Consequences and costs of lower extremity injuries.

Lower extremity injuries resulting from motor vehicle crashes are common and have become relatively more important as more drivers with newer occupant restraints survive high-energy crashes. CIREN data provide a greater level of clinical detail based on coding guidelines from the Orthopedic Trauma Association. These detailed data, in conjunction with long-term follow-up data obtained from patient interviews, reveal that the most costly and disabling injuries are those involving articular (joint) surfaces, especially those of the ankle/foot. Patients with such injuries exhibit residual physical and psychosocial problems, even at one year post-trauma.

Causes and outcomes of mild traumatic brain injury: an analysis of CIREN data.

Approximately one-half of vehicle occupants with traumatic brain injury (TBI) have a mild TBI (admission Glasgow Coma Scale (GCS) score of 13-15 with transient loss of consciousness). However, despite the label of "mild", many of these injuries result in long-term consequences; frequently these sequelae go unrecognized, as the patients are lost to medical follow-up. The Crash Injury Research Engineering Network (CIREN) project affords us the opportunity to examine the crash circumstances, injury sources and outcomes of mild TBI cases in greater detail.

A longitudinal study of former trauma center patients: the association between toxicology status and subsequent injury mortality.

BACKGROUND: Despite the current emphasis on injury prevention, little has been done to incorporate alcohol intervention programs into the care of the injured patient. The purpose of this study was to determine whether patients admitted to a trauma center with positive toxicology findings (TOX+) have a higher subsequent injury mortality than those without such findings (TOX-). METHODS: We followed a cohort of 27,399 trauma patients discharged alive between 1983 and 1995 to determine subsequent mortality. Death certificates were obtained to identify the cause of death. RESULTS: TOX+ patients had an injury mortality rate approximately twice that of the TOX- group (1.9% vs. 1.0%, p < 0.001). Overall, 22.7% of the deaths were due to injury; the TOX+ rate was 34.7% versus 15.4% for the TOX-. CONCLUSION: These data add strength to the premise that untreated substance abuse-related injury remains an untapped injury prevention opportunity.

Epidemic increases in cocaine and opiate use by trauma center patients: documentation with a large clinical toxicology database.

BACKGROUND: Although reports have documented alcohol and other drug use by trauma patients, no studies of long-term trends have been published. We assessed substance use trends in a large cohort of patients admitted to a regional Level I adult trauma center between July 1984 and June 2000. METHODS: Positive toxicology results, collected via retrospective database review, were analyzed for patients admitted directly to the center. Data were abstracted from a clinical toxicology database for 53,338 patients. Results were analyzed for alcohol, cocaine, and opiates relative to sex, age (< 40/> or = 40 years), and injury type (nonviolence/violence). Positive toxicology test result trends were assessed for the 3 years at the beginning and end of the period (chi2). Testing biases were assessed for sex, race, and injury type. RESULTS: The patient profile was as follows: men, 72%; age < 40 years, 69%; nonviolence victims, 77%. Alcohol-positive results decreased 37%, but cocaine-positive and opiate-positive results increased 212% and 543%, respectively (all p < 0.001). Cocaine-positive/opiate-positive results increased 152%/640% for nonviolence and 226%/258% for violence victims, respectively (all p < 0.001). In fiscal year 2000, cocaine-positive and opiate-positive results were highest among violence victims (27.4% for both drugs). Cocaine-positive and opiate-positive results among nonviolence victims were 9.4% and 17.6%, respectively. Patients who were minorities or victims of violence were not tested more frequently than other patients. CONCLUSION: Epidemic increases in cocaine and opiate use were documented in all groups of trauma patients, with the greatest increases being in violence victims. Alcohol use decreased for all groups.

Gender differences in adverse outcomes after blunt trauma.

