Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal.

BACKGROUND: The mechanism for clearing the cervical spine in patients with altered mental status remains controversial. Recommendations have ranged from removal of the cervical collar after 24 hours in patients with normal radiographs, to indefinite immobilization in a cervical collar, and recently cervical flexion-extension examinations using dynamic fluoroscopy. The purpose of this study was to evaluate the efficacy and safety of dynamic fluoroscopy flexion-extension examinations in identifying ligamentous cervical spine injury and clearing the cervical spine in patients with altered mental status after trauma. METHODS: Patients with a Glasgow Coma Scale score < 13 for greater than 48 hours after admission and normal cervical spine radiographs were candidates for fluoroscopic evaluation. The protocol required visualization of the entire cervical spine, through T1, through full extension and flexion under the direct supervision of a radiologist. Oblique fluoroscopic views were obtained, as necessary, to visualize the cervicothoracic junction. Demographic data, fluoroscopy time, total time per study, true and false positives and negatives, and complications were recorded. RESULTS: From July 1992 through December 1999, fluoroscopic examinations were performed on 301 patients. There were 297 true-negative examinations, 2 true-positive examinations (stable injuries), 1 false-negative examination, and 1 false-positive examination. The incidence of ligamentous injury identified by fluoroscopy in this study was 2 of 301 (0.7%). Unstable cervical spine ligamentous injuries were identified in only 0.02% of all trauma patients. One patient developed quadriplegia when fluoroscopic evaluation was performed after two protocol violations. CONCLUSION: Unstable cervical spine ligamentous injury without fracture is a rare occurrence. The cervical spine may be cleared after a normal cervical spine series (plain radiograph and computed tomographic scan) as recommended in the 1998 Eastern Association for the Surgery of Trauma guidelines. If dynamic fluoroscopy is to be used, adherence to the protocol, including review of the cervical spine radiographs before fluoroscopy and visualization of the entire cervical spine, C1-T1, is mandatory to ensure patient safety.

Delayed pulmonary hemorrhage 17 years after gunshot wound to the chest.

A 45-year-old male returned 17 years after a gunshot wound to the chest with intermittent hemoptysis that progressed to frank pulmonary hemorrhage. The complications of retained intrathoracic foreign bodies are briefly reviewed.

Domestic violence and the trauma surgeon: results of a study on knowledge and education.

BACKGROUND: Despite the frequency of domestic violence in trauma patients, little emphasis has been placed on this subject in the education of surgeons and emergency medicine physicians. The 1997 Advanced Trauma Life Support (ATLS) course included, for the first time, education about domestic violence. This study was done to test the hypothesis that baseline knowledge about domestic violence in trauma care providers is poor and is not improved by the 1997 ATLS course. STUDY DESIGN: A study on domestic violence was designed using attending general surgeons, general surgery and emergency medicine residents, and medical students as test subjects. An educational lecture and pre- and post-tests were developed using the Eastern Association for the Surgery of Trauma position paper on domestic violence and other peer-reviewed literature as information sources. Data collected included level of training, date ATLS course was taken, and pre- and post-test scores. Statistical analysis was performed with ANOVA, with significance attributed to p < 0.05. RESULTS: Ninety-two subjects attended the lecture and completed the pre- and post-tests. The overall mean pre-test score was 54 +/- 1. There was no difference in scores for the 1997 ATLS cohort (with domestic violence material) versus the group with earlier ATLS courses (52 +/- 2 versus 51 +/- 1). The group that had never taken ATLS scored significantly better on the pre-test than the other groups (58 +/- 2, p < 0.05). All groups had significantly increased scores on the post-test (mean 77 < 1, p < 0.001 versus pre-test). CONCLUSIONS: Baseline knowledge about domestic violence among surgeons and emergency medicine physicians was poor and was not improved by participation in the 1997 ATLS course. This study strongly supports the need for expanded domestic violence education for trauma care providers.

Pediatric restraint use in motor vehicle collisions: reduction of deaths without contribution to injury.

HYPOTHESIS: Restraint use for children in automobiles is mandated in every state, but injury patterns are unknown. Although use of pediatric retraints is associated with reducing morbidity and mortality, the injury distribution for specific anatomic sites may be altered in restrained vs unrestrained children. DESIGN: Review of trauma registry data, medical records, and autopsy findings. SETTING: Urban level I trauma center and tertiary care children's hospital. PATIENTS: All children aged 6 years or younger who were in motor vehicle collisions from June 1, 1990, through March 31, 1997. MAIN OUTCOME MEASURES: Age, weight, restraint use and type, collision data, Injury Severity Score (ISS), injury type, and outcome. RESULTS: We included 600 children. The restrained group showed a reduction in severe injuries for every anatomic site and had a lower mean ISS, fewer injuries, and more uninjured children. The restrained group also had a reduction in the incidence of hollow- and solid-organ abdominal injuries. CONCLUSIONS: Age-appropriate restraint devices decrease mortality and reduce the incidence of significant injury in motor vehicle collisions for all anatomic sites in young children. In contrast to injuries attributed to restraint use in adults, specific restraint-related injury patterns were not seen in children.

