Initial predictors associated with outcome in injured multiple traumatic limb amputations: a Kandahar-based combat hospital experience.

INTRODUCTION: Improvised explosive devices (IEDs) are the defining mechanism of injury during Operation Enduring Freedom. This is a retrospective analysis of initial management for IED blast injuries presenting with bilateral, traumatic, lower-extremity (LE) amputations with and without pelvic and perineal involvement. METHODS: A database of trauma admissions presenting to a North Atlantic Treaty Organization (NATO) Role 3 combat hospital in southern Afghanistan over a 7-month period was created to evaluate the care of this particular injury pattern. Patients were included if they were received from point of injury with at least bilateral traumatic LE amputations and had vital signs with initial resuscitation efforts. RESULTS: Thirty-two presented with double LE amputations (36%) and nine with triple amputations (10%). After excluding 10 patients who failed to meet the inclusion criteria, 22 patients were analysed. The mean age was 29 years, and the average ISS and admission haemoglobin were 22 and 11.3mgl(-1), respectively. Patients received an average of 54 units of blood products and underwent 1.6 operations with a mean operative time of 142.5min. The pattern of injury was associated with an increase in the total blood products required for resuscitation (pelvis n=12, p=0.028, gastrointestinal tract (GI) n=14, p=0.02, perineal n=15, p=0.036). There was no relationship between ISS or admission haemoglobin and the need for massive transfusion. Low Glasgow Coma Scale (GCS) was associated with increased 30-day mortality. Hollow viscus injury and operative hemipelvectomy were also associated with mortality. CONCLUSIONS: Early 30-day follow-up demonstrated that IED injuries with bilateral LE amputations with and without pelvic and perineal involvement are survivable injuries. Standard measures of injury and predictors of survival bore little relationship to observed outcomes and may need to be re-evaluated. Long-term follow-up is needed to assess the extent of functional recovery and overall morbidity and mortality.

Multidisciplinary trauma team care in Kandahar, Afghanistan: current injury patterns and care practices.

Multidisciplinary trauma care systems have been shown to improve patient outcomes. Medical care in support of the global war on terror has provided opportunities to refine these systems. We report on the multidisciplinary trauma care system at the Role III Hospital at Kandahar Airfield, Afghanistan. We reviewed the Joint Trauma System Registry, Kandahar database from 1 October 2009 to 31 December 2010 and extracted data regarding patient demographics, clinical variables and outcomes. We also queried the operating room records from 1 January 2009 to 31 December 2010. In the study period of 1 October 2009 to 31 December 2010, 2599 patients presented to the trauma bay, with the most common source of injury being from Improvised Explosive Device (IED) blasts (915), followed by gunshot wounds (GSW) (327). Importantly, 19 patients with triple amputations as a result of injuries from IEDs were seen. 127 patients were massively transfused. The in-hospital mortality was 4.45%. From 1 January 2010 to 31 December 2010, 4106.24 operating room hours were logged to complete 1914 patient cases. The mean number of procedures per case in 2009 was 1.27, compared to 3.11 in 2010. Multinational, multidisciplinary care is required for the large number of severely injured patients seen at Kandahar Airfield. Multidisciplinary trauma care in Kandahar is effective and can be readily employed in combat hospitals in Afghanistan and serve as a model for civilian centres.

The epidemiology of dog attacks in an urban environment and the risk of vascular injury.

We performed this study to determine the associated injuries after dog attacks and determine the incidence of vascular injury (VI) and potential associated factors. The registry at our Level I center was queried for admissions after dog bites between January 1,1992 and June 30, 2008. Demographic, injury, and outcome data were studied. We examined associations with VI. There were 86 eligible patients. Most were male (57, 66.3%). Mean age was 34.1 (+/- 20.1). Mean injury severity score was 3.9 (+/- 4.3). The most common serious injury was upper extremity fracture and/or dislocation (26, 30.2%), followed by VI (10, 11.6%) to the extremities (8, 9.3%) and neck (2, 2.3%). There were 44 (51.2%) operative cases including 28 (32.6%) wound debridements and 22 (25.6%) orthopedic interventions. Nine (10.5%) VI patients required operation. Mean length of stay was 5.7 (+/- 5.9) days. There were two (2.3%) deaths. Both were unrelated to the attack. No studied variable reliably predicted VI. Many patients admitted after dog attacks will require an operative intervention and several will harbor a VI. The presence of VI is unpredictable, lacking reliable associated patient and admission factors. A high index of suspicion is required in the evaluation of patients involved in dog attacks.

