Injury In Blunt Trauma Patients Research Articles

Developing a decision instrument to guide abdominal-pelvic imaging of blunt trauma patients: Methodology and protocol of the NEXUS abdominal-pelvic imaging study.

Although computed tomography (CT) of the abdomen and pelvis (A/P) can provide crucial information for managing blunt trauma patients, liberal and indiscriminant imaging is expensive, can delay critical interventions, and unnecessarily exposes patients to ionizing radiation. Currently no definitive recommendations exist detailing which adult blunt trauma patients should receive A/P CT imaging and which patients may safely forego CT. Considerable benefit could be realized by identifying clinical criteria that reliably classify the risk of abdominal and pelvic injuries in blunt trauma patients. Patients identified as "very low risk" by such criteria would be free of significant injury, receive no benefit from imaging and therefore could be safely spared the expense and radiation exposure associated with A/P CT. The goal of this two-phase nationwide multicenter observational study is to derive and validate the use of clinical criteria to stratify the risk of injuries to the abdomen and pelvis among adult blunt trauma patients. We estimate that nation-wide implementation of a rigorously developed decision instrument could safely reduce CT imaging of adult blunt trauma patients by more than 20%, and reduce annual radiographic charges by $180 million, while simultaneously expediting trauma care and decreasing radiation exposure with its attendant risk of radiation-induced malignancy. Prior to enrollment we convened an expert panel of trauma surgeons, radiologists and emergency medicine physicians to develop a consensus definition for clinically significant abdominal and pelvic injury. In the first derivation phase of the study, we will document the presence or absence of preselected candidate criteria, as well as the presence or absence of significant abdominal or pelvic injuries in a cohort of blunt trauma victims. Using recursive partitioning, we will examine combinations of these criteria to identify an optimal "very low risk" subset that identifies injuries with a sensitivity exceeding 98%, excludes injury with a negative predictive value (NPV) greater than 98%, and retains the highest possible specificity and potential to decrease imaging. In Phase 2 of the study we will validate the performance of a decision rule based on these criteria among a new cohort of patients to ensure that the criteria retain high sensitivity, NPV and optimal specificity. Validating the sensitivity of the decision instrument with high statistical precision requires evaluations on 317 blunt trauma patients who have significant abdominal-pelvic injuries, which will in turn require evaluations on approximately 6,340 blunt trauma patients. We will estimate potential reductions in CT imaging by counting the number of abdominal-pelvic CT scans performed on "very low risk" patients. Reductions in charges and radiation exposure will be determined by respectively summing radiographic charges and lifetime decreases in radiation morbidity and mortality for all "very low risk" cases. Trial registration: Clinicaltrials.gov trial registration number: NCT04937868.

Application of Computed Tomography in the Identification of Hollow Viscus Injuries in Blunt Trauma Patients

Purpose: Despite advances in diagnostic and imaging technologies, the diagnosis of traumatic hollow viscus injury (HVI) remains a great challenge in clinical practice. This study aimed to determine the accuracy of computed tomography (CT) in the diagnosis of HVI in emergent blunt trauma patients.Methods: The study was conducted on patients with abdominal trauma who were admitted to our center, regional emergency center, Kyung Hee University Medical Center, between January 2008 and December 2018. The clinical data of patients with abdominal trauma who underwent CT and abdominal surgery within 24 hours of hospitalization were analyzed to determine the diagnostic capacity of CT.Results: In total, 156 patients were included in the study. There were 88 cases of blunt trauma. Among these patients, 27 were diagnosed with HVI using CT, and 38 patients were diagnosed with HVI in the operating room. The median injury severity score for these patients was 10.0, the revised trauma score was 7.841, and the trauma injury severity score was 0.96. The sensitivity and specificity of CT in predicting HVI in these patients were 65.8%, and 96.0%, respectively. The positive and negative predictive values were 92.6%, and 78.7%, respectively.Conclusion: In urgent situations, CT findings alone are insufficient for diagnosing HVI. Further research on the HVI diagnostic capacity of CT is required.

