Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury.

Blunt trauma patients with rib fractures were studied to determine whether the number of rib fractures or their patterns were more predictive of abdominal solid organ injury and/or other thoracic trauma. Rib fractures were characterized as upper zone (ribs 1 to 4), midzone (ribs 5 to 8), and lower zone (ribs 9 to 12). Findings of sternal and scapular fractures, pulmonary contusions, and solid organ injures (liver, spleen, kidney) were characterized by the total number and predominant zone of ribs fractured. There were 296 men and 14 women. There were 38 patients with scapular fracture and 19 patients with sternal fractures. There were 90 patients with 116 solid organ injuries: liver (n = 42), kidney (n = 27), and spleen (n = 47). Lower rib fractures, whether zone-limited or overlapping, were highly predictive of solid organ injury when compared with upper and midzones. Scapular and sternal fractures were more common with upper zone fractures and pulmonary contusions increased with the number of fractured ribs. Multiple rib fractures involving the lower ribs have a high association with solid organ injury, 51 per cent in this series. The increasing number of rib fractures enhanced the likelihood of other chest wall and pulmonary injuries but did not affect the incidence of solid organ injury.

Prospective study of validity of neurologic signs in predicting positive cranial computed tomography following minor head trauma.

INTRODUCTION: The ability to discriminate among a large number of patients with mild head injury to detect those most likely to have an intracranial abnormality may offer an advantage in mass-casualty situations and when clinical needs exceed diagnostic capabilities. HYPOTHESIS: In patients with mild head injury (Glasgow Coma Scale score = 13-15), the likelihood of intracranial abnormality, as defined by cranial computed tomography (CT), varies according to presenting neurologic signs and symptoms. METHODS: This prospective study consisted of 152 patients with blunt head trauma and one or more of the following: initial loss of consciousness (LOC), headache, vomiting, convulsions, or amnesia. All underwent cranial CT within one hour of presentation. Positive CT findings were defined as cerebral contusion, extra-axial hematoma, intra-ventricular or subarachnoid hemorrhage, brain edema, and skull fracture. Clinical findings were tabulated and compared with CT findings. RESULTS: The most common symptoms were headache (61%) followed by followed by LOC (45%), vomiting (39%), amnesia (29%), and convulsions (4%). Convulsions were the most predictive of a CT positive finding (80%); history of LOC was least predictive (29%). The presence of two or more clinical findings tended to increase the likelihood of intracranial abnormality, but the association was neither consistent nor additive. CONCLUSIONS: Convulsions occurring in a patient with mild head injury are highly predictive of a positive intracranial finding on CT. Headache, amnesia, and vomiting are each likely to show positive findings in approximately 40-45% of cases. Although the least predictive of the neurologic findings studied, loss of consciousness still correlates with a positive cranial CT in 29% of cases. More than one sign or symptom increases the likelihood of concurrent brain injury.

Laparoscopic rapid totally diverting loop colostomy: a new twist on an old technique.

A minimally invasive variation of an established technique of colostomy is described. The method was originally published in 1977. In a setting where traditional celiotomy is not required, three ports are placed with the left lateral port used for the stoma. After initial peritoneal inspection, the colon segment and its mesentery are identified. A suture is passed forming a loop through the end of a soft latex drain, which is passed into the peritoneal cavity. Using the Goldfinger instrument, the mesentery is breached and the loop end of the drain is snared and brought back through the mesenteric defect. This maneuver enables the colon to be retracted through the port site for completion of the colostomy. Inserting the finger along the loop provides proximal and distal visual confirmation. The colon is stapled but not divided. Maturation of the stoma may be done immediately or delayed depending on the clinical circumstances.

Evaluation of postinjury hepatocyte function by central amino acid clearance.