Iliac artery injuries and pelvic fractures: a national trauma database analysis of associated injuries and outcomes.

BACKGROUND: Although infrequent, injury to the common or external iliac artery in association with pelvic fractures can be devastating, and descriptive data are lacking. This study was performed to determine the incidence, injury patterns, and outcomes of blunt iliac artery injuries (BIAIs) in association with moderate or severe pelvic fractures. METHODS: Patients with moderate or severe pelvic fractures (abbreviated injury score of 3 or 4) were identified from the National Trauma Databank. Records with and without common or external BIAI were compared. Admission variables included Emergency Department (ED) hypotension (systolic blood pressure <90), Glasgow Coma Score or=25, femur or lumbosacral fractures, solid organ injury, vascular injury, and hollow viscus injury. The association of BIAI with moderate or severe pelvic fractures was studied. Outcomes were also analyzed, and independent associations with BIAI were determined by logistic regression. RESULTS: Of 6,377 patients with moderate or severe pelvic fractures, 221 (3.5%) had an associated BIAI. Patients with BIAI were more likely to have ED hypotension, Glasgow Coma Score or=25, genitourinary injury, bowel injury, and severe (abbreviated injury score 4) pelvic fractures. BIAI was also associated with higher mortality, lower extremity amputation, compartment syndrome, and overall complications. Independent risk factors for BIAI included severe pelvic fracture, ED hypotension, ISS >or=25, genitourinary injury, and bowel injury. CONCLUSION: BIAI is a rare diagnosis, but when present it is associated with a higher rate of overall complications and mortality. Vigilance is warranted in the diagnosis and management of this infrequent injury, especially in the setting of severe pelvic fractures.

Prospective evaluation of a predictive model of mortality in patients with isolated head injury.

BACKGROUND: In a previous retrospective study, we developed a predictive model of survival in isolated head injuries based on easily available parameters such as age, mechanism of injury, Glasgow Coma Scale, and head Abbreviated Injury Scale (AIS). The purpose of the present study is to prospectively evaluate this predictive model. METHODS: Isolated head injuries admitted to a Level I urban trauma center were prospectively accrued from May 1, 2006 through April 30, 2007. Age, mechanism of injury, Glasgow Coma Scale, head AIS, and survival status were recorded for each patient. Patients with extracranial AIS >3, head AIS = 6, or hypotension were excluded. These data were entered into our previously developed predictive model and the percentage of correct classification was used to measure how well the predictive model predicted outcome. Sensitivity, specificity, positive and negative predictive values, and their 95% confidence intervals were calculated and compared with values obtained from our original, retrospective study. RESULTS: Seven hundred eighty-six patients met the criteria for inclusion in the study with an overall mortality of 5.8% (46 patients). When entered into our predictive model, the percentage of correct classification rate was 92% compared with the 94% rate seen in the original study, which is better than other available predictive tools based on combined scoring systems such as the Trauma and Injury Severity Score methodology. CONCLUSION: When evaluated prospectively, our predictive model has similar accuracy in predicting survival of all patients with head trauma as our original retrospective study and performs better than other predictive models such as the Trauma and Injury Severity Score methodology. This study demonstrates that a simple table based on easily obtained admission patient characteristics can rapidly provide information about the probability of survival in patients with head injuries.

Outcomes of blunt assault at a level I trauma center.

BACKGROUND: Physical assault is common in trauma patients. Penetrating injuries resulting from interpersonal violence have been well described in literature, but there have been few studies examining the injury patterns due to assaults with hands and feet or blunt instruments. METHODS: The Trauma Registry of an American College of Surgeons Level I center was queried for all patients with an E-code diagnosis of assault by hands and feet or blunt instrument for the period of January 1, 1992 to September 30, 2005. Demographic and injury pattern data were analyzed. Univariate and multivariable analysis was performed to identify independent predictors of mortality. RESULTS: There were 3,286 patients identified (89.7% male) with a mean age of 36 years +/- 13 years and mean injury severity score of 8 +/- 7. Overall, 65 (2.0%) patients required laparotomy, 10 (0.3%) required craniectomy, and 1 (0.03%) patient required thoracotomy. Traumatic brain injury was present in 66.5% (2,184). Mortality was 2.4% (80). Patients older than 55 years were more likely to be severely injured (injury severity score > or = 16) (23.4% vs. 14.6%, p < 0.001) and were more likely to die of injuries (4.8% vs. 2.1%, p < 0.05). Nineteen (0.6%) patients had documented fractures of the cervical spine and cervical spinal cord injury was not observed in any patient. CONCLUSIONS: Injuries due to assault rarely require operative intervention and have a low risk of cervical spine or cord injuries. However, many result in traumatic brain injury. Patients older than 55 years tend to be more severely injured and at higher risk of mortality.