BACKGROUND: High testosterone and low estradiol levels induce immunosuppression and adverse outcome after trauma in male animals. Gender-based outcome differences in human trauma have not been investigated. In order to test our hypothesis that female gender is associated with improved outcome after trauma, we conducted an inception cohort study at the R. Adams Cowley Shock Trauma Center, the adult trauma resource center for the state of Maryland. METHODS: All were blunt trauma patients (18,892) admitted from 1983 to 1995, stratified by Injury Severity Score (ISS) and age. Gender differences in mortality; nosocomial infection; and preinjury diabetes and cardiac, pulmonary, and liver diseases were determined. RESULTS: No significant differences in preinjury diseases were identified. Death and gender were independent variables in all groups except for patients who developed pneumonia. Male patients had a higher incidence of pneumonia in all groups except age 18 to 45, with an ISS < 15. The association between male gender and pneumonia was strongest in the age 46 to 65, ISS > 30 subgroup (p < 0.01). Among those with pneumonia, female patients were at 2.8 to 5.6 times higher risk for death than were male patients. CONCLUSION: These data suggest that gender has no relation to mortality in blunt trauma patients who do not develop pneumonia. In contrast, male gender was significantly associated with an increased incidence of pneumonia after injury, and female patients with pneumonia were at significantly higher risk for mortality.

The microbiology of necrotizing soft tissue infections.

OBJECTIVE: A large number of necrotizing soft tissue infections (NSTI) treated at a single institution over an 8-year period were analyzed with respect to microbial pathogens recovered, treatment administered, and outcome. Based on this analysis, optimal empiric antibiotic coverage is proposed. METHODS: A retrospective chart review of all patients with documented NSTI was conducted. Microbiologic variables were tested for impact on outcome using Fisher's exact test and multivariate analysis by logistic regression. RESULTS: Review of the charts of 198 patients with documented NSTI revealed 182 patients with sufficient microbiologic information for analysis. These 182 patients grew an average of 4.4 microbes from original wound cultures, although a single pathogen was responsible in 28 patients. Eighty-five patients had combined aerobic and anaerobic growth, the most common organisms being, in order, Bacteroides species, aerobic streptococci, staphylococci, enterococci, Escherichia coli, and other gram-negative rods. Clostridial growth was common but did not affect mortality unless associated with pure clostridial myonecrosis. Mortality was affected by the presence of bacteremia, delayed or inadequate surgery, and degree of organ system dysfunction on admission. CONCLUSIONS: NSTI are frequently polymicrobial and initial antibiotic coverage with a broad-spectrum regimen is warranted. The initial regimen should include agents effective against aerobic gram-positive cocci, gram-negative rods, and a variety of anaerobes. The most common organisms not covered by initial therapy were enterococci. All wounds should be cultured at initial debridement, as changes in antibiotic coverage are frequent once isolates are recovered.

Infective endocarditis in intravenous drug users: does HIV status alter the presenting temperature and white blood cell count?

The intent of this study was to determine if HIV seropositivity alters the maximum temperature (T(max)) and WBC count of febrile intravenous (i.v.) drug users with infective endocarditis (IE). A review of 497 charts of patients with endocarditis provided 228 eligible patient visits (46%), with 158 cases (69.3%) of IE among 126 patients (74 HIV+ and 52 HIV-). Mean T(max) for all patients with IE was 39.1 degrees C (102.4 degrees F). Mean T(max) was similar between the HIV+ (39.1 degrees C, 102.4 degrees F) and HIV- (39.2 degrees C, 102.5 degrees F) groups. There were no differences in mean T(max) among HIV+ patients with CD4 counts > 200 (39.0 degrees C, 102.3 degrees F), those with CD4 < or =200 (39.2 degrees C, 102.5 degrees F), and the HIV- group (39.2 degrees C, 102.5 degrees F). Nearly 8% of i.v. drug users with confirmed IE presented to the ED with a T(max) below 37.8 degrees C (100.0 degrees F). Mean WBC count was significantly lower in HIV+ (11.1 k/mm(3)) than in HIV- patients (15.4 k/mm(3)) and significantly lower in the group with CD4 < or =200 (8.0 k/mm(3)) than in the HIV- group. In conclusion, HIV infection was not associated with lower T(max), but it was associated with decreased WBC count in the general HIV+ group and in the group with CD4 < or =200.

