Efficacy of the motor component of the Glasgow Coma Scale in trauma triage.

BACKGROUND: National guidelines recommend that patients with Glasgow Coma Scale (GCS) scores of less than 14 be triaged to trauma centers. We hypothesized that the motor component of the GCS (GCSM) would be equally sensitive as the total GCS in head injury triage. METHODS: A 2-year retrospective review of 3,235 injured adults transported directly to a Level I trauma center. RESULTS: One thousand four hundred ten patients (44%) had prehospital GCS scores recorded. GCSM was found to have a sensitivity of 0.90 for Abbreviated Injury Scale (AIS) score = 5 head injury and 0.61 for AIS score > 3 injury, whereas the GCS had sensitivities of 0.92 and 0.62, respectively (p = not significant). Specificities were equal at 0.85 for AIS score = 5 and 0.89 for AIS score > 3. CONCLUSION: GCSM is equivalent to GCS for prehospital triage, and in view of its simplicity it should replace the GCS in triage schemes.

Multicenter, randomized, prospective trial of early tracheostomy.

OBJECTIVES: Determine the effect of early (days 3-5) or late (days 10-14) tracheostomy on intensive care unit length of stay (ICU LOS), frequency of pneumonia, and mortality, and evidence of short-term or long-term pharyngeal, laryngeal, or tracheal injury in head trauma, non-head trauma, and critically ill nontrauma patients. STUDY DESIGN: Randomized, prospective. SETTING: Five Level I trauma centers. METHODS: Data were obtained prospectively and included Acute Physiology and Chronic Health Evaluation III score (AIII), Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, type of endotracheal tube or tracheostomy, level of positive end-expiratory pressure, and peak inspiratory pressure. Patients were to undergo laryngoscopy for detection of injury according to the Lindholm criteria at the time of endotracheal tube or tracheostomy removal and be reevaluated at 3 to 5 months after discharge. RESULTS: One hundred fifty-seven patients were entered, 127 to early randomization (3-5 days) and 28 to late randomization (10-14 days); however, only 112 patients with early and 14 with late randomization had completed data forms for the primary study goals. An additional 22 patients from the early entry groups were rerandomized late. Early randomization data: the AIII score was higher (p < 0.05) in the head trauma tracheostomy (65 +/- 4) than in the nontracheostomy group (51 +/- 4) and in the nontrauma tracheostomy (92 +/- 6) than in the nontracheostomy group (68 +/- 7), but was equivalent in the non-head trauma group. Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, positive end-expiratory pressure, and peak inspiratory pressure were not significantly different in any of the groups. There were no significant differences in ICU LOS, frequency of pneumonia, or death in any of the groups after either early or late tracheostomy compared with continued endotracheal intubation. Only 83 patients underwent postextubation laryngoscopy. There were no significant differences between the groups; however, there were trends to more vocal cord ulceration and subglottic inflammation in the continued intubation group. No patient was seen in this study with late vocal cord or laryngeal stenosis; there were no tracheal-innominate artery fistulae. Seven of the patients with abnormal findings at extubation had normal 3- to 5-month postextubation laryngoscopy. CONCLUSION: Physician bias limited patient entry into the study. Although there were higher AIII scores in the head trauma early tracheostomy patients, there were no differences in the primary end points of ICU LOS, pneumonia, or death in any of the groups studied. Long-term endoscopic follow-up was poor, but no known late tracheal stenosis was seen.

Morbidity of negative coeliotomy in trauma.

Exploratory coeliotomy is essential in the care of abdominal trauma, but negative operation has a reported morbidity rate as high as 18 per cent. Ancillary studies such as computerized tomography, diagnostic peritoneal lavage and abdominal ultrasound have improved both sensitivity and specificity of evaluation in blunt and penetrating trauma, thus decreasing the rate of negative coeliotomy. A retrospective study of 50 consecutive negative laparotomies (10.5 per cent of all trauma laparotomies) at our Trauma Center revealed a morbidity rate of 22 per cent and mortality of 6 per cent. Although the negative coeliotomy rate was lower for blunt than penetrating trauma, morbidity was significantly higher for blunt trauma. Extra-abdominal injury alone could not account for this difference. We conclude that negative coeliotomy in penetrating trauma does not carry excessive morbidity. Negative coeliotomy in blunt trauma is accompanied by high morbidity and mortality, so adjunct diagnostic procedures should be utilized in this population in an effort to minimize negative laparotomies.

Complications of anticoagulation for pulmonary embolism in low risk trauma patients.

