Outcomes of admitted geriatric trauma victims.

Conflicting data exist as to the outcome of elderly victims of trauma. With recent improved outcomes for functional recovery, aggressive management of these patients has been advocated. The purpose of this study is to determine outcomes of admitted elderly trauma victims based on initial mechanism of injury and the degree to which other factors affected their overall outcome. A prospective study involving admitted patients > or =65 years was performed at an urban university center from September 15, 1996 until August 31, 1997. Patients sustaining any potentially serious form of trauma were included. Data about mechanism of injury (MOI), comorbid conditions, preinjury medications, types of injuries sustained, length of stay, functional outcome, and ultimate disposition were recorded. Two hundred thirty-nine consecutive patients were enrolled. Mean age was 78.1 +/- 8.1 years. There were 130 women (54%) and 109 men (46%). MOI was as follows: 132 low-mechanism falls (LMFs), 64 high-mechanism motor vehicle crashes (HMMVCs), 22 high-mechanism falls (HMFs), 8 pedestrian versus car (PVCs), and 13 other types. Mean length of stay surviving beyond the ED was 12.9 days. 8 patients were either DOA or died in the ED. There were 19 in-hospital deaths. Deaths were seen in 14% of HMMVCs, 13.6% HMFs, 9.1% LMFs, 25% PVCs, and 7.7% for other mechanisms. Overall outcomes by mechanism were categorized as functional (or baseline), fair, alive but poor, and dead. Functional outcomes were seen in 76.6% of HMMVCs, 81.8% of HMFs, 84.1% of LMFs, 50% of PVCs, and 84.6% for all other injuries. Forty-five percent were discharged home, 26% went to rehabilitation units, 16% went to nursing homes, and 11% died; the remaining 2% were either transferred to a psychiatric facility or to another hospital. Preexisting comorbid conditions did not appear to play a significant role in the ultimate outcomes of these patients. Severity of injury was the leading determinant of death, but severely injured patients often had functional outcomes. Elderly trauma victims most often achieve functional outcomes despite multiple or severe injuries.

Ovarian small cell carcinoma: a rare neoplasm in a 15-year-old female.

Abdominal masses in children are uncommon. Ovarian neoplasms are uncommon in young children and adolescents, and typically are benign. Small cell carcinoma of the ovary is an extremely rare condition, with a very poor prognosis. We report the case of a 15-year-old female who presented to the emergency department with abdominal distention, abnormal vaginal bleeding, and constipation secondary to a large intra-abdominal mass, ultimately diagnosed as ovarian small cell carcinoma.

Sternoclavicular joint injuries.

Injuries to the sternoclavicular (SC) joint are infrequently encountered. However, retrosternal SC joint dislocations are potentially life-threatening injuries which must be recognized by the examining physician and treated as soon as possible. Plain radiography often fails to fully distinguish SC joint injuries, and computed tomography has emerged as the diagnostic modality of choice for defining the injury complex and surrounding injuries. We have encountered 6 cases of SC joint injuries over the past 3 years and describe their presentation and management.

Geriatric trauma: outcomes of elderly patients discharged from the ED.

This study was undertaken to investigate which patients 65 years of age or older have adverse outcomes after discharge from the emergency department (ED) after an injury. Patients were enrolled prospectively at an urban university center from September 15, 1996, until August 31, 1997. Patients sustaining any potentially serious form of injury were included. Data about comorbid conditions, preinjury medications, and types of injuries sustained were recorded. Patients were contacted at home at least 30 days after discharge and were questioned about their overall health, need for admission since ED discharge, and whether any complications developed. One hundred five consecutive patients were enrolled, but 5 patients were lost to follow-up. There were 74 low-mechanism falls (LMFs), 11 low-mechanism motor vehicle crashes (LMMVCs), 8 high-mechanism motor vehicle crashes (HMMVCs), 3 high-mechanism falls (HMFs), and 4 other types of injuries. Follow-up ranged from 30 to 147 days, with a mean of 49 days. On follow-up, 88 patients were doing well, 9 were fair, and 3 were doing poorly; of the latter, their poor health was unrelated to their injuries. Complications included 2 extremity infections and 1 poorly healing wound. Eleven patients were seen in an ED within the first 30 days after injury, 6 of whom for problems related to their initial injury or its management. These results show that there is a subset of elderly victims of trauma who may be safely discharged home after appropriate evaluation. Return visits to the ED were just as often related to comorbid conditions as to initial injury.

