Aetiologies and outcomes of wounds in an outpatient programme.

This study reviewed the records of all new patients seen in an outpatient wound-care programme during a six-month period. Most of the 115 patients were referred by physicians in internal medicine or family practice (48%) or surgeons (39%); 101 had a wound (88%). Of the 92 who had their wound measured at the time of their first clinic visit, 72 (78%) had their largest wound located on a lower extremity and 40% of all lower extremity wounds were on the feet. Wounds were most frequently due to pressure (36%), venous insufficiency (16%), diabetic neuropathy (16%), or arterial insufficiency (13%). Within 12 months of their initial presentation, wound closure was documented in 35 of the 92 patients (38%). Of the four most common aetiologies, the healing rate was highest in wounds attributable to venous insufficiency (67%) (p < 0.02).

Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity.

OBJECTIVE: To describe the nature of delayed hemothorax occurring after blunt thoracic trauma and to identify the population at risk for this complication. METHODS: A retrospective review was conducted of 36 consecutive patients with hemothorax consequent to blunt trauma. Criteria for the definition of delayed hemothorax were established involving normal interval chest radiographs or computed tomographic scans during hospitalization. RESULTS: Twelve cases of delayed development of hemothorax were identified. Ninety-two percent of cases occurred in patients with multiple or displaced rib fractures. Presentation occurred from 18 hours to 6 days after injury. Eleven of the 12 cases were heralded by a prodrome of new pleuritic chest pain and dyspnea that occurred from 4 to 19 hours before treatment. CONCLUSION: Delayed hemothorax after blunt trauma is a unique entity occurring in patients with multiple or displaced rib fractures. Vigilance for the recognizable prodrome in the high-risk population should allow early remediation of this complication.

Aetiologies and outcomes of wounds in an outpatient programme.

This study reviewed the records of all new patients seen in an outpatient wound-care programme during a six-month period. Most of the 115 patients were referred by physicians in internal medicine or family practice (48%) or surgeons (39%); 101 had a wound (88%). Of the 92 who had their wound measured at the time of their first clinic visit, 72 (78%) had their largest wound located on a lower extremity and 40% of all lower extremity wounds were on the feet. Wounds were most frequently due to pressure (36%), venous insufficiency (16%), diabetic neuropathy (16%), or arterial insufficiency (1 3%). Within 12 months of their initial presentation, wound closure was documented in 35 of the 92 patients (38%). Of the four most common aetiologies, the healing rate was highest in wounds attributable to venous insufficiency (67%) (p < 0.02).

Long-term functional status and mortality of elderly patients with severe closed head injuries.

OBJECTIVE: To evaluate long-term clinical outcome of elderly patients with severe closed head injuries. DESIGN: Retrospective study. PATIENTS AND METHODS: All patients older than 65 years of age admitted to a regional trauma center with a diagnosis of closed head injury and an admission Glasgow Coma Scale (GCS) score of 8 or less. Using chi 2 analysis, Student's t test, and multiple logistic regression, we correlated age, sex, mechanism of injury, pupillary reactivity, alcohol and drug use, admission GCS score, Injury Severity Score, Revised Trauma Score, heart rate, and blood pressure to the main outcome measures, i.e. long-term functional outcome and mortality. RESULTS: Among 40 elderly patients who met the criteria, 27% were still alive at the end of 38 +/- 3 month follow-up. Eighty-five percent of patients who were discharged from the hospital were still alive long-term, but did not show significant neurologic improvement. In a univariate analysis, GCS and pupillary reactivity were predictive for long-term functional outcome and mortality. In a multivariate analysis, GCS and heart rate were predictive. All patients with an admission GCS score of 3 died in-hospital. All patients with an admission GCS score of 3 to 7 were either deceased or lived in persistent vegetative or dependent functional states. CONCLUSIONS: Elderly patients with severe closed head injuries have high in-hospital mortality. Those who survived the hospital stay had high long-term survival, but did not show significant functional improvement. Prediction of long-term functional status is vital to the trauma care of elderly patients with severe closed head injuries.

Vehicular trauma triage by mechanism: avoidance of the unproductive evaluation.

An instrument was developed using routinely available field data to identify the sizable subgroup of stable vehicular trauma victims initially triaged to the trauma center by mechanism indicators alone who are in reality at minimal risk for serious injury. The six most common vehicular mechanism indicators seen at a level I trauma center were evaluated: rollover, head-on greater than 30 mph, intrusion, prolonged extrication, other death in same vehicle, and ejection. Review of 1235 consecutive trauma team activations yielded 349 victims with a qualifying vehicular mechanism. Outcome indicators were used to classify patients into two groups: Minor Injury (MI) and Severe Injury (SI). Nineteen common field data elements routinely reported on arrival by the regional Emergency Medical Service (EMS) personnel were then reviewed. Data patterns associated only with the MI group were sought. A checklist was developed for Mechanism vehicular trauma utilizing physiologic, anatomic, and neurologic elements. A single positive element would define trauma team activations. Retrospectively, use of this instrument would have excluded 56% of the MI group from unproductive trauma team referral, but nearly none of the SI group. We conclude that an identifiable subset of trauma patients referred by vehicular mechanism criteria alone could be safely evaluated on arrival in the emergency department as a form of secondary triage rather than by referral to the trauma team. The use of an appropriate exclusionary instrument can still preserve the sensitivity of trauma team activation for severely injured victims.

Functional scoring of multi-trauma patients: who ends up where?

To help map the continuum from injury to return to full function, the Functional Independence Measure (FIM) was used in an acute care setting to identify and track disability, to focus rehabilitative efforts during the acute phase of care, and to help demonstrate what is truly important in getting patients back to full functional status. A total of 109 patients were assessed over a 13-month period. FIM scores were based on a patient's ability to routinely perform certain tasks in 18 areas of function and ranged from 1 to 7. The change in FIM scores from admission to discharge was used to determine those patients to be discharged home and those patients to be discharged to a rehabilitation facility. We conclude that the FIM is a very useful tool that produced a very good measure of a patient's total function, tracked progress or lack of it through acute hospitalization, and correctly categorized and quantitated dysfunction (both cognitive and physical) as discharge planning was being done.

Subacute sequelae of carbon monoxide poisoning.

From January 1980 to August 1983, 213 patients with carbon monoxide poisoning were seen; 131 received hyperbaric oxygen and had no sequelae. Eighty-two patients were treated with normobaric oxygen; ten (12.1%) returned with clinically significant sequelae. The specific neurological sequelae included headaches, irritability, personality changes, confusion, and loss of memory. This recurrent symptomatology developed within one to 21 days (mean, 5.7 days) after the initial exposure, although no reexposure occurred. These recurring symptoms resolved rapidly with hyperbaric oxygen therapy. We recommend that hyperbaric oxygen therapy be used whenever CO poisoning symptoms recur.