Pregnant women and car restraints: beliefs and practices.

OBJECTIVE: Motor vehicle collisions are a leading cause of death and disability in pregnant women. The purpose of this study was to examine current restraint practices by pregnant women. Additionally, the beliefs and knowledge of pregnant women about restraint laws and effectiveness were studied. METHODS: From May of 1997 to January of 1998, women were surveyed at initial prenatal visit at four obstetrical clinics. Data collected included age, gravida, ethnicity, educational level attained, payor source, restraint use, and knowledge of effectiveness of restraint use. RESULTS: A total of 807 women completed surveys. Most always wore restraints before pregnancy, but increased restraint use during pregnancy (79% vs. 86%, chi2, p = 0.02). Only 52% used restraints properly. Significantly fewer women believed restraints were beneficial to mother and fetus in late pregnancy compared with early pregnancy. Only 21% of women were educated on proper restraint use during pregnancy. Comparison by payor mix showed no difference in use or education received. CONCLUSIONS: Most women use restraints and continue to do so during pregnancy, but they use them improperly. Pregnant women are familiar with mandatory restraint laws but are less informed about restraint use in pregnancy. Few women receive education from health care providers about proper restraint use. This study highlights the need for aggressive educational efforts to improve car restraint use in pregnant women, thereby reduce maternal and fetal injury and death.

Base deficit in the elderly: a marker of severe injury and death.

BACKGROUND: Base deficit has been used as a marker of significant injury and to predict resource utilization and mortality. The significance of base deficit in trauma patients 55 years and older has not been specifically evaluated. The purpose of this study was to determine the utility of base deficit in assessing older trauma patients versus a younger cohort. METHODS: Data were obtained from the trauma registry on trauma patients admitted to a Level I trauma center. Arterial blood gases were obtained within 1 hour of arrival, by protocol, in 2,631 patients, and of these, 274 patients were 55 years or older. Data are presented as means+/-SEM. Statistical analysis was done by paired t test, analysis of variance, and chi2 analysis. Significance was attributed to a p value < 0.05. RESULTS: Patients older than 55 years were significantly more likely to have sustained blunt trauma (86 vs. 69%; p < 0.001). Despite similar Injury Severity Scores and base deficit values, older patients had markedly greater mortality and intensive care unit lengths of stay. A base deficit of < or = -6 had positive predictive values for Injury Severity Scores > or = 16 for 76% of patients younger than 55 years and 78 % of patients 55 years and older. The negative predictive value of a normal base deficit for Injury Severity Scores < or = 16 was 60% for the younger cohort and only 40% for patients 55 years and older (p < 0.001; chi2). CONCLUSIONS: A base deficit of < or = -6 is a marker of severe injury and significant mortality in all trauma patients, but it is particularly ominous in patients 55 years and older. Patients older than 55 years may have significant injuries and mortality risk without manifesting a base deficit out of the normal range.

Intracranial pressure monitor placement by midlevel practitioners.

BACKGROUND: The timely treatment of patients with head injuries is affected by the availability and commitment of neurosurgeons. Use of midlevel practitioners (MLPs) may permit more efficient neurosurgical coverage. Intracranial pressure monitoring is among the most frequently used neurosurgical procedures. The purpose of this study was to examine the placement of intracranial pressure (ICP) monitors by MLPs. METHODS: Medical records and trauma registry data for a Level I trauma center were reviewed from December 1993 to June 1997. Patients who had ICP monitors placed were included. Patient data recorded were age, mechanism of injury, injury type, ICP monitor placement and length of placement, complications related to the ICP monitor, and outcomes. RESULTS: Two hundred ten patients had 215 monitors placed. ICP monitors were placed by neurosurgeons (105), MLPs (97), and general surgery residents (13), and remained in place a mean of 4 days. No major complications attributable to ICP monitor placement occurred; 19 minor complications (malfunction, dislodgment) were noted. Eleven monitors placed by neurosurgeons (10%), seven placed by MLPs (7%), and one placed by a resident (8%) had complications. CONCLUSION: ICP monitor placement by MLPs is safe. Use of MLPs may aid neurosurgeons in providing prompt monitoring of patients with head injuries.