Injury patterns with snowboarding.

Snowboarding is a winter sport that has shown a considerable increase in popularity during the last 2 decades. As a result, there has been a continued rise in the number of visits to the emergency department (ED) for injuries sustained while snowboarding. Previous studies have concluded that those injured tend to be male, younger, and more inexperienced than their alpine skiing counterparts. This study examines the injury patterns seen in one ED during peak winter sport recreational months over a 5-year period. This retrospective review describes 71 patients with a broad spectrum of injury patterns, but reports a higher incidence of head and spinal injuries than previously documented. Furthermore, recommendations to prevent future injuries as well as education for first responders and physicians regarding the high likelihood of serious injury is discussed.

Good outcomes of open pelvic fractures.

While pelvic fractures are common injuries, those which communicate with an open wound are much less commonly encountered. These injuries have been associated with high morbidity and mortality in previous studies. We investigated our experience with open pelvic fractures retrospectively over a 79-month period. A total of 17 patients were identified, representing 2.7% of all pelvic fractures seen during this time period. There were no fatalities among the 15 patients who were not in cardiac arrest on arrival. Associated injuries were present in all patients. Functional outcome was good in eight patients and fair in seven. Although open pelvic fractures are severe injuries, survival in our study was 100% in those not arriving in cardiac arrest.

Vaginal evisceration.

Intestinal evisceration through the vagina is exceptionally rare. We report the cases of two patients presenting with this unusual clinical condition. Predisposing factors and management of vaginal evisceration are discussed.

Tension pneumoperitoneum caused by blunt trauma.

Tension pneumoperitoneum (TPP), the accumulation of free intraabdominal air under pressure, is a rare event. TPP usually occurs from bowel surgery or bowel perforations. Less commonly, TPP occurs in the presence of pneumothoraces or during positive pressure ventilation. Trauma has rarely been a reported cause of TPP. The cases of 2 patients with TPP after blunt trauma are reported. The pathophysiology and management of TPP are discussed.

Outcomes of anticoagulated trauma patients.

Patients on warfarin are at high risk for potentially life-threatening hemorrhage even after relatively minor trauma. Outcomes of these patients and the potential complications of reversing the effects of anticoagulation have received little attention. This study was performed to determine the overall outcome of orally anticoagulated patients who sustained injury as well as to determine any untoward effects of reversing their anticoagulated states. A retrospective study of injured patients on warfarin was conducted on patients admitted to an urban, university, tertiary-referral, level I trauma center between 1/1/93 and 12/31/96. Surviving patients were followed for a period of at least 1 month. Injuries were grouped by anatomic site. Charts were reviewed for degree of anticoagulation on admission (ie, initial international normalized ratio [INR]), survival, adverse effects of reversal of anticoagulation, and reinstitution of warfarin therapy. Discharged patients were contacted at home for follow-up. Thirty-five consecutive patients, 18 men and 17 women, on warfarin therapy at the time of their injuries were reviewed. The mean age was 75 years, with a range of 39 to 96. The mean follow-up period was 12.7 months. Reasons for anticoagulation included atrial fibrillation, prosthetic heart valves, revascularized limb, hypercoagulable state, deep venous thrombosis, pulmonary embolism, phlebitis, and aortic stenosis. Mean admission INR was 3.2, with a range of 1.6 to 10.0. There were 8 in-hospital deaths. Intracranial hemorrhages accounted for the majority of injuries. Ten patients were not given reversal therapy. Four complications were attributable to reversal therapy (upper extremity hemiplegia, transient ischemic attack, deep venous thrombosis, arterial thrombosis). Twenty-one patients had their warfarin reinstituted. Follow-up of surviving patients ranged from 1.5 to 42 months. Patients on warfarin are at high risk for intracranial hemorrhage following trauma. Patients on warfarin may be reversed during the acute period following injury, but transient complications may arise. Further prospective studies need to be conducted to determine which anticoagulated trauma patients may not require reversal therapy.