Trauma patients are at significant risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). Anticoagulation is standard therapy for DVT/PE, but may cause severe complications. We reviewed the course of 70 trauma ICU patients treated over a 28-month period. Thirty-six patients (51.4 percent) were treated by continuous IV heparin and/or oral warfarin. Of these, 13 patients (36 percent) developed complications requiring termination of anticoagulation. These included recurrent PE (four), subdural hematomas (three), hemothorax (two), heparin-induced thrombocytopenia (one), hemorrhagic pericardial effusion (one), retroperitoneal hematoma (one), and sudden unexplained drop in hemoglobin and shock (one). All patients with subdural hematomas had no prior evidence of head injury on brain computed tomography. All patients with recurrent PE received adequate anticoagulation therapy. Age > 55 was associated with increased risk of complications (8 of 13; p = .02:chi 2). Thirty-four other patients (48.6 percent) received inferior vena caval filters with no related complications or deaths. Anticoagulation for DVT/PE should be used selectively in trauma patients and avoided in elderly patients. Such patients should undergo early caval filter placement.

Bacterial translocation occurs in humans after traumatic injury: evidence using immunofluorescence.

UNLABELLED: We evaluated the occurrence of bacterial translocation (BT) in humans after traumatic injury. Twenty trauma patients (18 with blunt trauma) requiring celiotomy and without hollow viscus injury were studied. After surgical hemostasis and repair, portal venous blood (PVB) was sampled for culture. Additionally, a mesenteric lymph node (MLN) was harvested for culture and indirect immunofluorescence analysis using, first, mouse monoclonal antibody to E. coli beta-galactosidase, then goat anti-mouse immunoglobulin G (IgG). Injury Severity Score (ISS), Trauma Score (TS), and period of hemorrhagic shock (HS; systolic BP < 90 mm Hg with blood loss > 500 mL) were recorded before specimens were obtained. RESULTS: Fifteen patients initially had HS (mean period of 60 minutes). Mean TS and ISS were 10 and 29, respectively. Seven patients did not have HS (mean TS and ISS, 10 and 13). Three patients received antibiotics preoperatively. Portal venous blood culture produced positive results in only three patients (two with HS) and culture of the MLN specimen was positive in one. However E. coli beta-galactosidase was detected within the cytoplasm of macrophages in all MLNs. One patient developed multiple organ failure. CONCLUSION: Bacterial translocation occurs in humans following traumatic injury and may be independent of HS. Culture techniques may not detect BT since organisms may have been phagocytized by macrophages. The clinical significance of BT in trauma patients remains unclear.

Blunt abdominal aortic trauma in children: case report.

Injuries to the abdominal aorta as a result of blunt trauma in children are extremely rare. We encountered one such injury and a review of the literature revealed seven additional cases. Lower extremity ischemia, abdominal bruit, or paraplegia may suggest that diagnosis at the time of injury. Delayed presentations are characterized by abdominal pain or a pulsatile mass, with or without bruit. A high index of suspicion with early aortography is indicated to diagnose blunt aortic trauma.

Continuous pulse oximetry and the diagnosis of pulmonary embolism in critically ill trauma patients.

The diagnosis of pulmonary embolism (PE) may be difficult to establish in trauma patients, particularly those who are unresponsive or mechanically ventilated. Based on a prior retrospective study, we hypothesized that patients monitored by continuous pulse oximetry who experienced a 10% or greater sudden sustained drop in arterial oxygen saturation (SaO2) without a change in static lung compliance (Cst) were most likely to have had a PE. We followed SaO2 in 972 patients admitted to our trauma ICU during the 18-month period ending in December 1990. Forty-eight patients (5%) with SaO2 changes, but no Cst changes, were evaluated for suspected PE using pulmonary arteriography (PA). Of these, 21 (44%) had a positive PA study. All patients with a positive PA had either clear chest roentgenograms or no change in underlying pulmonary pathologic processes. Of the remainder, 26 had evidence of a new pathologic entity on chest roentgenograms and only one patient had a SaO2 decrease, no change in Cst, and a negative PA. All mechanically ventilated trauma patients should have SaO2 monitored continuously. Patients with a > 10% drop in Sao2 with no change in Cst and no new roentgenographic chest findings should undergo PA. Based on our experience, this approach would yield a sensitivity, specificity, and predictive value of 100%, 99.9%, and 95%, respectively, for the diagnosis of clinically significant PE.

Abbreviated injury scaling of head injury as a prognostic tool for functional outcome.

The use of Abbreviated Injury Scaling for the head region (HAIS) was evaluated as a prognostic index of functional outcome in 503 consecutive patients with severe injury to the brain who survived initial resuscitation. Although a strong statistical relationship between HAIS and outcome as measured by the Glasgow Outcome Scale was demonstrated, its clinical usefulness is limited. HAIS may be most useful as a classifier for comparative studies of populations and for the evaluation of therapeutic modalities.

