The efficacy of a two-tiered trauma activation system at a level I trauma center.

BACKGROUND: By using current American College of Surgeons trauma center triage criteria, 52% of patients transported to our level I trauma center are discharged home from the emergency department (ED). Because the majority of our trauma transports were based solely on mechanism of injury, we instituted, in 1990, a two-tiered trauma team activation system. Patients are triaged into major and minor trauma alert categories based on prehospital provider information. For minor trauma patients, respiratory therapy, operating room staff, and blood bank do not respond. The current study evaluated this triage system. METHODS: Trauma registry data on all trauma activations from 1998 to 2007 were analyzed. RESULTS: There were 20,332 trauma activations: 5,881 were major trauma, 14,451 minor trauma. The mean Injury Severity Score in major versus minor patients was significantly different (11.7 vs. 3.6, p < 0.0001). Significant differences (p < 0.0001) were also noted for all other markers of serious injury: Injury Severity Score >16, ED blood pressure <90, Glasgow Coma Score

The natural history of stab wounds of the diaphragm: implications for a new management scheme for patients with penetrating thoracoabdominal trauma.

For most patients with abdominal stab wounds expectant management has become the norm. Thoracoabdominal stab wounds, however, raise concern about possible diaphragmatic injury, and diagnostic minilaparotomy, laparoscopy, or thoracoscopy have been advocated in such patients. The present study examined the natural course of an untreated diaphragmatic stab wound. With Institutional Review Board approval eight 25- to 30-kg anesthetized pigs underwent a small upper-midline laparotomy. A 1.5- to 2-cm incision was made in each diaphragm-in the muscular portion on one side and in the tendinous area on the other side. Thereafter a 12-F catheter was placed into each thoracic cavity and attached to suction to resolve pneumothoraces. The laparotomy incision was closed, and the thoracic catheters were removed. Six weeks later the animals were reanesthetized, and the diaphragmatic stab wounds were examined at laparotomy. Fifteen of the 16 (93.8 per cent) diaphragmatic wounds were completely healed. All eight stab wounds in the muscular portion of either diaphragm healed spontaneously. In one animal there was a persistent defect in the tendinous portion of the left diaphragm at the site of the stab wound. The tip of the left lateral segment of the liver and the superior pole of the spleen were found in the defect at laparotomy. We conclude that the vast majority of stab wounds to either the muscular or tendinous diaphragm heal spontaneously. Thus invasive procedures to assess the status of the diaphragm in all patients with thoracoabdominal stab wounds is unwarranted.

The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system.

BACKGROUND: Continuing controversy surrounding the value of scene helicopter evacuation of urban trauma victims led to the present study. METHODS: A retrospective review was performed of all patients brought to our trauma center from the injury scene by helicopter from 1990 to 2001. RESULTS: The study included 947 consecutive patients, 911 with blunt trauma and 36 with penetrating injuries. The mean Injury Severity Score (ISS) was 8.9. Fifteen patients died in the emergency department, 312 patients (33.5%) were discharged home from the emergency department (mean ISS, 2.7), and 620 patients were hospitalized (mean ISS, 11.4). Three hundred thirty-nine of the hospitalized patients (54.7%) had an ISS < or = 9; 148 patients had an ISS > or = 16. Eighty-four patients (8.9%) required early operation, mostly for open extremity fractures; only 17 patients (1.8%) underwent surgery for immediately life-threatening injuries. For 54.7% of the patients, the helicopter was judged to be clearly faster than would have been possible by ground transport. In 140 additional patients (14.8%) with prolonged scene time, the helicopter was probably faster than ground ambulance. Considering faster transport time and either the need for early operation or hospitalization with an ISS > or = 9 as advantageous, a maximum of 22.8% of the study population possibly benefited from helicopter transport. CONCLUSION: The helicopter is used excessively for scene transport of trauma victims in our metropolitan trauma system. New criteria should be developed for helicopter deployment in the urban trauma environment.

Blunt trauma patients with prehospital pulseless electrical activity (PEA): poor ending assured.

BACKGROUND: The paucity of information on the outcome of patients experiencing prehospital pulseless electrical activity (PEA) after blunt injury led to the present study. METHODS: A retrospective review was performed of all blunt trauma victims with prehospital PEA from 1997 to 2001 in an urban county trauma system. RESULTS: One hundred ten patients, 78 men and 32 women, met study criteria. Seventy-nine patients had PEA at the scene, and 31 experienced PEA en route to a trauma center. All patients were transported in advanced life support ambulances. Cardiopulmonary resuscitation was initiated when PEA was detected. Vital signs were regained en route or at the trauma center by 25 patients (23%). The incidence of pupillary reactivity at the scene was higher in patients who regained vital signs (48% vs. 16%). Only one patient, who has significant residual neurologic impairment, survived. The mean Injury Severity Score of this population was 45.1. CONCLUSION: If these grim results are corroborated by other investigators, consideration should be given to allowing paramedics to declare blunt trauma victims with PEA dead at the scene.