Medical conditions and car crashes.

Most previous studies of medical conditions associated with driver safety have focused on specific diseases. This analysis is based on a linkage of police report and hospital discharge data, and correlates various medical diagnostic categories and specific conditions with police determinations of driver culpability for all drivers admitted to Maryland hospitals during a 3-year period. Using odds ratios, various conditions have been identified which are associated with an increased risk of crash culpability. Further research is needed to confirm these findings, and to determine the role of the conditions vs. the possible influence of medications prescribed to treat these conditions.

Use of blood alcohol concentration and laboratory tests to detect current alcohol dependence in trauma center patients.

OBJECTIVE: To assess the utility of laboratory markers of severe alcoholism in a cross-sectional population of male trauma center patients, who have a high rate of current alcohol dependence (CAD). METHODS: A total of 684 men were assessed for CAD by using standard criteria, all of whom had complete laboratory data. The ability of tests to predict CAD was ascertained by using Student's t test, sensitivity, specificity, and area under the curve (AUC) of receiver operating characteristic curves. RESULTS: Mean values of five tests were individually associated with a CAD diagnosis. Gamma-glutamyltransferase, aspartate aminotransferase, and mean corpuscular volume had sensitivities less than or equal to 0.51 and AUC less than or equal to 0.67. Blood alcohol concentration (BAC) and serum osmolality had sensitivities of 0.64 and 0.74 and AUC of 0.74 and 0.76, respectively. Each marker, when combined with BAC, showed little improvement in AUC over BAC alone. CONCLUSIONS: Laboratory tests are not highly predictive of CAD in male trauma patients. A combination of BAC tests and interview screens is suggested for use in this patient population.

Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes.

BACKGROUND: Recent reports suggest that early fracture fixation worsens central nervous system (CNS) outcomes. We compared discharge Glasgow Coma Scale (GCS) scores, CNS complications, and mortality of severely injured adults with head injuries and pelvic/lower extremity fractures treated with early versus delayed fixation. METHODS: Using trauma registry data, records meeting preselected inclusion criteria from the years 1991 to 1995 were examined. We identified 171 patients aged 14 to 65 years (mean age, 32.7 years) with head injuries and fractures who underwent early fixation (< or = 24 hours after admission) (n = 147) versus delayed fixation (> 24 hours after admission) (n = 24). RESULTS: Patients were severely injured, with a mean admission GCS score of 9.1, Revised Trauma Score of 6.2, Injury Severity Score of 38, median intensive care unit length of stay of 16.5 days, and hospital length of stay of 23 days. No differences between groups were found by age, admission GCS score, Injury Severity Score, Revised Trauma Score, intensive care unit length of stay, hospital length of stay, shock, vasopressors, major nonorthopedic operative procedures, total intravenous fluids or blood products, or mortality rates. In survivors, no differences in discharge GCS scores or CNS complications were found. CONCLUSION: We found no evidence to suggest that early fracture fixation negatively influences CNS outcomes or mortality.

Screening trauma patients for alcoholism according to NIAAA guidelines with alcohol use disorders identification test questions.