Clinical predictors of unstable cervical spinal injury in multiply injured patients.

All victims of major blunt trauma have been said to be at risk of cervical spinal injury. In a prospective study of 410 such patients at our institution, we identified 13 patients (6.12 per cent) with unstable cervical spines. Loss or defect of consciousness following injury (regardless of duration), neurological deficit consistent with cervical cord or nerve root injury and neck tenderness were significantly predictive of an unstable cervical spine. Immediate radiographic investigation of the cervical spine is mandatory in such patients, but may not be required in patients without these signs.

Is routine computed tomography scanning too expensive for mild head injury?

OBJECTIVE: To compare relative costs of treating mildly head-injured patients by routine admission or by using skull radiographs or cranial computed tomography (CT) scanning to screen patients for admission. DESIGN: Retrospective record review, hypothetical costs based on actual patient course and requirements. SETTING: Southern New Jersey Regional Trauma Center at Cooper Hospital/University Medical Center. PARTICIPANTS: 658 consecutive mildly head-injured patients admitted from 1986 to 1988. All were given cranial CT scans. MEASUREMENTS: Records were reviewed retrospectively and hypothetical costs were calculated based on actual length of hospitalization, surgical intervention, etc. These costs were compared for different treatment protocols. MAIN RESULTS: The average cost if every patient had been admitted for observation given skull radiographs, with CT scans done on those exhibiting skull fracture or later deterioration, was $1,207. If the CT scan had been used to identify patients with intracranial lesions and the others had been discharged, costs would have been almost 10% less. Had skull radiography been used to screen admissions, costs would have been 22% below those of routine CT scanning. However, these small savings are likely to be reduced by additional expenses related to missed intracranial lesions. CONCLUSIONS: Every patient with loss of consciousness or post-traumatic amnesia should have routine CT scanning. If the scan is normal and there are no other reasons for admission, the patients can be discharged safely from the emergency department. This represents optimal care from a medical standpoint and is justified from a cost-effectiveness point of view.

Routine initial computed tomography of the chest in blunt torso trauma.

Computer tomography (CT) is an effective technique in the initial evaluation of the abdomen and head following blunt trauma. To evaluate the role of CT of the thorax, a prospective study comparing routine early thoracic CT scanning with initial chest roentgenogram (CXR) was carried out on 73 patients with blunt torso trauma undergoing concomitant abdominal CT examination. Initial CXR and CT scans were interpreted independently by radiologists in a blinded fashion. CXR diagnosed more bony injuries than CT, while the CT identified pulmonary contusions and effusions more accurately. Only those contusions diagnosed by CXR proved clinically significant. Patient treatment was changed in one case based on CT findings. In the absence of CXR findings, chest CT scanning frequently identifies abnormalities with limited clinical significance. Although more sensitive, CT of the thorax has a limited role in the initial emergent evaluation of victims of blunt torso trauma.

Blunt traumatic bladder rupture: the role of retrograde cystogram.

STUDY OBJECTIVE: We evaluated the importance of microscopic and gross hematuria and the role of retrograde cystography and computed tomography (CT) in the diagnosis of blunt traumatic bladder rupture. DESIGN: All cases at a Level I trauma center between January 1, 1986, and March 31, 1989, were reviewed retrospectively. SETTING: Level I trauma center, university hospital. TYPE OF PARTICIPANTS: All patients with acute blunt abdominal trauma admitted to this Level I trauma center. INTERVENTIONS: The patients' charts were reviewed with emphasis on mode of diagnosis, treatment, and outcome. MEASUREMENTS AND MAIN RESULTS: Twenty-one patients had bladder rupture. All 21 had hematuria with more than 50 RBCs/high-power field, 17 gross and four microscopic. Twenty patients underwent retrograde cystography, which accurately identified bladder rupture, and one was found at laparotomy for other injuries. Seven patients had CT of the abdomen and pelvis, which failed to demonstrate bladder rupture. There were no associated urethral injuries in any of the patients with bladder rupture. CONCLUSION: Significant (more than 50 RBCs/high-power field) hematuria is the principal indication for evaluation for blunt bladder injury, and retrograde cystography is the diagnostic procedure of choice. CT is neither sensitive nor specific enough as primary diagnostic modality.

Evaluation of the abdomen in intoxicated patients: is computed tomography scan or peritoneal lavage always indicated?

