determine factors that predict morbidity and mortality in patients with traumatic duodenal injury (DI). A retrospective review from July 1996 to March 2003 identified 52 patients admitted to our trauma center (age 24.4 +/- 2.1 years, ISS = 18.8 +/- 1.76). The mortality rate for patients with duodenal injury was 15.4 per cent (n = 8). The mechanisms of injury were blunt (62%), gun shot wound (GSW) (27%), and stab wound (SW) (11%). There was no difference in mortality based on mechanism of injury. Management was primarily nonoperative [n = 30 (57%)]. Of those with perforation (n = 22), 64 per cent underwent primary repair (n = 14), 23 per cent duodenal resection (n = 5), 9 per cent duodenal exclusion (n = 2), and one patient pancreaticoduodenectomy. The method of initial surgical management was not related to patient outcome. Univariate analysis demonstrated that nonsurvivors were older, more, hypotensive in the emergency department, had a more negative initial base deficit, had a lower initial arterial pH, and had a higher Injury Severity Score. Nonsurvivors were also more likely to have an associated inferior vena cava (IVC) injury. Multivariate regression analysis revealed age, initial lowest pH, and Glasgow Coma Score to be independent predictors of mortality, suggesting that the physiologic presentation of the patient is the most important factor in predicting mortality in patients with traumatic DIs.

Is field hypotension a reliable indicator of significant injury in trauma patients who are normotensive on arrival to the emergency department?

There is a subset of trauma patients who are hypotensive in the field but normotensive on arrival to the emergency department (ED). Our objective was to evaluate the presence, type, and severity of injuries in these patients. Data were retrospectively reviewed from patients treated at a level 1 trauma center over 1 year. Hypotension was defined as systolic blood pressure (SBP) less than 90 mm Hg. Forty-seven patients were included. The mechanism of injury was blunt in 37 patients and penetrating in 10. The average field SBP was 76 +/- 11 mm Hg. The average SBP on arrival to the ED was 120 +/- 19 mm Hg. The average injury severity score (ISS) was 16.3 +/- 10.3 (range, 1-43). Twenty-four patients (51%) had significant injury (ISS > or = 16). Nine patients (19%) had critical injury (ISS > or = 25). Twenty-six patients (55%) required surgery, and 43 (91%) required ICU admission. Common injury sites included the head and neck (57%), thorax (44%), pelvis and extremities (40%), and abdomen (34%). Overall mortality was 10 per cent (n = 5). All patients that died had significant head and neck injuries (AIS > or = 3). Field hypotension was a significant marker for potential serious internal injury requiring prompt diagnostic workup.