Patterns, management options and outcome of blunt thoracic aortic injuries: a 20-year experience from a Tertiary Care Hospital

BackgroundBlunt Thoracic aortic injury (BTAI) is the second leading cause of mortality after head injuries in blunt trauma patients. There is a paucity of information on the presentation, management and outcome of BTAIs from the Middle Eastern region. We explored the patterns, management options and outcomes of BTAIs in a level I trauma center.MethodsWe conducted a retrospective observational study on all adult patients who were admitted with BTAIs between 2000 and 2020. Patients were compared for the management option (conservative vs endovascular aortic repair (TEVAR) vs open surgery) and outcomes. Comparison between the respective groups was performed using one-way analysis of variance for continuous variables, and Pearson chi-square test for categorical variables. Kaplan–Meier curve and Cox regression analysis were performed for the outcome.ResultsEighty-seven patients had BTAI (82% male) with mean age 37.3 ± 14.5 years. The mean injury severity score was 30 ± 10 and the aortic injury grade was III (I–IV). Grade III (41.4%) and Grade IV (33.3%) injuries were more common followed by Grade II (13.8%) and Grade I (11.5%). Forty percent of cases were treated conservatively whereas aortic interventions were performed in 60% of cases (n = 52). The TEVAR was performed in 33 patients (63.5%), and 19 (36.5%) were treated with open surgery (14 with graft interposition and 5 with clamp and direct repair). The aortic injury grade was significantly higher in the intervention groups as compared to the conservative group (p = 0.001). Patients with Grade IV injuries were more likely to be treated by open repair whereas a higher frequency of patients with grade III was managed by TEVAR (p = 0.001). All the patients with Grade I–II were treated conservatively. The overall in-hospital mortality rate was 25.3% and it was significantly higher in the conservative group (40.0%) in comparison to the open repair (31.6%) and TEVAR (6.1%) group (P = 0.004). More of the non-survivors sustained head injuries (P = 0.004), had higher ISS (P = 0.001) and greater aortic injury grades (P = 0.002), and were treated non-operatively (P = 0.001).ConclusionsBTAI seems not common in trauma, however, one quarter of cases died in a level 1 trauma center, prehospital deaths were not analyzed, and postmortem examination was lacking. The associated head injury and aortic injury grade have an impact on the management option and hospital outcome. The conservative and TEVAR options were performed almost equally in 78% of cases. TEVAR and open surgery were performed only for aortic injury grade III or IV whereas the conservative treatment was offered for selected cases among the 4 injury grades. However, the mortality was higher in the conservative followed by the open surgery group and mostly due to the associated severe head injury. TEVAR should be considered for patients requiring intervention unless contraindicated due to technical difficulties. Appropriately selected patients with low-grade injuries may be managed conservatively. Long-term follow-up is needed in young adults for concerns of aortic remodeling and complications.

Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes.

Magnetic resonance imaging (MRI) is often used in practice to investigate for cord or discoligamentous injury following blunt trauma and a normal computed tomography (CT). This study investigates the MRI findings and surgical outcomes of patients in this cohort. Retrospective analysis of patients following trauma with suspected cervical spine injury from 2016 to 2019. Inclusion criteria included patients receiving a normal CT of the cervical spine and subsequent MRI due to cervical spine injury symptomatology (persistent tenderness and/or neurology). Inclusion criteria included: age ≥16 years, alert and <72 h from CT to MRI. Mann-Whitney and χ2 statistical analysis techniques were employed. Two hundred and twenty-eight patients with persistent midline tenderness and/or persistent neurology following blunt trauma and negative CT report were included. One hundred and eighty-one patients received an MRI for persistent tenderness of which 35 revealed abnormal MRI findings. Twenty-one cases required no treatment, 14 cases were treated with a rigid collar with no patients requiring operative management. Forty-seven patients received an MRI for neurological symptoms following blunt trauma and negative CT, with 11 abnormal MRI findings. Management included no treatment (three cases), application of rigid collar (six cases) and operative management (two cases). No alert neurologically intact patient with 'persistent tenderness only' received operative management following a normal CT examination. While MRI is sensitive for detecting soft tissue injuries, the prevalence for detecting clinically significant cervical spine injury in blunt trauma patients in the absence of neurology is low. The utility of MRI in this cohort is questionable considering prolonged spinal immobilisation is not without harm.