STUDY OBJECTIVE: To investigate the necessity of intensive evaluation of the intoxicated patient with normal mentation for intra-abdominal injury after blunt torso trauma. DESIGN: Retrospective study; trauma registry and medical records. SETTING: Level I regional trauma center serving a population of 2.3 million. PARTICIPANTS: Adult victims of blunt trauma more than 17 years old, admitted between January 1, 1986, and December 31, 1989, with suspected blunt abdominal injury and serum ethanol of more than 100 mg/dL and Glasgow Coma Score of 15. INTERVENTION: All patients had serum ethanol levels measured in mg/dL and computed tomography (CT) scan of the abdomen and/or diagnostic peritoneal lavage (DPL). RESULTS: Criteria were met by 92 patients. Eighty-nine underwent CT scans, two had DPL, and one had both. Of 17 patients complaining of abdominal pain and/or tenderness on palpation, six (35.3%) had blood in the peritoneal cavity demonstrated by CT scan or DPL and underwent celiotomy. All 75 patients without abdominal pain or tenderness had negative CT scan or DPL, with no missed injury. CONCLUSION: In the intoxicated blunt trauma patient with normal mentation, the physical examination is a reliable indicator of abdominal injury. Elevated alcohol level, per se, should not be considered an absolute indication for DPL or abdominal CT.

Time of rehabilitation admission and severity of trauma: effect on brain injury outcome.

Outcome after traumatic brain injury, defined by the Glasgow Outcome Scale (GOS) and length of stay in acute rehabilitation, was measured in 59 patients admitted to an intensive rehabilitation program to examine the effects of severity of the initial brain injury, severity of multiple trauma, and length of stay in the acute care hospital. Severity of initial brain injury, best measured by length of coma, was the most significant predictor of GOS outcome. Length of acute hospitalization was a small, but significant, predictor of GOS. Severity of initial brain injury, length of acute hospitalization, and gender emerged as predictors of length of rehabilitation hospital stay. Although length of acute hospitalization is apparently affected by severity of brain injury, it adds significantly--more than severity of brain injury--to the prediction of length of rehabilitation.

Serum amylase determination and blunt abdominal trauma.

To determine the value of serum amylase sampling as an indicator of intra-abdominal injury, the records of 940 consecutive victims of blunt trauma were retrospectively reviewed. The sensitivity, specificity, and predictive value were poor in the determination of intra-abdominal injury, whether accompanied by craniofacial injury or not. It was concluded that routine serum amylase determination is of no value in the clinical management of the patient suffering blunt injury.

The failure of serial pneumatic cuff venous occlusion plethysmography to predict patients at risk for pulmonary emboli after trauma.

Over a three month period, attempts to perform serial Pneumatic Cuff Venous Occlusion Plethysmography (VP) were carried out in 51 severely injured patients felt to be at risk for Pulmonary Embolus (PE). Studies could not be performed in 25 of these patients due to the nature of their injuries. Of the remaining 26 patients, two showed evidence of deep vein thrombosis (DVT). Venography confirmed the diagnosis in only one of these patients. Serial VP failed to predict PE in all five patients in whom it was diagnosed. This article concludes that serial VP is not an effective predictor of PE in these patients.

Impact of a required request law on vital organ procurement.

"Mandatory" or required request for donation of the organs of patients dying in hospitals has been promulgated as a means of increasing the rate of organ harvest and alleviating the critical shortage of transplantable organs. Although the federal and many state governments have passed legislation to make such requests compulsory, the efficacy of this approach has not been demonstrated. Examination of the experience at our trauma center and in this region, before and after the enactment of a "strong" required request law by the State of New Jersey, did not reveal a statistically significant change in organ procurement. We conclude that such laws are unlikely to achieve the desired result in the absence of fundamental changes in the attitudes of the public and treating physicians.

Pulmonary embolism in major trauma patients.

In a 1-year retrospective review, 30 pulmonary emboli were diagnosed among 1,316 trauma patients who survived for at least 24 hours after admission to a Level I trauma center. Pelvic fractures, age over 55 years, severe single or multiple system trauma, and cannulation of central veins all appear to place injured patients at increased risk. Long bone fractures were not associated with an increased risk. The majority of pulmonary emboli were diagnosed during the first week of hospitalization with some as early as 24 hours and none later than 15 days postinjury. Although the etiology of these early emboli is uncertain, prolonged immobilization does not appear to play a role in placing these patients at increased risk for thromboembolic events. Pulmonary embolism should be suspected in any injured patient with respiratory compromise, and an aggressive approach to diagnosis is warranted.

Myocardial contusion without creatine kinase--MB elevation.

Myocardial contusion after chest trauma remains one of the major complexities of trauma care today. Diagnostic methods such as 12-lead electrocardiography and echocardiography, as well as activity of the biochemical marker creatine kinase and the MB subfraction, have not been shown to be sensitive or specific indicators. We report a case of an intraoperatively proved myocardial contusion without creatinine kinase or creatine kinase MB elevation.