Coincident meningitis and intracerebral hemorrhage in an unresponsive adult.

Intracerebral hemorrhage is an unusual complication of central nervous system infection. A 54-year-old man presented to our emergency department unresponsive following an acute intracerebral hemorrhage that likely occurred as a complication of pneumococcal meningitis. Although the simultaneous presence of meningitis and intracerebral hemorrhage is rare, prompt identification and treatment of each is essential to maximize the outcome. The intracranial complications and various presentations of bacterial meningitis in adults are reviewed.

Disseminated herpes simplex virus infection in a neonate.

The emergency department (ED) evaluation of the neonate with sepsis or symptoms suggesting sepsis usually includes a complete blood count, catheterized urinalysis with culture, blood cultures, cerebrospinal fluid analysis and culture, and possibly a chest radiograph. Admission for observation for neonates at high risk for sepsis is universal. Depending on the patient's presentation and the preference of the admitting physician, intravenous antibiotics are started. Typically, ampicillin and either an aminoglycoside or cefotaxime are chosen because they cover the likely pathogens in this age group, ie, group B streptococci, Escherichia coli and other gram-negative enterics, and Listeria monocytogenes. Coverage for viral infection, most notably herpes simplex virus (HSV), is only rarely instituted in the ED and is usually considered if the patient has obvious ulcerative lesions or if the mother has known HSV infection. Unfortunately, antiviral therapy with acyclovir or vidaribine has to be started in the early stages of infection to be effective. If antiviral therapy is started after viral entry into cells, morbidity is severe and mortality approaches 80%. Neonates who survive are usually severely disabled. Broadening the indications for initiating antiviral therapy to include the neonate whose mother has any history of a sexually transmitted disease may prevent the sequelae of untreated or inadequately treated HSV infection. A case is reported of an 8-day-old girl who developed disseminated HSV infection and died as a result of hepatic failure.

Sagittal sinus thrombosis after closed head injury.

Superior sagittal sinus thrombosis (SSST) is an unusual disorder, most often attributed to hematological abnormalities, oral contraceptive use, or association with the puerperium. Although SSST secondary to trauma has been reported, it still remains an extremely rare entity. Antemortem diagnosis of SSST is made by findings on computed tomographic scanning, cerebral angiography, or magnetic resonance imaging. Prognosis is variable and spontaneous resolution has been reported. Successful treatment options of spontaneous cases include systemic anticoagulation and thrombolytic therapy along with supportive measures. There are currently no guidelines for the management of SSST associated with traumatic brain injury. This report describes a case of SSST in a man who sustained a closed head injury.

Spontaneous rupture of an amyloid spleen in a patient on continuous ambulatory peritoneal dialysis.

An unusual case is reported of spontaneous rupture of the spleen in a 67-year-old woman suffering from end-stage renal disease secondary to amyloidosis. The splenic rupture is attributed to amyloid involvement of the spleen.

Injuries distracting from intraabdominal injuries after blunt trauma.

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

Nonconvulsive status epilepticus.

A 49-year-old man presented with dizziness and altered behavior associated with a nonconvulsive seizure. He had a long history of well-controlled tonic-clonic seizures and daily episodes of 10-second staring spells. Despite normal neurological and laboratory examinations, an emergent electroencephalogram showed changes consistent with nonconvulsive generalized status epilepticus.