Drinking pattern criteria (drinking frequency and number of drinks per occasion) issued by the National Institute on Alcohol and Abuse and Alcoholism (NIAAA) to screen primary practice patients for alcohol problems were evaluated in 1216 injured patients treated in a regional trauma center. Vehicular crash victims predominated (50.2%, of whom 64.5% were drivers), followed by victims of violence (31.2%) and nonviolent-injury victims (18.5%). Alcohol Use Disorders Identification Test (AUDIT) questions #1 (drinking frequency) and #2 (drinks/day) were used to assess the patients for current alcohol dependence (CAD). AUDIT responses roughly approximating NIAAA guidelines (high threshold: drinks > or = 4 times/week, > or = 5 drinks/day) and those indicating less drinking (low threshold: drinks > or = 2-3 times/ week, > or = 3 drinks/day) were chosen. Comparisons were made relative to sensitivity and specificity of responses in detecting CAD. When low threshold responses were used for either question, sensitivity to detect CAD increased overall (#1 from 0.53 to 0.80, #2 from 0.62 to 0.88) as well as among the subgroups of patients, whereas specificity remained high or at acceptable levels overall (#1 from 0.95 to 0.82, #2 from 0.92 to 0.71) and among the subgroups of patients. Study findings suggest that, among injured drivers and other groups of trauma center patients, lesser amounts of drinking should be used as screening criteria for CAD than are used for the general population.

Effect of change in velocity on the development of medical complications in patients with multisystem trauma sustained in vehicular crashes.

Medical complications such as sepsis or multiple organ system failure increase the morbidity and mortality associated with injuries sustained in car crashes. This study addresses the question of the association, if any, between one crash characteristic, i.e. change in velocity (delta v), and subsequent medical complications. Data on seventy-six severely injured patients were obtained as part of an in-depth, trauma-center-based study of the biomechanics of vehicular trauma. Factors found to be predictive of the development of complications included patient age > or = 36 years, delta v > or = 30 mph, and injury severity score > or = 25. Vehicle occupants involved in crashes with a delta v > or = 30 mph had a risk of complications more than five times greater than for those in the lower delta v group. Better knowledge of the dynamics and severity of the crash could help clinical staff anticipate the development of complications and initiate timely prevention strategies.

Discourse after closed head injury in young children.

This study examined narrative discourse in 23 children, ages 6 to 8 years, who sustained a severe closed head injury (CHI) at least 1 year prior to assessment. Narratives were analyzed at multiple levels using language and information structure measures. Results revealed significant discourse impairments in the CHI group on all measures of information structure, whereas differences in the linguistic domain failed to reach significance. In addition, effects of age at injury and lateralization of lesion on discourse were considered. Although no significant differences were found according to age at injury, a consistent pattern of generally poorer discourse scores was found for the early injured group (< 5 years). With regard to lesion focus, the group findings were unimpressive. However, preliminary examination of individual CHI cases with relatively large lateralized lesions suggested that the late injured children may show the language-brain patterns reported in brain-injured adults, whereas early injured children may not.

Magnetic resonance imaging in relation to functional outcome of pediatric closed head injury: a test of the Ommaya-Gennarelli model.

OBJECTIVE: To characterize late neuropathological findings of pediatric closed head injury (CHI), to assess depth of brain lesion in relation to acute severity, and to assess long-term outcome to test the Ommaya-Gennarelli model. METHODS: Magnetic resonance imaging (MRI) at least 3 months postinjury in a prospective sample (n 5 169) and at least 3 years after CHI in a retrospective sample (n 5 82) was studied. Lesion volume was measured by planimetry. Acute CHI severity was measured by the Glasgow Coma Scale. Patients were classified according to the depth of the deepest parenchymal lesion into no lesion, subcortical, and deep central gray/brain stem groups. The outcomes were assessed by the Glasgow Outcome Scale and the Vineland Adaptive Behavior Scale, which were performed at the time of the MRI in the retrospective sample and up to 3 years postinjury in the prospective sample. RESULTS: Focal brain lesions were present in 55.4% of the total sample. Depth of brain lesion was directly related to severity of acute impairment of consciousness and inversely related to outcome, as measured by both the Glasgow Outcome Scale and the Vineland Adaptive Behavior Scale. A rostrocaudal gradient of hemispheric lesion frequency was observed, whereas the posterior lesions of the corpus callosum were particularly common. Total lesion volume could not explain the depth of lesion effect. CONCLUSION: Our findings extend support for the Ommaya-Gennarelli model to pediatric CHI, indicating that depth of brain lesion is related to functional outcome. The relative frequency of focal brain lesions revealed by late MRI is higher than that of previous findings using acute computed tomography. Future investigations could explore whether depth of lesion observed using late MRI is sensitive to neuroprotective interventions.

