Economic problem of referred trauma cases in Siriraj Hospital.

To improve the service for referred trauma patients, the authors have to know the types of injury, the cost, and the reimbursement for each individual category. Therefore, the authors studied the characteristics of accident of patients transferred for treatment at Siriraj Hospital, including types of trauma (wounds), cost of treatment (excluding doctor's fees) and charges for treatments for each group. There were 678 trauma cases referred to the Division of Trauma Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital from 1st September 2002 to 31st August 2003 and of these, 571 cases were admitted From the admitted cases, the most common injury was the musculoskeletal system (38.6%), followed by nervous system injury (15.1%), eye injury (8.1%), toxic substance injury (6.3%), burns (5.8%), and others. The total cost of treatment was 36,249,150 baht. The reimbursement was 30,135,709 baht. There were four categories where the reimbursed amount was below the actual cost. They were burns, followed by nervous system injury, eye injury and skin or subcutaneous tissue injury. To deal with the referred cases in trauma center level I, the center should prepare to manage the common trauma groups such as musculoskeletal system injury, nervous system injury and eye injury. Burns, nervous system injury, eye injury and skin or subcutaneous tissue injuries are the major groups that cost more than the reimbursement amount. The reimbursement of these groups should be reconsidered in the future to solve the problem.

Management of life threatening hemorrhage from facial fracture.

Persisted bleeding from facial fractures after nasal packing or direct pressure is not common, however if it happens, the mortality rate is very high. The study of the treatment for this group of surviving patients was made to find the guideline for management of these patients. From the period of 1 January 1993 to 31 December 2002, 3756 cases of facial fractures were treated at the Trauma Center, Faculty of Medicine, Siriraj Hospital. There were 14 life-threatening hemorrhage cases and 9 patients survived. They were 3 Le Fort fracture, 2 nasal fracture, 1 mandibular fracture and 3 multiple facial fractures. Repacking of nasal cavities was performed and was able to stop bleeding successfully in 2 cases. Three cases required operation and 3 cases had angiography and embolization. One case still bled after operation and needed angiography and embolization. The present study shows that the adequacy of nasal packing or wound compression should be evaluated first. Early operation could stop bleeding in nearly half of the cases. Angiography and embolization can be used alone or adjunct to the operation to control bleeding with good result.

Zygomatic fracture at Siriraj Hospital.

A prospective study was made of patients with zygomatic bone fracture at Siriraj Hospital from January 1st, 1995 to December 31st, 2000 to evaluate their etiology, type of fracture, complications of fracture, operative techniques used and the results of treatment. Out of 2127 cases that presented to the Facial Fracture Clinic, Division of Trauma Surgery, Department of Surgery during this period, there were 431 cases of fractured zygoma. Most of the cases, which were more common in males, were caused by traffic accidents. The peak age-incidence was 21-30 years old and the most common type of fracture was trimalar. Common complications of fracture were sensory impairment, limitation of opening the mouth and diplopia. In order to reduce the fractures, a Gillies' approach was used in 210 cases, an infraorbital approach in 203 cases, Dingman's approach in 87 cases and a Gingivo buccal approach in 20 cases and applied internal fixation in 216 cases. The floor of the orbit was repaired in 36 cases. The post-operative wound infection rate was 1.1%. The authors conclude that zygomatic fracture is a common facial fracture caused by traffic accidents. Open reduction with or without internal fixation by a variety of approaches provides good functional and cosmetic results with very few complications.

Epidemiological pattern of renal injuries and their evaluation and management.

To determine the epidemiological pattern of renal injuries and to define appropriate methods for their evaluation and management. Material and Methods: We reviewed retrospectively the medical records of 65 patients who were admitted to Siriraj Hospital, between September 1996 and February 2000. Details of patients, mechanism of injury, chief complaint, hematuria, associated injuries, radiographic assessment, management and complications of renal injury were analysed. Results: The study group consisted of 54 men and 11 women with a mean age of 31 years. Blunt and penetrating trauma occurred in 55 (85%) and 10 (15%) patients, respectively. Hematuria was present in 62 patients (95%) and absent in 3 patients (5%). Associated organ injuries were present in 37 patients (57%) and mostly occurred in blunt trauma patients. Chest injuries were the most common cause of associated injuries. Associated abdominal injuries in 17 patients (26%) involved primarily the liver and spleen. In hemodynamically stable patients, preoperative staging was performed in 47 patients (72.3%) with an intravenous pyelogram (IVP). Of 55 patients with blunt renal injuries, 32 (58%) were managed nonoperatively and 23 (42%) underwent exploratory laparotomy. In patient with blunt trauma requiring laparotomy, 6 (26%) underwent renal exploration while the remaining 17 (74%) were treated with expec-tant management and 3 (17.6%) of them had renal complications. Nine out of 10 penetrating trauma patients required laparotomy with renal exploration, but none of them had renal complications. Conclusion: In the evaluation of renal injuries and the accurate staging of these, it is important to define the full extent of the injury in order to decide on the most appropriate management. This will avoid unnecessary surgery in patients with minor injuries and these with limited major injuries, and will avoid the risk of secondary surgery, renal loss and other complications in patients with extensive injuries treated by operation.

Facial fractures in sport.

Injury from sport is an important area in medicine today. Facial injuries in sport have, until received little publicity in Thailand. The purpose of this paper is to focus on facial fractures in sport. A descriptive analysis is made of facial fracture injuries, using facial fracture records in Siriraj Hospital between 1991 and 1995. It was found that only 47 cases (2.0%) resulted from sporting activities. Eighty-nine percent were men. The peak incidence occurred at ages between 11 and 20 years. The most common types of sport associated with facial injuries were soccer (61.7%), followed by rugby (6.4%), basketball (4.3%), water-skiing (4.3%) and ratten ball (4.3%). A total of 34 cases (72.3%) were recorded with nasal fracture, plus eight cases (17.0%) of zygomatic fracture, three cases (6.4%) of maxillary fracture and two cases (4.3%) of mandibular fracture. Included in this series, were two cases of severe fracture, one caused by water-skiing and the other by soccer.

Facial fractures from blunt object injury treated at Siriraj Hospital.

There were 1,819 cases of facial fracture from blunt object injury treated by the Division of Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, during the period January 1, 1983 to December 31, 1988. The male-to-female ratio was 3.5:1. The ages of the patients ranged from 2 to 93 years, with the most frequent range encountered being between 21 and 30 years (44.5%). The most common was traffic accidents (54.1%), followed by physical assault, sports, occupational and self-inflicted injury among others. There were 1,749 new cases and 70 cases referred by other hospitals. The facial fractures were classified into five groups: 1. Nasal fracture (30.0%), 2. Mandibular fracture (26.5%), 3. Zygomatic fracture (24.2%), 4. Maxillary fracture (15.7%), 5. Frontal fracture (3.6%).

Application of a net around the severely injured liver : A case report.

An anternative modality in control of severe bleeding form liver injury by using a surgifix compression was presented. The patient was an 8 year old boy with severe laceration of the liver from blunt abdominal trauma. Only one unit of blood could be cross-matched for him due to Ante Lewis and Rh-blood group. Laparotomy was performed, the liver fragments were pulled together with a net (PresnetR) and reinforced with abdominal swab packing. The packing and the net were removed three days later. There was no further bleeding and the lacerated liver began to heal. The postoperative period was uneventful. He was discharged home after 16 days in hospital.