Base deficit as an indicator or resuscitation needs in patients with burn injuries.

The utility of base deficit (BD) as a marker of shock and as an indicator of resuscitation requirements has been recognized in the trauma population. Base deficit in thermally injured patients has not been closely examined. The purpose of this study was to evaluate the usefulness of initial BD related to other resuscitation parameters in thermally injured patients. Burn center records over a 2-year period were reviewed; patients who survived at least 24 hours and had initial arterial blood gases were included. Parkland estimated fluid requirements underestimated actual volume requirements, but Parkland-calculated fluid requirements were related (p < 0.01) to actual volume requirements. BD had a better correlation to actual volume requirements, and a BD of -6 or less correlated with larger burn size (23% +/- 2% vs 47% +/- 9% total body surface area), and markedly increased mortality rate (9% vs 72%, p < 0.001).

Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation.

OBJECTIVE: The purpose of this study was to determine the incidence of indirect spinal column injury in patients sustaining gunshot wounds to the head. METHODS: A retrospective review of patient records and autopsy reports was conducted of patients admitted with gunshot wounds to the head between July of 1990 and September of 1995 were included. Those with gunshot wounds to the neck and those who were dead on arrival were excluded. RESULTS: A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was determined either clinically, radiographically, or by review of postmortem results. No patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct spinal injury from bullet passage that were apparent from bullet trajectory. More intubation attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with immobilization versus five attempts in four patients without cervical spine immobilization, p = 0.008). CONCLUSIONS: Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.

Can Ringer's lactate be used safely with blood transfusions?

BACKGROUND: Blood bank recommendations specify that Ringer's lactate solution (LR) should be avoided while transfusing blood. However, there are few studies either evaluating or quantifying increased coagulation during rapid infusion of LR and blood. DESIGN AND METHODS: Whole blood (WB, n = 25) and packed red blood cells (PRBC, n = 26) were rapidly admixed with normal saline (NS), Lactate solution and LR with 1 g (LR-1), 2 g (LR-2), and 5 g (LR-5) CaCl2/L solutions for assessment of infusion time, filter weight, and clot formation. RESULTS: No significant differences in infusion time or filter weight using WB or PRBC with NS or LR were seen. No significant difference in clot formation between NS and LR with WB or PRBC was found, but the presence of visible clot was increased in the LR-5 group (P = 0.013, WB, and P = 0.002, PRBC). CONCLUSION: A comparison of LR and NS with rapid infusion rates of blood showed no significant difference between infusion time, filter weight and clot formation. Blood bank guidelines should be revised to allow the use of LR in the rapid transfusion of PRBC.

Does free fluid on abdominal computed tomographic scan after blunt trauma require laparotomy?

BACKGROUND: Abdominal computed tomographic (CT) scans are used in the evaluation of blunt trauma. The purpose of this study was to determine if isolated intraperitoneal fluid seen on CT scan necessitates laparotomy. METHODS: Trauma registry records of patients who underwent abdominal computed tomography from January 1994 through January 1997 were studied. Data were reviewed for age, gender, CT scan interpretation, associated injuries, and operative findings. RESULTS: Abdominal injury was identified in 126 patients. Seventy-eight patients had evidence of solid-organ injury and 17 patients had extraperitoneal injury. Isolated intraperitoneal fluid was identified in 31 patients. All patients with isolated fluid underwent laparotomy; 29 of these procedures (94%) were therapeutic. Bowel injuries occurred in 18 patients and mesenteric injuries in 8 patients. Five patients had intraperitoneal bladder rupture, and undetected solid-organ injuries were found in two patients. Other organs injured included the stomach, pancreas, ovary, and uterus. CONCLUSION: Exploratory laparotomy was therapeutic in 94% of patients. Isolated intraperitoneal fluid on CT scan after blunt trauma mandates laparotomy.

Base deficit is superior to pH in evaluating clearance of acidosis after traumatic shock.

OBJECTIVE: This study was done to evaluate the differences in base deficit (BD) clearance, pH normalization, and the occurrence of complications between survivors and nonsurvivors after trauma. DESIGN: Concurrent data entry with retrospective review. METHODS: Trauma patients meeting registry criteria from July 1990 through August 1995 with arterial blood gases performed within 1 hour of admission and admission BD < or = -6 were included. Data was grouped by BD category (moderate, -6 to -9; severe, < or = -10). Group means +/- SEM were compared with a two-tailed t test. MEASUREMENTS AND MAIN RESULTS: Six hundred seventy-four patients met entry criteria. Survivors in both the moderate and severe BD groups had improved their BD within 4 hours and normalized their BD by 16 hours. Nonsurvivors did not improve their BD category until 8 hours (for the severe group) and 16 hours (for the moderate group) and did not normalize BD before 24 hours. The BD differences between survivors and nonsurvivors were significant at each time interval, whereas pH differences were significant at 2 hours in the moderate group and at 2, 16, and 24 hours in the severe group. Patients who failed to improve their BD > -6 had an increased frequency of adult respiratory distress syndrome, multiple organ failure, and mortality. CONCLUSION: Base deficit reveals differences in metabolic acidosis between survivors and nonsurvivors not shown by pH determinations and is clearly a better marker of acidosis clearance after shock.