Clinical and Laboratory Evaluation of Blunt Trauma Patients for the Early Diagnosis of Intra-Abdominal Injuries

Background: Blunt abdominal trauma is seen with increasing frequency in emergency rooms and is continuous to be associated with significant morbidity and mortality. Intra-abdominal injuries following blunt trauma are of great medico-legal importance to forensic experts. Aim: The study aimed to investigate the contribution of non-invasively and rapidly obtained clinical presentation and biochemical parameters in the early diagnosis of intra- abdominal (IA) injuries in blunt trauma patients, then develop a scoring system and investigate its clinical applicability as pre-test to determine whether abdominal CT should be performed during the diagnosis or not. This may help to decrease number of malpractice claims due to medical negligence. Methods and results: A prospective study was conducted on 30 adult patients with blunt abdominal trauma presented to Emergency department (ED) of Ain shams university hospitals (ASUHS). Patients were classified into two groups: group 1: adult patients with blunt abdominal trauma with normal CT abdomen. Group 2: adult patients with blunt abdominal trauma with abnormal CT abdomen. For every patient, demographic, trauma, and clinical data were collected. Laboratory parameters measured included blood hemoglobin level, liver enzymes, kidney function tests, pancreatic enzymes and finally CT abdomen was done. The mean age for the adult patients with blunt abdominal trauma was 34 ± 11 years. Male to female ratio was 2:1 with no significant importance. There was no significant difference between both groups of the study as regards aetiology and delay time of trauma and the most common cause of BAT was motor car accidents that compromised (36.7%) of all patients. There was no significant difference between both groups of study as regards abdominal symptoms and signs. Regarding vital signs, incidence of patients with high pulse rate per minute more than 100 bpm and high respiratory rate more than 20 brpm were highly significant in group II than group I. There was no significant difference between both groups regarding blood pressure. As regards the conscious level, there was significant difference between both groups of study. Hemoglobin level was significantly lower group II than group I with cutoff point level equal to or less than 9.8gm/dl. AST, ALT, urea, creatinine, amylase and lipase levels showed no significant difference between both groups. According to CT, the spleen was the most injured organ in blunt abdominal trauma patients (43.8%) followed by the liver 4 cases (25%). Conclusion: A scoring system could be done by the sum of points obtained from each parameter (Hb level, pulse rate, respiratory rate, and conscious level). The score points range from (0-4). It was found that the patients with score (0-2) were mainly with normal CT abdomen. On the other hand, patients with score (1-4) were mainly with positive CT findings. So, this scoring system can be used for the early prediction of the presence of IAIs in BAT patients and as a pretest for the need of CT. Recommendations: Blood hemoglobin level, pulse rate, respiratory rate and conscious level can be used as early predictors of IAIs in BAT patients. A scoring system using blood hemoglobin, pulse rate, respiratory rate and conscious level can be used as a pretest probability to determine the need for abdominal CT for the detection of intra-abdominal injury.

Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures

A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI. The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed. From 59198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001). The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.

Not Yet Time to Abandon Cervical Collars in Blunt Trauma

In the evidence-based summary by Serigano et al. (Ref 1.) published in this issue of Academic Emergency Medicine under the Brass Tacks series, the authors critically appraise the evidence for the long-standing practice of prehospital and emergency department cervical spinal motion restriction (SMR) in blunt trauma patients. They highlight the absence of class I data demonstrating a benefit and describe some of the potentially harmful side effects of cervical collars.