Predictive model to identify trauma patients with blood alcohol concentrations > or = 50 mg/dl.

OBJECTIVE: To develop a simple model for identification of trauma patients who are likely to have a blood alcohol concentration > or = 50 mg/dL (BAC + 50). METHODS: Demographic, clinical, and BAC data were collected from the clinical trauma registry and toxicology data base at a Level I trauma center. Logistic regression was used to analyze data from 11,206 patients to develop a predictive model, which was validated using a subsequent cohort of 3,523 patients. RESULTS: In the model development cohort, alcohol was detected in the blood of 3,180 BAC-tested patients (28.7%), of whom 91.2% had a BAC + 50 status. Preliminary analysis revealed associations between a BAC + 50 status and sex, age, race, injury type (intentional vs. unintentional), and time of injury (night vs. day and weekend vs. weekday). A predictive model using four attributes (sex and injury type) identified patients at low, medium, and high risk for being BAC + 50. The model was validated using the second group of patients. CONCLUSION: Injured patients with a high probability of being alcohol positive can be identified using a simple scoring system based on readily available demographic and clinical information.

The accuracy of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test in screening trauma center patients for alcoholism.

OBJECTIVE: To evaluate the accuracy of questionnaire screening instruments to identify lifetime alcohol dependence among trauma center patients. METHODS: The study was conducted at a Level I trauma center between September 1994 and November 1996. Patients meeting eligibility requirements (> or = 18 years old, admission from injury scene, > or = 2 days of hospitalization, intact cognition) were evaluated for alcohol abuse and dependence. Screening instruments consisted of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test. Screening results were compared with lifetime alcohol dependence diagnoses made using the in-depth Psychoactive Substance Use Disorders section of the Structured Clinical Interview. Accuracy was quantified as sensitivity, specificity, positive/negative predictive values, and receiver operating characteristic curves (used to calculate area under the curve). RESULTS: Of the 1,118 patients studied, lifetime alcohol dependence was diagnosed by Structured Clinical Interview in 397 (35.5%), and abuse was diagnosed in 90 (8.1%) others. The CAGE was the best predictor of lifetime alcohol dependence, i.e., had the largest area under the curve (93%) and the highest sensitivity (84%), specificity (90%), positive predictive value (82%), and negative predictive value (91%). Among patients testing positive for alcohol, 63% had a lifetime alcohol dependence diagnosis. CONCLUSION: The CAGE is an efficient screening test to detect alcohol dependence in trauma center populations. It should be used in combination with alcohol testing to identify patients at risk of alcohol use problems.

Necrotizing soft tissue infections. Risk factors for mortality and strategies for management.

OBJECTIVE: The authors evaluate in a retrospective fashion the factors influencing outcome in a large group of patients presenting with necrotizing soft tissue infections, and, based on this analysis, propose a plan for optimal care of such patients. SUMMARY BACKGROUND DATA: In many smaller series of patients with necrotizing soft tissue infections, similar analyses of risk factors for mortality have been performed, producing conflicting conclusions regarding optimal care. In particular, debate exists regarding the impact of concurrent physiologic derangements, type and extent of infection, and the role of hyperbaric oxygen in treatment. METHODS: A retrospective chart review of 198 consecutive patients with documented necrotizing soft tissue infections, treated at a single institution during an 8-year period, was conducted. Using a model for logistic regression analysis, characteristics of each patient and his/her clinical course were tested for impact on outcome. RESULTS: The mortality rate among the 198 patients was 25.3%. The most common sites of origin of infection were the perineum (Fournier's disease; 36% of cases) and the foot (in diabetics; 15.2%). By logistic regression analysis, risk factors for death included age, female gender, extent of infection, delay in first debridement, elevated serum creatinine level, elevated blood lactate level, and degree of organ system dysfunction at admission. Diabetes mellitus did not predispose patients to death, except in conjunction with renal dysfunction or peripheral vascular disease. Myonecrosis, noted in 41.4% of the patients who underwent surgery, did not influence mortality. CONCLUSIONS: Necrotizing soft tissue infections represent a group of highly lethal infections best treated by early and repeated extensive debridement and broad-spectrum antibiotics. Hyperbaric oxygen appears to offer the advantage of early wound closure. Certain markers predict those individuals at increased risk for multiple-organ failure and death and therefore assist in deciding allocation of intensive care resources.

