Geriatric falls: injury severity is high and disproportionate to mechanism.

OBJECTIVE: Falls are a well-known source of morbidity and mortality in the elderly. Fall-related injury severity in this group, however, is less clear, particularly as it relates to type of fall. Our purpose is to explore the relationship between mechanism of fall and both pattern and severity of injury in geriatric patients as compared with a younger cohort. METHODS: Our trauma registry was queried for all patients evaluated by the trauma service over a 412-year period (1994-1998). Two cohorts were formed on the basis of age greater than 65 or less than or equal to 65 years and compared as to mechanism, Injury Severity Score (ISS), Abbreviated Injury Scale score, and mortality. RESULTS: Over the study period, 1,512 patients were evaluated, 333 greater than 65 years and 1,179 less than or equal to 65 years of age. Falls were the injury mechanism in 48% of the older group and 7% of the younger group (p < 0.05). Falls in the older group constituted 65% of patients with ISS >15, with 32% of all falls resulting in serious injury (ISS >15). In contrast, falls in the younger group constituted only 11% of ISS >15 patients, with falls causing serious injury only 15% of the time (both p < 0.05). Notably, same-level falls resulted in serious injury 30% of the time in the older group versus 4% in the younger group (p < 0.05), and were responsible for an ISS >15 30-fold more in the older group (31% vs. <1%; p < 0.05). Abbreviated Injury Scale evaluation revealed more frequent head/neck (47% vs. 22%), chest (23% vs. 9%), and pelvic/extremity (27% vs. 15%) injuries in the older group for all falls (all p < 0.05). The mean ISS for same-level falls in the older group was twice that for the younger group (9.28 vs. 4.64, p < 0.05), whereas there was no difference in mean ISS between multilevel and same-level falls within the older group itself (10.12 vs. 9.28, p > 0.05). The fall-related death rate was higher in the older group (7% vs. 4%), with falls seven times more likely to be the cause of death compared with the younger group (55% vs. 7.5%) (both p < 0.05). Same-level falls as a cause of death was 10 times more common in the elderly (25% vs. 2.5%, p < 0.05). CONCLUSION: Falls among the elderly, including same-level falls, are a common source of both high injury severity and mortality, much more so than in younger patients. A different pattern of injury between older and younger fall patients also exists.

Acute bilateral adrenal hemorrhage secondary to rough truck ride.

Acute bilateral adrenal hemorrhage secondary to indirect trauma is rare. This condition may mimic an acute surgical abdomen. We present such a patient in whom the anatomic diagnosis was confirmed by serial computed tomographic (CT) scans, and adrenal insufficiency by biochemical tests. The response to steroid replacement therapy was remarkable. Although the patient had normal coagulation parameters at the time of presentation, subtle changes resulting from earlier anticoagulation may have been a contributing factor.

Outpatient mediastinoscopy.

The reported experience with outpatient mediastinoscopy is limited. We have performed 65 mediastinoscopies in a hospital-based ambulatory surgical unit during the past 2 1/2 years. This represents 54% of our total mediastinoscopies during the period and 85% of the total for the past year. One patient was admitted overnight because of hypoxemia that was relieved by thoracentesis. All other patients were discharged from the outpatient recovery room without problems. No other early and no late complications occurred. The cost savings were substantial, and patient satisfaction was high. We conclude that mediastinoscopy can be performed safely in the outpatient setting in many patients.

Hypersensitivity myocarditis and hepatitis associated with imipramine and its metabolite, desipramine.

We present two cases of myocarditis and hepatitis with histologic characteristics of hypersensitivity-mediated drug reactions associated with imipramine and its metabolite, desipramine. In one case, death was directly attributed to myocarditis; in the second case, the patient died of an acute myocardial infarct, but myocarditis may have played a contributory role. One patient was taking imipramine, and therapeutic concentrations of imipramine and desipramine were documented in postmortem blood. The other patient was receiving desipramine documented by in-patient hospital medication records. Both cases had liver lesions associated in the medical literature with adverse drug reaction to imipramine. Although myocarditis has been previously associated with amitriptyline, these cases appear to be the first reported in association with imipramine/desipramine. The fact that one patient was taking only desipramine suggests that it may be the offending agent.