ABSTRACT
BACKGROUND: Delayed splenic vascular injury (DSVI) is traditionally considered a rare, often clinically occult, harbinger of splenic rupture in patients with splenic trauma that are managed conservatively. The purpose of our study was to assess the incidence of DSVI and associated features in patients admitted with blunt splenic trauma and managed nonoperatively. MATERIALS AND METHODS: A retrospective analysis was conducted over a 4-y time. Patients admitted with blunt splenic trauma, managed no-operatively and with a follow-up contrast-enhanced computed tomography (CT) scan study during admission were included. The CT scans were reviewed for American Association for the Surgery of Trauma splenic injury score, amount of hemoperitoneum, and presence of DSVI. Logistic regression models were used to investigate the risk factors associated with DSVI. RESULTS: A total of 100 patients (60 men and 40 women) constituted the study group. Follow-up CT scan demonstrated a 23% incidence of DSVI. Splenic artery angiography validated DSVI in 15% of the total patient population. Most DSVIs were detected only on arterial phase CT scan imaging. The American Association for the Surgery of Trauma splenic injury score (odds ratio = 1.73; P = 0.045) and the amount of hemoperitoneum (odds ratio = 1.90; P = 0.023) on admission CT scan were associated with the development of DSVI on follow-up CT scan. CONCLUSIONS: DSVI on follow-up CT scan imaging of patients managed nonoperatively after splenic injury is common and associated with splenic injury score assessed on admission CT scan.
Subject(s)
Conservative Treatment , Delayed Diagnosis , Spleen/injuries , Splenic Artery/injuries , Vascular System Injuries/diagnosis , Wounds, Nonpenetrating/diagnosis , Wounds, Nonpenetrating/therapy , Adolescent , Adult , Aged , Aged, 80 and over , Female , Follow-Up Studies , Humans , Incidence , Injury Severity Score , Logistic Models , Male , Middle Aged , Retrospective Studies , Risk Factors , Spleen/blood supply , Spleen/diagnostic imaging , Splenic Artery/diagnostic imaging , Tomography, X-Ray Computed , Vascular System Injuries/epidemiology , Vascular System Injuries/etiology , Young AdultABSTRACT
BACKGROUND: Previous studies of traumatic brain injury (TBI) outcomes in elderly patients on oral antithrombotic (OAT) therapies have yielded conflicting results. Our objective was to examine the effect of premorbid OAT medications on outcomes among elderly TBI patients with intracranial hemorrhage. METHODS: We performed a retrospective analysis of elderly TBI patients (≥65 years) with closed head injury and evidence of brain hemorrhage on computed tomography scan from 2006 to 2010. Patient demographics, injury severity, clinical course, hospital and intensive care unit length of stay, and disposition were collected. Comparison of patients stratified by premorbid OAT use was performed using nonparametric Kruskal-Wallis and Fisher's exact tests. Multivariable logistic regression was used to compare groups and identify predictors of primary outcomes, including mortality, neurosurgical intervention, hemorrhage progression, complications, and infection. RESULTS: A total of 1,552 patients were identified: 543 on aspirin only, 97 on clopidogrel only, 218 on warfarin only, 193 on clopidogrel and aspirin, and 501 on no antithrombotic agent. Blood products were administered to reverse coagulopathy in 77.3% of patients on antithrombotic medications. After adjusting for covariates, including medication reversal, OAT use was associated with increased mortality (p = 0.04). Warfarin use was identified as a key predictor (odds ratio, 2.27; p = 0.05), in contrast to the preinjury use of antiplatelet medications, which was not associated with increased risk of in-hospital death. Rates of neurosurgical intervention differed between groups, with patients on warfarin undergoing intervention more frequently. Survivor subset analysis demonstrated that hemorrhage progression was not associated with preinjury antithrombotic therapy, nor were rates of complication or infection, hospital and intensive care unit lengths of stay, or ventilator days. CONCLUSION: Preinjury use of warfarin, but not antiplatelet medications, influences survival and need for neurosurgical intervention in elderly TBI patients with intracranial hemorrhage; hemorrhage progression and morbidity are not affected. The importance of antithrombotic therapy may lie in its impact on initial injury severity. LEVEL OF EVIDENCE: Epidemiologic study, level III.