Thoracic vertebrae fracture: Is it an indicator of abdominal injury?

Traumatic vertebral fracture accounts for 10-15% of trauma related admissions. While the correlation between lumbar vertebral fractures and abdominal injuries is well established, the relationship between thoracic vertebral fractures (TVF) and abdominal injuries is comparatively less well elucidated. Using a large national trauma database, we aimed to examine the incidence and severity of associated abdominal injuries in blunt trauma patients suffering from TVF. A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic vertebrae spine fractures following blunt mechanisms of trauma between 1997 and 2018 were examined, comparing the incidence and severity of associated intraabdominal organs injuries with and without TVF. Demographics and outcomes between the two cohorts were compared. From 362,924 blunt trauma patients, 4967 (1.37%) had isolated TVF. Mean age was 49.8years and 61.9% were males. The most common mechanism of injury was fall following by MVC. The patients with TVF had significantly higher rates of increased ISS score (ISS>16, 28.45% vs. 10.42%, p<0.001) and higher mortality rate (3.5% vs. 2%, p<0.0001). Patients with TVF had 2-3 times more intraabdominal organ injuries (p<0.001). The most commonly injured organ was spleen (3.28%); followed by liver (2.64%) and kidney (1.47%). An analysis of non-isolated thoracic spine fractures showed same distribution in age, ISS, mechanisms, patterns of intra-abdominal injury, mortality rate and laparotomy rate. Clinicians should have an elevated suspicion for intra-abdominal injuries when a thoracic spine fracture is identified, which may necessitate further evaluation.

Role of cervical spine MRI in the setting of negative cervical spine CT in blunt trauma: Critical additional information in the setting of clinical findings suggestive of occult injury

Background and purposeCervical spine injury is common in the setting of blunt trauma and there is consensus that cervical spine CT (CSCT) is the image modality of choice for initial evaluation for blunt trauma related injuries of the cervical spine. However, there is disagreement in the literature with regards to further evaluation of blunt trauma patients with cervical spine MRI (CSMRI) after negative CSCT when there is persistent clinical concern for occult trauma related injury. The purpose of this study is to examine the utility of CSMRI for detection of occult injury in blunt trauma patients after negative CSCT. Materials and methodsWe reviewed records for 7,301 patients admitted for blunt trauma (November 2007–December 2013) and identified 259 who underwent CSMRI after a negative CSCT. These CSMRIs were reviewed to determine the number and type of significant CT occult injuries identified and clinical indications that led to CSMRI acquisition. Results and conclusionsCSMRI detected significant injuries following negative CSCT in 31% (81/259) of patients. There were 15 cord contusions/infarcts, 9 bone contusions/fractures, 7 spinal canal hemorrhages and 66 soft tissue injuries. Upper extremity neurological deficit had greatest positive predictive value (PPV) for detection of CT-occult injury on CSMRI of 43% (23/53), followed by equivocal CSCT findings (38%, 18/47), presence of extra-cervical injuries (34%, 20/58), midline cervical tenderness (20%, 17/85), and isolated lower extremity neurological deficit (0%, 0/16). CSMRI is recommended following negative CSCT in the evaluation of blunt cervical spine trauma when appropriate clinical concerns are present.