Medical versus surgical management of diverticulitis in patients under age 40.

BACKGROUND: Diverticulitis in patients under age 40 is a distinct entity. We compared the medical versus surgical management of diverticulitis for complications and outcomes in these patients. METHODS: A retrospective review was performed for treatment, hospitalizations, complications, and outpatient visits. Complications included readmission, recurrent symptoms after antibiotic therapy, and postoperative problems. RESULTS: Twenty-nine patients had a radiographic or surgical diagnosis of diverticulitis (18 surgical, 11 medical). Medically managed patients had significantly more emergency department visits (4.7 +/- 6.6 versus 0.3 +/- 0.6, P < or =0.01), and readmissions (7 versus 4, P < or =0.02). Three surgical patients (17%) had a total of 6 complications as compared with 6 medical patients (55%) with 25 complications (chi square, P < or =0.05). All medically treated patients had recurrent symptoms, and 6 required surgery. CONCLUSION: Medically managed patients had significantly more emergency department visits and complications than those managed surgically. Surgery is the indicated treatment for the first episode of diverticulitis in patients under age 40.

More guns and younger assailants. A combined police and trauma center study.

OBJECTIVE: To test the hypothesis that guns have become the weapon of choice for assaults and that both assailants and victims have become progressively younger. DESIGN: Retrospective review of trauma center and police department data sources. SETTING: Regional trauma center with university affiliation; municipal police department. SUBJECTS: Victims of assault with a deadly weapon from 3 discontiguous years. MAIN OUTCOME MEASURES: Age of assailant and victim, type of injury, frequency of blunt vs penetrating injury. RESULTS: From June 1991 to May 1992 and June 1993 to May 1994, the incidence of penetrating trauma increased from 27% to 35% of trauma center admissions (chi 2 test; P < .001). During the period from June 1985 to May 1994, assault with a deadly weapon increased by 220% and firearms became the most common assault mechanism (from 32% to 54%; chi 2 test; P < .001). Assailants using guns became significantly younger, with the percentage of assailants aged 11 to 20 years increasing from 24% to 47% (chi 2 test; P = .001). The ages of assault victims also decreased (P < .003), but were more evenly distributed across age categories. CONCLUSIONS: The incidence of penetrating trauma has increased in both absolute numbers and in relative proportion to blunt trauma. Firearms have become the weapon of choice and the single largest group of assailants are 11 to 20 years of age. The use of concurrent police and trauma center databases provides a more cogent basis for developing effective violence prevention strategies.

Effect of alcohol on the utility of base deficit in trauma.

OBJECTIVE: Base deficit (BD) is an indicator of metabolic acidosis and is used as an index of shock and resuscitation for trauma patients. Ethanol causes an increase in lactate production and may cause metabolic acidosis in otherwise normal patients. The effects of alcohol on BD have not been investigated. This study was performed to determine the effects of ethanol on the utility of BD for assessing shock and resuscitation among trauma patients. DESIGN: Retrospective review of trauma registry, blood bank, and medical records data. METHODS: Data were collected for trauma patients admitted to the University Medical Center Level I trauma service from July 1990 through August 1995 with an arterial blood gas and blood alcohol level obtained within 1 hour of admission. MEASUREMENTS AND MAIN RESULTS: The Trauma Score and the Revised Trauma Score were slightly higher (p < 0.001), and the Injury Severity Score was significantly lower (p < 0.001) in the presence of alcohol. These changes were present until patients reached the severe BD category (< or = -10), at which point there were no significant differences across all blood alcohol levels. In spite of these changes, there was no difference in intensive care unit or hospital length of stay in any BD or blood alcohol group. In patients with a BD < or = -6, there was a decreased requirement for transfusion in the presence of alcohol (57 vs. 78%; p < 0.001, chi2), but the majority of patients in both groups required blood transfusion. CONCLUSION: Ethanol can contribute significantly to metabolic acidosis among trauma patients and may confound the utility of BD to some degree. There was no difference in intensive care unit or overall length of stay, however, regardless of ethanol level, and the majority of patients with a BD < or = -6 still required transfusion. Even in the presence of ethanol, a BD < or = -6 remains a powerful indicator of major injury, increased length of stay, and transfusion requirement.