Blunt assault is associated with failure of nonoperative management of the spleen independent of organ injury grade and despite lower overall injury severity.

OBJECTIVE: Nonoperative management (NOM) of blunt splenic injuries has become standard of care for its high success rate. We observe that many blunt assault (BA) patients fail NOM despite lower overall injury severity. We performed this study to determine whether BA is independently associated with failed initial NOM (FiNOM) of splenic injuries. METHODS: Using the Trauma Registry at our level I center, we reviewed data of all patients with blunt splenic injuries, who did not undergo immediate operative management of the spleen, admitted from January 1, 1992 to December 31, 2007. Initial NOM was defined as any patient who did not undergo immediate (< or =12 hours after admission) operative intervention for the spleen or did not undergo operation for the spleen at any time during the admission. FiNOM was defined as any patient who underwent operative management of the spleen greater than 12 hours after admission. Logistic regression was performed to determine whether BA was independently associated with FiNOM. RESULTS: FiNOM occurred in 57 of the 419 (13.6%) patients initially managed nonoperatively. FiNOM decreased significantly in non-BA patients from 15.8% (1992-1999) to 6.2% (2005-2007) (p = 0.05) over time. This was not true for BA patients (33.3% vs. 30%) (p = 0.78). FiNOM for BA patients was 36.1% (13 of 36) versus 11.5% (44 of 383) for all other mechanisms combined. FiNOM was increased across all Organ Injury Scale scores for the spleen in BA patients. BA was independently associated with FiNOM. CONCLUSIONS: BA is associated with FiNOM independent of severity of splenic injury. Despite an increasingly successful policy of NOM in all blunt splenic injuries, this does not apply for BA. BA should be an important factor considered when initial NOM is contemplated for blunt splenic injury because of the high failure rates compared with all other mechanisms.

Coagulopathy in severe traumatic brain injury: a prospective study.

BACKGROUND: The incidence and risk factors for traumatic brain injury (TBI)-associated coagulopathy after severe TBI (sTBI) and the effect of this complication on outcomes have not been evaluated in any large prospective studies. METHODS: Prospective study of all patients admitted to the surgical intensive care unit (ICU) of an urban, Level I trauma center from June 2005 through May 2007 with sTBI (head Abbreviated Injury Scale score of >or=3). Criteria for TBI-coagulopathy included a clinical condition consistent with coagulopathy, i.e. sTBI, in conjunction with a platelet count <100,000 mm3 and/or elevated international normalized ratio and/or activated partial thromboplastin time. The following potential risk factors with p < 0.2 on bivariate analysis were included in a stepwise logistic regression analysis to identify independent risk factors for TBI coagulopathy and its association with mortality: age, mechanism of injury (blunt [B] or penetrating [P]), presence of hypotension upon admission, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), head and other body area Abbreviated Injury Scale, isolated head injury, diffuse axonal injury, cerebral edema, intracranial hemorrhage (intraventricular, parenchymal, subarachnoid, or subdural), pneumocephalus, and presence of midline shift. RESULTS: A total of 436 patients (392 blunt, 44 penetrating) met study criteria, of whom 387 patients had isolated SHI. TBI coagulopathy occurred in 36% of all patients (B: 33%, P: 55%; p < 0.0075) and in 34% of patients with isolated head injury (B: 32%, P: 54%; p = 0.0062). Independent risk factors for TBI-coagulopathy in isolated sTBI were found to include a GCS score of or=16, presence of cerebral edema, subarachnoid hemorrhage, and midline shift. ICU lengths of stay were significantly longer in SHI patients who developed TBI coagulopathy (12.7 vs. 8.8 days; p = 0.006). The development of TBI coagulopathy in SHI was associated with increased mortality, adjusted odds ratio (95% confidence interval): 9.61 (4.06-25.0); p < 0.0001. CONCLUSION: The incidence of TBI coagulopathy in SHI is high, especially in penetrating injuries. Independent risk factors for coagulopathy in isolated head injuries include GCS score of or=16, hypotension upon admission, cerebral edema, subarachnoid hemorrhage, and midline shift. The development of TBI coagulopathy is associated with longer ICU length of stay and an almost 10-fold increased risk of death.