Management of blunt adrenal gland injury in a community-based hospital

IntroductionInjury of the adrenal gland in blunt trauma is rare. The routine usage of the whole body computed tomography (CT) scan helps in early diagnosis. We aimed to study the incidence, mechanism of injury, management, and outcome of adrenal injury in blunt trauma patients treated in a community-based hospital. MethodsCT scan of the abdomen of all blunt trauma patients who were admitted to our institution between October 2010 and March 2018 were retrospectively reviewed. The files of all the patients with CT scan-detected adrenal injuries were retrieved. Studied variables included demography, mechanism of injury, associated injuries, GCS, ISS, Intensive Care Unit admission, hospital stay, and outcome. Results4991 blunt trauma patients were admitted to the hospital. CT scan of the abdomen was performed for 2359 (47%) patients. Blunt adrenal injuries were diagnosed in eleven male patients (0.22%). The main mechanism of injury was motor vehicle collisions in eight (72.7%) patients. Nine (81.8%) patients had right adrenal gland injury. The mean (range) ISS was 22 (6–50). All patients had intra-adrenal hematoma and periadrenal fat stranding. None of our patients had acute adrenal insufficiency. One patient died (overall mortality 9.1%). ConclusionsThe incidence of blunt adrenal injury, although rare, is similar in a community-based hospital to those reported from trauma I centers. It is associated with severe and multiple organ injuries. Blunt adrenal injuries are usually self-limiting.

Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less

PurposeEarly diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients. MethodsA retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13–15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant. ResultsThere were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3–12 that including 6351 (72%) patients with GCS of 3–8 and 2380 (28%) patient with GCS of 9–12. In these 8731 patients with GCS of 3–12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3–12, 1256 (89%) patients with GCS 3–8, 148 (11%) patients with GCS 9–12. In the 5095 stable blunt trauma patients with GCS 3–8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9–12 was 50.1%. In the unstable patients with GCS 3–8, 60.5% of them had TBI, and in subgroup of patients with GCS 9–12, only 37.2% suffered from TBI. ConclusionThe utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.

Accuracy of clinical, laboratory, and computed tomography findings for identifying hollow viscus injury in blunt trauma patients with unexplained intraperitoneal free fluid without solid organ injury

BackgroundWe sought to define the accuracy of findings for detecting hollow viscus injury (HVI) in patients with blunt abdominal trauma (BAT) and unexplained intra-peritoneal free fluid without solid organ injury (UIPFFWSOI). MethodsWe screened all consecutive hemodynamically stable patients presenting to a quaternary-care trauma-centre who had an abdominal computed tomography (CT) scan for BAT and UIPFFWSOI (January 2007–December 2014). ResultsOf 3796 patients identified during the study period, 39 presented with UIPFFWSOI. Fifteen underwent therapeutic laparotomy. Seatbelt sign (+LR approaches infinity), diffuse peritonitis (+LR approaches infinity), number of CT cuts with fluid (c-statistic = 0.65), and a lower arterial pH at presentation (c-statistic = 0.62) were most predictive of HVI. Patients operated on within 24 h had shorter stays than those operated on later (median 9 vs. 14 days, p = 0.03). ConclusionsOur findings suggest that clinical examination and measurements of intraperitoneal fluid volume may help identify HVIs in BAT patients.

When Should Abdominal Computed Tomography Be Considered in Patients with Lower Rib Fractures?

BackgroundLower rib fractures are considered as a marker of intra-abdominal organ injury. Abdominal computed tomography (CT) is the “gold standard” examination for patients with lower rib fractures. However, the reported incidence of concomitant intra-abdominal injuries (IAI) is 20%–40%. ObjectiveThe purpose of this study was to evaluate the incidence of intra-abdominal organ injuries in blunt trauma patients with lower rib fractures. MethodsMedical charts and radiology reports of patients with lower rib (from the 8th to 12th rib) fractures admitted to our center during a 6-year period were retrospectively reviewed. Patients were divided into two groups. Group I included patients with intra-abdominal injury (IAI) diagnosed either by CT or on urgent laparotomy, and Group II included those with normal abdominal CT scans. Data included demographics, mechanism of injury, laboratory tests, radiology results including number and location of fractured ribs, and incidence of IAI. ResultsOverall 318 patients were included in the study. Fifty-seven patients (17.9%) had 71 IAIs compared with 265 (82.1%) patients with no IAI. Logistic regression identified age younger than 55 years (relative risk [RR] = 7.2; 95% confidence interval [CI] 3.1–16.8; p = 0.001), bilateral rib fractures (RR = 3.9; 95% CI 1.1–13.5; p = 0.03) and decreased levels of hematocrit (RR = 2.4; 95% CI 1.2–4.8; p = 0.016) as independent risk factors for the presence of IAI. ConclusionsAbdominal CT should be considered in blunt trauma patients with lower rib fractures who are younger than 55 years of age and have bilateral rib fractures and decreased levels of hematocrit on admission.