Spinal cord injury. A preventable public burden.

BACKGROUND: Spinal cord injury (SCI) is a devastating occurrence with important consequences for the individual and society. Previous studies have documented the epidemiology and costs of SCI and the rehabilitation needs after SCI; however, data about the preventability of SCI are lacking. OBJECTIVE: To test the hypotheses that most SCIs are preventable and that much of the cost of SCI is borne by the public. DESIGN: Retrospective review of medical records and trauma registry data. SETTING: A 417-bed county hospital with a level I trauma center. METHODS: To evaluate the preventability of SCI, the records of trauma patients sustaining SCI from July 1, 1990, through June 30, 1995, were reviewed. The criteria for preventability of blunt injuries included the following: failure to use restraint devices; intoxication of drivers, motorcyclists, or pedestrians; and falls or diving accidents involving the use of drugs or alcohol. The criteria for preventability of penetrating injuries included the following: illegal possession of a firearm, accidental discharge of a weapon, and suicide attempts. Statistics were performed with the paired Student t test and chi 2 with significance attributed to a P value less than .05. RESULTS: Spinal cord injury occurred in 150 patients; 71% of the injuries were the result of blunt trauma. Injury was potentially preventable in 74% of the blunt injuries and 66% of the penetrating injuries (P = .15). Patients with a penetrating SCI were younger (P < .001) and relied more on public funding than did those with a blunt SCI (65% vs 81%; P = .05). CONCLUSIONS: Most SCIs are preventable with strict enforcement of existing statutes. Furthermore, the financial burden of these preventable injuries is largely borne by the public.

Admission base deficit predicts transfusion requirements and risk of complications.

BACKGROUND: Trauma center resource management could be facilitated by a readily available indicator of resource consumption. This marker should identify patients more likely to require transfusion and intensive care services and to develop complications. Base deficit (BD) has been shown to be a valuable indicator of shock, abdominal injury, fluid requirements, efficacy of resuscitation, and to be predictive of mortality after trauma. This study was performed to determine whether BD could be used to identify which patients were likely to require blood transfusion in the first 24 hours of hospitalization, and to develop shock-related complications and increased intensive care unit (ICU) and hospital stays. METHODS: A retrospective review of 2,954 patients admitted to the Valley Medical Center Level I trauma service from July 1990 through August 1995 was done using the trauma registry and blood bank data bases. Medical record review was done to supplement missing data. RESULTS: Transfusion requirements increased as the BD category became more severe (p < 0.001). Transfusions were required within 24 hours of admission in 72% of patients with a BD < or = -6 versus 18% of patients with a BD > -6 (p < 0.001, chi 2). Both ICU and hospital length of stay increased with worsening BD (p < 0.015 and p < 0.05, respectively). The frequency of adult respiratory distress syndrome (ARDS) (p < 0.01), renal failure (p = 0.015), coagulopathy (p < 0.001), and multiorgan system failure (MOF) (p = 0.002) all increased with increasingly severe BD. Discriminate analysis using Injury Severity Score (ISS) and BD category demonstrated predictive accuracy of 81%, 77%, and 77% for coagulopathy, ARDS, and MOF, respectively. Mortality also increased with worsening BD. When stratified by BD category, there was no difference between observed and predicted survival. CONCLUSIONS: Admission BD identifies patients likely to require early transfusion and increased ICU and hospital stays, and be at increased risk for shock-related complications. Patients with BD < or = -6 should undergo type and cross-match rather than type and screen. The use of ISS and BD category probability curves may identify candidates for early invasive monitoring.

Maxillary sinusitis in the surgical intensive care unit: a study using bedside sinus ultrasound.

PURPOSE: This study investigates the incidence of acute maxillary sinusitis (AMS) in the surgical intensive care unit (SICU). METHODS: One hundred consecutive patients admitted to the SICU were examined in a prospective observational mode. Bedside sinus ultrasound (SUS) was performed on admission and every 48 hours. Patients with sinus fluid by SUS and unexplained sepsis underwent confirmatory sinus aspiration. RESULTS: The development of fluid in the maxillary sinus was identified in 15 patients by SUS. Acute maxillary sinus occurred in only 1 (1%). CONCLUSION: This study shows SUS to be a simple, efficient method for determining the presence of maxillary sinus fluid in the SICU. Acute maxillary sinus was an unusual finding. Our policy of avoidance of nasal instrumentation may have contributed to the low incidence of AMS in this high-risk patient population.