Subject(s)
Anticoagulants/administration & dosage , Aspirin/administration & dosage , Brain Injuries/complications , Brain Injuries/mortality , Intracranial Hemorrhages/etiology , Intracranial Hemorrhages/mortality , Intracranial Hemorrhages/surgery , Platelet Aggregation Inhibitors/administration & dosage , Ticlopidine/analogs & derivatives , Warfarin/administration & dosage , Administration, Oral , Aged , Brain Injuries/diagnostic imaging , Clopidogrel , Female , Humans , Intracranial Hemorrhages/diagnostic imaging , Length of Stay/statistics & numerical data , Male , Retrospective Studies , Survival Rate , Ticlopidine/administration & dosage , Tomography, X-Ray Computed , Trauma Severity IndicesABSTRACT
BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with significant morbidity following injury. The incidence and risk factors for PTSD are not well described in the civilian trauma population. We proposed to screen all trauma patients in the outpatient trauma clinic for acute PTSD symptoms and identify risk factors for PTSD. METHODS: We prospectively screened 1,386 injured patients who presented for follow-up in trauma clinic (January 2009 to September 2010) using an established PTSD screening test (PTSD Checklist-Civilian, PCL-C). A PCL-C score of ≥35, with a known sensitivity of >85% for PTSD, was considered screen-positive (PCL-C-POS). Backward stepwise logistic regression was used to determine independent risk factors for PCL-C-POS. RESULTS: Over 25% of trauma clinic patients met the threshold for positive PTSD screen (PCL-C-POS). The highest incidence (43%) was in patients who sustained assault (blunt or penetrating). Regression analysis revealed that age <55 years, female gender, motor vehicle collision, and assaultive mechanism (blunt or penetrating, excluding self-inflicted or accidental injury) were independent predictors of PCL-C-POS status. As the severity of symptoms increased (higher PCL-C scores), the risk associated with assaultive mechanism significantly increased in a dose-response fashion (p < 0.05). CONCLUSIONS: This study confirms the high incidence of acute PTSD symptoms in trauma patients and supports the feasibility of PTSD screening in the outpatient trauma clinic. Among all mechanisms of injury, patients who sustain interpersonal violence are at the highest risk of developing acute PTSD symptoms. These results suggest that PTSD screening in outpatient trauma clinic may allow early detection and referral of patients with PTSD. LEVEL OF EVIDENCE: II.
Subject(s)
Accidents , Injury Severity Score , Risk Assessment/methods , Stress Disorders, Post-Traumatic/diagnosis , Trauma Centers , Wounds and Injuries/complications , Adult , Female , Follow-Up Studies , Hospitals, University , Humans , Incidence , Male , Pennsylvania/epidemiology , Prognosis , Prospective Studies , Risk Factors , Stress Disorders, Post-Traumatic/epidemiology , Stress Disorders, Post-Traumatic/etiology , Wounds and Injuries/diagnosis , Wounds and Injuries/psychologyABSTRACT
BACKGROUND: With liberal use of computed tomography in the diagnostic management of trauma patients, incidental findings are common and represent a major patient-care and medical-legal concern. Consequently, we began an initiative to capture, notify, and documentadequately incidental finding events with a dedicated incidental finding coordinator. We hypothesized a dedicated incidental finding coordinator would increase incidental finding capture and promote notification, follow-up, and documentation of incidental finding events. METHODS: A quality-improvement project to record and follow-up incidental findings postinjury was initiated at our level I trauma center (April 2007-March 2008, prededicated incidental finding). Because of concerns for inadequate documentation of identified incidental finding events, we implemented a dedicated incidental finding coordinator (April 2008-March 2009, postdedicated incidental finding). The dedicated incidental finding coordinator documented incidental findings daily from trauma admission radiology final reads. Incidental findings were divided into 3 groups; category 1: attention prior to discharge; category 2: follow-up with primary doctor within 2 weeks; category 3: no specific follow-up. For category 1 incidental findings, in-hospital consultation of the appropriate service was verified. On discharge, patient notification, follow-up, and documentation of events were confirmed. Certified mail or telephone contact was used to notify either the patient or the primary doctor in those who lacked appropriate notification or documentation. RESULTS: Admission rates and incidental finding categories were similar across the 2 time periods. Implementation of a dedicated incidental finding coordinator resulted in more than a 165% increase in incidental finding capture (n = 802 vs n = 302; P < .001). Patient notification was attempted, and appropriate documentation of events was confirmed in 99.8% of patients. Patient notification was verified, and follow-up was initiated in 95.8% of cases. CONCLUSION: The implementation of a dedicated incidental finding coordinator resulted in more than a 2.5-fold higher capture of incidental findings. Dedicated attention to incidental findings resulted in a near complete initiation of patient notification, follow-up, and hospital record documentation of incidental finding events. Inadequate patient notification and follow-up would delay appropriate care and potentially would result in morbidity or even mortality. A dedicated incidental finding coordinator represents a potential solution to this patient-care and medical-legal dilemma.