302 Rib Fractures in the PanScan Era

Rib fractures are the most common thoracic injuries in blunt trauma patients. Fractures of the first and second ribs are traditionally thought to be indicative of significant trauma and are associated with serious injuries, particularly to the great vessels. Increased chest CT utilization in blunt trauma evaluation may diagnose minor, clinically irrelevant fractures. We sought to determine 1) The frequency of rib fracture seen on chest CT only (SOCTO) versus chest x-ray (CXR), 2) The frequency of rib fracture associated great vessel injuries, and 3) Mortality considering patients with rib fracture SOCTO and fractures of the first or second rib. Focusing primarily on patients who had both CXR and chest CT, we conducted a pre-planned analysis of two prospectively enrolled cohorts with the following inclusion criteria: age > 14 years, blunt trauma within 12 hours of ED presentation, and receiving CXR or chest CT during trauma evaluation. We defined rib fractures and other thoracic injuries according to CT reports and followed patients through their hospital course to determine clinical outcomes. Of 21,382 enrolled subjects, 8661 (40.5%) had both CXR and chest CT and 2071 (23.9%) of these had rib fractures, making it the most common thoracic injury. 286 subjects (3.3%) had first or second rib fractures. Rib fractures were SOCTO in 1368 (66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%: mean difference 42.9%, 95% confidence interval [CI] 41.4% to 44.4%) and mortality (5.6% versus 2.7%: mean difference 2.9%, 95% CI 1.8% to 4.0%) than patients without rib fractures. Mortality of patients with rib fracture SOCTO was not significantly different than that of patients with fractures also seen on CXR (4.8% versus 5.7%: mean difference 0.9%, 95% CI -2.2 to 4.8%). Great vessel or aortic injury was higher amongst patients with first or second rib fractures (2.8% versus 0.5%: mean difference 2.3%, 95% CI 0.3 to 4.3%). Patients with first or second rib fractures had significantly higher mortality than patients with fractures of ribs 3-12 (7.34% versus 4.18%: mean difference 3.2%, 95% CI 0.2% to 6.97%). Under current blunt trauma imaging protocols that commonly include chest CT, most rib fractures are SOCTO. Patients with rib fractures had higher admission rates and mortality than patients without rib fractures, but there is no difference in mortality of patients with rib fractures SOCTO compared with those whose fractures were seen on CXR. Patients with first or second rib fractures had a higher prevalence of great vessel injury and their mortality was significantly higher.

The epidemiology of thoracolumbar trauma: A meta-analysis

PurposeTo describe the epidemiology of thoracolumbar fractures and associated injuries in blunt trauma patients. MethodsA systematic review and metaanalysis was performed based on a MEDLINE database search using MeSH terms for studies matching our inclusion criteria. The search yielded 21 full-length articles, each sub-grouped according to content. Data extraction and multiple analyses were performed on descriptive data. ResultsThe rate of thoracolumbar fracture in blunt trauma patients was 6.90% (±3.77, 95% CI). The rate of spinal cord injury was 26.56% (±10.70), and non-contiguous cervical spine fracture occurred in 10.49% (±4.17). Associated injury was as follows: abdominal trauma 7.63% (±9.74), thoracic trauma 22.64% (±13.94), pelvic trauma 9.39% (±6.45), extremity trauma 18.26% (±5.95), and head trauma 12.96% (±2.01). Studies that included cervical spine fracture with thoracolumbar fracture had the following rates of associated trauma: 3.78% (±5.94) abdominal trauma, 21.65% (±16.79) thoracic trauma, 3.62% (±1.07) pelvic trauma, 18.36% (±4.94) extremity trauma, and 15.45% (±11.70) head trauma. A subgroup of flexion distraction injuries showed an associated intra-abdominal injury rate of 38.70% (±13.30). The most common vertebra injured was L1 at a rate of 34.40% (±15.90). T7 was the most common non-junctional vertebra injured at 3.90% (±1.09). Burst/AO type A3 fractures were the most common morphology 39.50% (±16.30) followed by 33.60% (±15.10) compression/AO type A1, 14.20% (±8.08) fracture dislocation/AO type C, and 6.96% (±3.50) flexion distraction/AO type B. The most common etiology for a thoracolumbar fracture was motor vehicle collision 36.70% (±5.35), followed by high-energy fall 31.70% (±6.70). ConclusionsHere we report the incidence of thoracolumbar fracture in blunt trauma and the spectrum of associated injuries. To our knowledge, this paper provides the first epidemiological road map for blunt trauma thoracolumbar injuries.

