Thoracic and neck trauma. Part four.

Previous parts to this series on thoracic and neck trauma discussed the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 described specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. Section 3 examined other types of thoracic injuries and their management, such as trauma to the diaphragm and heart. This final part provides a brief but concise overview of neck anatomy, trauma and management.

Thoracic and neck trauma. Part three.

Previous parts to this series on thoracic and neck trauma discussed the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 describes specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. This section, part 3 of 4, discusses other types of thoracic injuries and their management, such as trauma to the diaphragm and heart.

Thoracic and neck trauma. Part two.

In the previous part of this four part series on thoracic trauma the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis were discussed. Part 2 describes specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. Sections 3 and 4 will examine other types of thoracic injuries and their management, such as trauma to the diaphragm and heart. The final part provides a brief but concise overview of neck anatomy, trauma and management.

Thoracic and neck trauma. Part one.

This is the first of a four part series discussing thoracic trauma. Part one discusses the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 describes specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. Section 3 examined other types of thoracic injuries and their management, such as trauma to the diaphragm and heart. The final part provides a brief but concise overview of neck anatomy, trauma and management.

Improved trauma patient outcomes after implementation of a dedicated trauma admitting service.

BACKGROUND: Regionalised trauma systems have been shown to improve the outcome of seriously injured patients. However, it is not clear which components of these systems have the most impact on patient outcomes. The study evaluates the association between implementation of a single, dedicated trauma admitting service at an urban trauma centre and subsequent patient outcomes. METHODS: This was a retrospective review of prospectively collected trauma registry data at the St George Public Hospital, a level I urban trauma centre in Sydney, Australia. Two concurrent 18-month periods, before and after implementation of a full-time trauma service, were compared for differences in patient mortality, complication rates, and ED, ICU and hospital lengths of stay. RESULTS: There were 962 patients admitted to the hospital in the 18 months immediately preceding the implementation of the trauma service (the PRE group) and 990 patients in the subsequent 18 months (the POST group). There were no significant differences between groups with respect to patient demographics or mechanism of injury, although a higher proportion of patients in the POST group had injury severity scores (ISS) above 15 (30.6% versus 24.8%, p=0.02). There was an 8% reduction in death rate among the most severely injured patients (ISS>15), in the POST group as compared to the PRE group (12.2% and 20.2% respectively, p=0.007). CONCLUSIONS: The implementation of a full-time trauma service in this hospital was associated with a reduction in death rate among the most severely injured patients, and a decrease in LOS in patients with an ISS<15.

Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice.

BACKGROUND: Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM. METHODS: Blunt trauma patients [Injury Severity Score (ISS) >or=16] with a major pelvic fracture (Abbreviated Injury Score, pelvis >or=3) and hemodynamic instability [admission systolic blood pressure (SBP) or=6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean +/- SD. RESULTS: A total of 217 patients (mean age 41 +/- 19 years, 71% male, ISS 42 +/- 16) were studied. The admission SBP was 96 +/- 37 mmHg and the Glascow Coma Scale (GCS) 11 +/- 5. Patients received 4 +/- 2 liters of fluids including 4 +/- 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%). CONCLUSION: HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by.

Multifocal cutaneous mucormycosis complicating polymicrobial wound infections in a tsunami survivor from Sri Lanka.

A man injured in the tsunami of Dec 26, 2004, returned to Sydney for management of his soft-tissue injuries. Despite broad-spectrum antibiotics, surgical wound debridement, and vigilant wound care, his condition worsened. Muscle and fat necrosis developed in a previously debrided thigh wound, and necrotising lesions arose from previous abrasions. Histological analysis showed mucormycosis in three non-contiguous sites, and Apophysomyces elegans was isolated from excised wound tissue. Wound infections, both bacterial and fungal, will undoubtedly add to the morbidity and mortality already recorded in tsunami-affected areas. Other cases [correction] of cutaneous mucormycosis might develop in survivors, but this disease can be difficult to diagnose and even harder to treat, particularly in those remaining in affected regions.

Cardiac thromboemboli complicating a stab wound to the heart.

A 27-year-old man was noted to have neurologic deficit 4 days following cardiorrhaphy to repair a penetrating cardiac injury. Cerebral computed tomography scan showed multiple embolic infarcts and two-dimensional echocardiography revealed the source as thrombus in the left ventricle. Although this entity has been described following blunt chest trauma and cardiac contusion, it has not been noted in association with penetrating injury. Intracardiac thrombus with systemic emboli should be considered as a possible complication following cardiorrhaphy for penetrating trauma.

Caught in the Crossfire: the effects of a peer-based intervention program for violently injured youth.

PURPOSE: To assess the effect of a hospital-based peer intervention program serving youth who have been hospitalized for violent injuries on participant involvement in the criminal justice system and violent reinjury and death after hospital discharge. METHODS: A total of 112 violently injured youth (ages 12-20 years; 80% male; predominantly African-American [60%] and Latino [26%]) hospitalized in Oakland, California participated in a retrospective case-control study. Clients were matched by age and injury severity. Treatment and control youth were followed for 6 months after their individual dates of injury. The outcome variables of rate of entry/reentry into the criminal justice system, rate of rehospitalization for violent injuries and rate of violence-related deaths were compared for treatment and control groups using an odds ratio analysis. RESULTS: Intervention youth were 70% less likely to be arrested for any offense (odds ratio [OR] = 0.257) and 60% less likely to have any criminal involvement (OR = 0.356) when compared with controls. No statistically significant differences were found for rates of reinjury or death. CONCLUSION: A peer-based program that intervenes immediately after, or very soon after, youth are violently injured can directly reduce at-risk youth involvement in the criminal justice system.

Compartment syndrome in multiple uninjured extremities: a case report.

Compartment syndrome is a common problem in trauma patients. It can occur within any space bound by a dense fascial layer, such as the extremities or abdomen. It exists when increased tissue pressure within the limited anatomic space compromises perfusion. Failure to decompress the compartment leads to a self-perpetuating ischemia-edema process and resultant irreversible tissue damage. In the extremities, it typically arises from a vascular injury in that same extremity. Herein is reported a case of the unexpected development of compartment syndrome in multiple uninjured extremities in a trauma patient with hypotension requiring systemic vasopressors.