Semantic memory following pediatric head injury: relationship to age, severity of injury, and MRI.

The effects of closed head injury (CHI) severity (mild vs. severe) and age at injury were analyzed in a longitudinal study (3. 12 months postinjury) of semantic memory which used magnetic resonance imaging (MRI) to characterize focal brain lesions. Semantic memory was evaluated by word and category fluency, semantic verification, semantic clustering in word list recall, and vocabulary. Episodic memory was assessed by word list recall. Comparison of normal control (n = 104) data with the patients' data (n = 77) at 3 months postinjury disclosed semantic and episodic memory deficits in the severe CHI patients. Analysis of the longitudinal data revealed significant effects of age at injury for all of the semantic memory measures. The effects of injury severity were confined to the latency of verifying correct statements. Volume of left frontal and extrafrontal lesions was predictive of performance on several semantic memory measures, but less robust for right hemisphere lesions.

Frontal lobe changes after severe diffuse closed head injury in children: a volumetric study of magnetic resonance imaging.

In view of the pathophysiology and biomechanics of severe closed head injury (CHI) in children, we postulated that the frontal lobes sustain diffuse injury, even in the absence of focal brain lesions detected by magnetic resonance imaging (MRI). This study quantitated the morphological effects of CHI on the frontal lobes in children who sustained head trauma of varying severity. The MRI findings of 14 children who had sustained severe CHIs (Glasgow Coma Scale score of < or = 8) were compared with the findings in a matched group of 14 children having sustained mild head injuries (Glasgow Coma Scale score of 13-15). The patients ranged in age from 5 to 15 years at the time of their MRIs, which were acquired at least 3 months postinjury. MRI findings revealed no focal areas of abnormal signal in the frontal lobes. Volumetric analysis disclosed that the total prefrontal cerebrospinal fluid increased and the gray matter volume decreased in the patients with severe CHI, relative to the mildly injured comparison group. Gray matter volume was also reduced in the orbitofrontal and dorsolateral regions of the brains of children with severe CHI, relative to the children who sustained mild head trauma. These volumetric findings indicate that prefrontal tissue loss occurs after severe CHI in children, even in the absence of focal brain lesions in this area. Nearly two-thirds of the children who sustained severe CHIs were moderately disabled after an average postinjury interval of 3 years or more, whereas 12 of the 14 patients with mild CHIs attained a good recovery (2 were moderately disabled) by the time of study.(ABSTRACT TRUNCATED AT 250 WORDS)

Lower extremity fractures in motor vehicle collisions: the role of driver gender and height.

In a previous study it was noted that there was a higher incidence of lower-extremity fractures among women drivers. Analyses were based on a linkage between trauma registry and police crash report data. The present study addresses the issue of whether the differences noted are attributed to driver gender or are merely a reflection of differences in driver height. An inverse association was noted between driver height and the incidence of lower-extremity fractures. Those shorter than average (5'7") for this population had a 64% increase in lower-extremity fracture, which can be mainly attributed to ankle/tarsal injuries. Thus, the incidence of these injuries appears to be a function of driver height, with an increase among shorter drivers, most of whom are women.