Predictors of "occult" intra-abdominal injuries in blunt trauma patients.

to assess predictors of intra-abdominal injuries in blunt trauma patients admitted without abdominal pain or abnormalities on the abdomen physical examination. We conducted a retrospective analysis of trauma registry data, including adult blunt trauma patients admitted from 2008 to 2010 who sustained no abdominal pain or abnormalities on physical examination of the abdomen at admission and were submitted to computed tomography of the abdomen and/or exploratory laparotomy. Patients were assigned into: Group 1 (with intra-abdominal injuries) or Group 2 (without intra-abdominal injuries). Variables were compared between groups to identify those significantly associated with the presence of intra-abdominal injuries, adopting p<0.05 as significant. Subsequently, the variables with p<0.20 on bivariate analysis were selected to create a logistic regression model using the forward stepwise method. A total of 268 cases met the inclusion criteria. Patients in Group I were characterized as having significantly (p<0.05) lower mean AIS score for the head segment (1.0 ± 1.4 vs. 1.8 ± 1.9), as well as higher mean AIS thorax score (1.6 ± 1.7 vs. 0.9 ± 1.5) and ISS (25.7 ± 14.5 vs. 17,1 ± 13,1). The rate of abdominal injuries was significantly higher in run-over pedestrians (37.3%) and in motorcyclists (36.0%) (p<0.001). The resultant logistic regression model provided 73.5% accuracy for identifying abdominal injuries. The variables included were: motorcyclist accident as trauma mechanism (p<0.001 - OR 5.51; 95%CI 2.40-12.64), presence of rib fractures (p<0.003 - OR 3.00; 95%CI 1.47-6.14), run-over pedestrian as trauma mechanism (p=0.008 - OR 2.85; 95%CI 1.13-6.22) and abnormal neurological physical exam at admission (p=0.015 - OR 0.44; 95%CI 0.22-0.85). Intra-abdominal injuries were predominantly associated with trauma mechanism and presence of chest injuries.

Assessing Incidence and Risk Factors of Cervical Spine Injury in Blunt Trauma Patients Using the National Trauma Data Bank

Despite the potentially devastating impact of missed cervical spine injuries (CI), there continues to be a large disparity in how institutions attempt to make the diagnosis. To better streamline the approach among institutions, understanding incidence and risk factors across the country is paramount. We evaluated the incidence and risk factors of CI using the National Trauma Databank for 2008 and 2009. We performed a retrospective review of the National Trauma Databank for 2008 and 2009 comparing patients with and without CI. We then performed subset analysis separating injury by patients with and without fracture and ligamentous injury. There were a total of 591,138 patients included with a 6.2 per cent incidence of CI. Regression found that age, Injury Severity Score, alcohol intoxication, and specific mechanisms of motor vehicle crash (MVC), motorcycle crash (MCC), fall, pedestrian stuck, and bicycle were independent risk factors for overall injury (P < 0.0001). Patients with CI had longer intensive care unit (8.5 12.5 vs 5.1 7.7) and hospital lengths of stay (days) (9.6 14.2 vs 5.3 8.1) and higher mortality (1.2 per cent vs 0.3%), compared with those without injury (P < 0.0001). There were 33,276 patient with only fractures for an incidence of 5.6 per cent and 1875 patients with ligamentous injury. Just over 6 per cent of patients suffer some form of CI after blunt trauma with the majority being fractures. Higher Injury Severity Score and MVC were consistent risk factors in both groups. This information will assist in devising an algorithm for clearance that can be used nationally allowing for more consistency among trauma providers.