It has been demonstrated by other investigators that central plasma clearance of amino acids accurately predicts hepatocyte function in patients with liver disease and correlates with clinical outcome. This methodology has not heretofore been studied in the trauma patient. It is our hypothesis that central amino acid clearance in trauma patients is more reflective of hepatocyte function than traditional liver function tests. We examined the plasma amino acid clearance rates using L-[1-13C]phenylalanine. Clearance rates were compared to standard liver function tests (LFTs) and the sensitivity and predictability of the technique were determined. The study was conducted on uninjured control subjects and in seriously injured patients, both with and without significant liver injuries. Compared to baseline values in the control group, initial phenylalanine breath scores were reduced in the injured, but exceeded control levels at 7 days postinjury. These changes were statistically significant. There was no difference between those with and without liver trauma. LFTs showed inconsistent and conflicting results. Thus, central amino acid clearance measured by L-[1-13C]phenylalanine oxidation is depressed immediately following injury but reaches supranormal levels at 7 days postinjury. Compared to LFTs, amino acid clearance suggests initial hepatocyte suppression followed by hyperactivity and is a more accurate determinant of hepatocyte function.

Epidemiology of workplace-related fall from height and cost of trauma care in Qatar.

BACKGROUND: This study was designed to identify the incidence, injury patterns, and actual medical costs of occupational-related falls in Qatar, in order to provide a reference for establishing fall prevention guidelines and recommendations. SETTINGS AND DESIGN: Retrospective database registry review in Level 1 Trauma Center at Tertiary Hospital in Qatar. MATERIALS AND METHODS: During a 12-month period between November 1(st) 2007 and October 31(st) 2008, construction workers who fell from height were enrolled. A database was designed to characterize demographics, injury severity score (ISS), total hospital length of stay, resource utilization, and cost of care. STATISTICAL ANALYSIS: Data were presented as proportions, mean ± standard deviation or median and range as appropriate. In addition, case fatality rate and cost analysis were obtained from the Biostatistics and finance departments of the same hospital. RESULTS: There were 315 fall-related injuries, of which 298 were workplace related. The majority (97%) were male immigrants with mean age of 33 ± 11 years. The most common injuries were to the spine, head, and chest. Mean ISS was 16.4 ± 10. There was total of 29 deaths (17 pre-hospital and 12 in-hospital deaths) for a case fatality rate of 8.6%. Mean cost of care (rounded figures) included pre-hospital services Emergency Medical Services (EMS), trauma resuscitation room, radiology and imaging, operating room, intensive care unit care, hospital ward care, rehabilitation services, and total cost (123, 82, 105, 130, 496, 3048,434, and 4418 thousand United States Dollars (USD), respectively). Mean cost of care per admitted patient was approximately 16,000 USD. CONCLUSIONS: Falling from height at a construction site is a common cause of trauma that poses a significant financial burden on the health care system. Injury prevention efforts are warranted along with strict regulation and enforcement of occupational laws.

Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: a multicenter study.

BACKGROUND: Although the use of stapling devices in elective colon surgery has been shown to be as safe as handsewn techniques, there have been concerns about their safety in emergency trauma surgery. The purpose of this study was to compare stapled with handsewn colonic anastomosis following penetrating trauma. METHODS: This was a prospective multicenter study and included patients who underwent colon resection and anastomosis following penetrating trauma. Multivariate logistic regression analysis was used to identify independent risk factors for abdominal complications and compare outcomes between stapled and handsewn repairs. RESULTS: Two hundred seven patients underwent colon resection and primary anastomosis. In 128 patients (61.8%) the anastomosis was performed with handsewing and in the remaining 79 (38.2%) with stapling devices. There were no colon-related deaths and the overall incidence of colon-related abdominal complications was 22.7% (26.6% in the stapled group and 20.3% in the handsewn group, p = 0.30). The incidence of anastomotic leak was 6.3% in the stapled group and 7.8% in the handsewn group (p = 0.69). Multivariate analysis adjusting for blood transfusions, fecal contamination, and type of antibiotic prophylaxis showed that the adjusted odds ratio (OR) of complications in the stapled group was 0.83 (95% CI, 0.38-1.74, p = 0.63). In a second multivariate analysis adjusting for blood transfusions, hypotension, fecal contamination, Penetrating Abdominal Trauma Index, and preoperative delays the adjusted OR in the stapled group was 0.99 (95% CI, 0.46-2.11, p = 0.99). CONCLUSION: The results of this study suggest that the method of anastomosis following colon resection for penetrating trauma does not affect the incidence of abdominal complications and the choice should be surgeon's preference.