Subject(s)
Incidental Findings , Wounds and Injuries/diagnostic imaging , Adult , Aged , Aged, 80 and over , Disclosure , Documentation , Female , Follow-Up Studies , Humans , Male , Medical Records , Middle Aged , Prospective Studies , Quality Assurance, Health Care , Radiography , Trauma Centers/standards , Young AdultABSTRACT
BACKGROUND: Cervical (C)-spine clearance protocols exist both to identify traumatic injury and to expedite rigid collar removal. Computed tomography (CT) of the C-spine in trauma patients facilitates the removal of immobilization collars in patients who are neurologically intact, and magnetic resonance imaging (MRI) has become an indispensable adjunct for evaluating trauma patients with neurologic deficits. Yet, the management of patients with impaired mental status who lack neurologic deficits attributable to the spinal cord remains controversial. C-spine MRI has been suggested and employed as an imaging modality to exclude occult C-spine instability in this population of patients. However, currently available data are inconclusive as to the necessity of MRI in the C-spine clearance of obtunded or comatose trauma patients with a normal CT. METHODS: The records of patients undergoing contemporaneous CT and MRI of the C-spine in a level I trauma center from January 2003 to December 2006 were retrospectively analyzed. From this group, patients admitted with a Glasgow Coma Scale score =13 and a normal C-spine CT with sagittal and coronal reconstructions were identified. Patients were excluded if a neurologic deficit potentially referable to the spinal cord was identified. The results of C-spine MRI in this group were tabulated and analyzed. RESULTS: A total of 690 patients were identified who had undergone contemporaneous C-spine CT and MRI. Of this group, 180 patients (26.2%) were identified as having a normal CT with sagittal and coronal reconstructions, no neurologic deficit, and Glasgow Coma Scale score =13. Within this group, the average time interval between CT and MRI was 4.6 days (median, 4 days). Among these 180 patients, C-spine MRI identified 38 patients (21.1%) with acute traumatic findings in the cervical spine. However, none of these patients had a missed unstable injury and no patient required surgery or developed evidence of delayed instability. CONCLUSION: Our data suggests that, outside of its appropriate application to patients with a neurologic deficit, MRI is unlikely to uncover unstable C-spine injuries in patients who are obtunded or comatose when C-spine CT using modern imaging protocols is normal.
Subject(s)
Cervical Vertebrae , Glasgow Coma Scale/statistics & numerical data , Magnetic Resonance Imaging/statistics & numerical data , Spinal Injuries/diagnostic imaging , Tomography, X-Ray Computed , Trauma Centers/statistics & numerical data , Unnecessary Procedures , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Retrospective Studies , Spinal Injuries/diagnosis , Spinal Injuries/physiopathologyABSTRACT
BACKGROUND: Many trauma patients who are not severely injured arrive at trauma centers via helicopter emergency medical services (HEMS). OBJECTIVE: To compare the injury severity of patients sent to trauma centers by HEMS from community emergency departments (EDs) with the injury severity of those triaged by prehospital providers to HEMS directly from accident scenes. METHODS: All records were reviewed from trauma-related missions during 1997for a single HEMS system, extracting information on location, time of day, patient age and gender, mechanism of injury, initial vital signs, Revised Trauma Score (RTS), and the extent of care required during transport. These records were then matched with outcome information routinely supplied to the HEMS system by affiliated trauma centers. Information from patients flown directly from scenes was then compared with that for patients flown from community EDs. RESULTS: Information was obtained for 658 patients flown from scenes and 345 flown from community EDs. There were similar proportions of patients in the two groups, with Injury Severity Scale (ISS) scores less than 6 (11.0% vs. 13.5%), between 6 and 14 (47.0% vs. 49.3%), and greater than 15 (42.0% vs. 37.1%); these were not statistically different (p > 0.05). There was also no significant difference between the groups in the RTS, mean ISS score, intensive care unit length of stay, hospital length of stay, or disposition. CONCLUSIONS: Scene and interhospital HEMS trauma missions in this system involve patients of similar injury severities. Prehospital providers may triage trauma patients to HEMS transport with proficiency similar to that of community ED physicians.