Femur fractures should not be considered distracting injuries for cervical spine assessment

IntroductionThe National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries. ObjectivesWe sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging. MethodsWe retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated. ResultsOf 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%). ConclusionsIn our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.

Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach

ABSTRACT Purpose In a previous work, we presented a protocol for the management of patients with complex pelviperineal injuries (CPI) resulting from blunt trauma. This treatment protocol included: early hemorrhage control, surgical debridement of devitalized tissue, selective loop transverse colostomy according to the location of the perineal wound, distal colonic irrigation with saline solution, pulsatile saline solution irrigation of the perineal wound, maintenance of the perineal wound open, management of bone fractures and visceral injuries, surgical revisions at intervals of 24 to 48 hours, presumptive antibiotic therapy, early nutritional support, and definitive repair of wound defect and visceral injuries after infection control and metabolic recovery. In order to determine whether the evolution of the authors's protocol for the assessment and management of patients with CPI is associated with improved patient outcome we conduct this review. Materials and methods The medical records of 42 patients with CPI resulting from blunt trauma admitted in the level I trauma center at the HC-USPSM, were reviewed. Demographic data, mechanism of trauma, revised trauma score (RTS) and injury severity score (ISS), classification of perineal injuries, associated systemic trauma, infection complications and mortality rates (overall, early and late) were collected. Results The early mortality was 19% and the late mortality was 17%. The overall mortality was 36%. Patients who died had higher average ISS (average ISS = 45) comparing to patients who survived (average ISS = 25) with significant statistical difference (p &lt; 0.05). Damage control principles applied to CPI was the standard of care and a selective approach to perform fecal stream diversion were used. Conclusion The results of this study showed that the use of this protocol was effective and reinforced the importance of the priority in early control of hemorrhage, early fecal diversion in selected cases, multiple surgical perineal revisions, and avoidance of complex visceral injury repair at the first surgical intervention. How to cite this article Teixeira Jr FJR, do Couto Netto SD, Collete e Silva FS, Mori ND, Fontes B, Poggetti RS, Birolini D, Bernini CO, Utiyama EM. Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach. Panam J Trauma Crit Care Emerg Surg 2015;4(2):87-95.

The severity of liver injury following blunt trauma does not correlate with the number of fractured ribs: an analysis of a national trauma registry database.

Rib fractures are a marker of severe injury, predicting a higher incidence of associated injuries. The purpose of this study was to assess whether an increasing number of rib fractures predicts the severity of liver injury in blunt trauma patients. We performed a retrospective cohort study involving blunt trauma patients with concomitant liver injuries and rib fractures who were registered in a national trauma registry. Of 57,130 patients with blunt torso injuries, 14,651 patients sustained rib fractures, and 2,899 patients suffered liver injuries. Concomitant liver injury occurred in 1,087 of the patients with rib fractures (7.4%), while 1,812 patients sustained liver injury without rib fractures (4.3%). The presence of six or more rib fractures predicted a higher incidence of liver injury. Among the patients with liver injury, those with concomitant rib fractures had a higher Injury Severity Score (ISS), but similar mortality rates. Among the patients with concomitant rib fractures and liver injury, there was no relationship between the number of fractured ribs and the severity of the liver injury. Although the presence of rib fractures was associated with an increased probability of liver injury in patients with blunt torso trauma, there is no relationship between the number of fractured ribs and the severity of liver injury.