Isolated Extremity Trauma Research Articles

No trauma-related diagnosis in emergency trauma room whole-body computer tomography of patients with inconspicuous primary survey

PurposeWhole-body computer tomographic examinations (WBCT) are essential in diagnosing the severely injured. The structured clinical evaluation in the emergency trauma room, according to ATLS® and guidelines, helps to indicate the correct radiological imaging to avoid overtriage and undertriage. This retrospective, single-center study aimed to evaluate the value of WBCT in patients with an inconspicuous primary survey and whether there is any evidence for this investigation in this group of patients.MethodsThis retrospective, single-center study was conducted with patients admitted to a maximum-care hospital and supraregional trauma center in Germany and part of the TraumaNetwork DGU® in southwest Germany between January 2012 and November 2017. Hospital files were used for evaluation, and WBCT was carried out using a 32-row MSCT device from Siemens Healthineers, Volume Zoom, Erlangen, Germany. For evaluation, non-parametric procedures such as the chi-square test, U test, Fisher test, and Wilcoxon rank sum test were used to test for significance (p < 0.05).ResultsFrom 3976 patients treated with WBCT, 120 patients (3.02%) showed an inconspicuous primary survey. This examination did not reveal any trauma sequelae in any of this group. Additionally, 198 patients (4.98%) showed minor clinical symptoms in the primary survey, but no morphological trauma sequence could be diagnosed in WBCT diagnostics. Three hundred forty-two patients were not admitted as inpatients after WBCT and discharged to further outpatient treatment because there were no objectifiable reasons for inpatient treatment. Four hundred fifteen patients did not receive WBCT for, e.g., isolated extremity trauma, child, pregnancy, or death.ConclusionNot one of the clinically asymptomatic patients had an imageable injury after WBCT diagnostics in this study. WBCT should only be performed in severely injured patients after clinical assessment regardless of “trauma mechanism.” According to guidelines and ATLS®, the clinical examination seems to be a safe and reliable method for reasonable and responsible decision-making regarding the realization of WBCT with all well-known risk factors.

Socioeconomic status is associated with greater hazard of post-discharge mortality than race, gender, and ballistic injury mechanism in a young, healthy, orthopedic trauma population

ObjectivesTo explore the utility of legacy demographic factors and ballistic injury mechanism relative to popular markers of socioeconomic status as prognostic indicators of 10-year mortality following hospital discharge in a young, healthy patient population with isolated orthopedic trauma injuries. MethodsA retrospective cohort study was performed to evaluate patients treated at an urban Level I trauma center from January 1, 2003, through December 31, 2016. Current Procedure Terminology (CPT) codes were used to identify upper and lower extremity fracture patients undergoing operative fixation. Exclusion criteria were selected to yield a patient population of isolated extremity trauma in young, otherwise healthy individuals between the ages of 18 and 65 years. Variables collected included injury mechanism, age, race, gender, behavior risk factors, Area Deprivation Index (ADI), and insurance status. The primary outcome was post-discharge mortality, occurring at any point during the study period. ResultsWe identified 2539 patients with operatively treated isolated extremity fractures. The lowest two quartiles of socioeconomic status (SES) were associated with higher hazard of mortality than the highest SES quartile in multivariable analysis (Quartile 3 HR: 2.2, 95% CI: 1.2–4.1, p = 0.01; Quartile 4 HR: 2.2, 95% CI: 1.1–4.3, p = 0.02). Not having private insurance was associated with higher mortality hazard in multivariable analysis (HR 2.0, 95% CI: 1.3–3.2, p = 0.002). The presence of any behavioral risk factor was associated with higher mortality hazard in univariable analysis (HR: 1.8, p < 0.05), but this difference did not reach statistical significance in multivariable analysis (HR: 1.4, 95%: 0.8–2.3, p = 0.20). Injury mechanism (ballistic versus blunt), gender, and race were not associated with increased hazard of mortality (p > 0.20). ConclusionLow SES is associated with a greater hazard of long-term mortality than ballistic injury mechanism, race, gender, and medically diagnosable behavioral risk factors in a young, healthy orthopedic trauma population with isolated extremity injury.

Takotsubo Cardiomyopathy Following Traumatic Hand Amputation: A Case Report.

IntroductionTakotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease.Case ReportWe describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point-of-care ultrasound associated with traumatic hand amputation. The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition 10 days later.ConclusionEmergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.

Radiation Exposure in Patients with Isolated Limb Trauma: Acceptable or Are We Imaging Too Much?

The aim of our study was to investigate the cumulative effective dose of radiation resulting from medical imaging in orthopaedic patients with isolated extremity trauma. Deidentified radiology records of consecutive patients without age restriction with isolated extremity trauma requiring operative treatment at a regional hospital were reviewed retrospectively over a 1-year period, and the effective dose per patient for each study type of plain film X-ray, computed tomography, and operative fluoroscopy was used to calculate cumulative effective dose. Values were summarised as mean, ± standard deviation, maximum, and proportion with overdose (>20 mSv). The study cohort included 428 patients (193 male and 235 female) with an average age of 44 years (±28). There were 447 procedures performed, i.e., all involved operative fluoroscopy, 116 involved computed tomography, and 397 involved X-ray. The mean cumulative effective dose per patient was 1.96 mSv (±4.98, 45.12). The mean cumulative effective dose for operative fluoroscopy was 0.32 mSv (±0.73, 5.91), for X-ray was 1.12 mSv (±3.6, 39.23) and for computed tomography was 2.22 mSv (±4.13, 20.14). The mean cumulative effective dose of 1.96 mSv falls below the recommended maximum annual exposure of 20 mSv. This study can serve as a guide for informing clinicians and patients of the acceptable radiation risk in the context of isolated extremity trauma.

The Role of Pain Scoring in Multi-detector Computed Tomography Indications in Pediatric Occult Fractures

Introduction: Computed tomography (CT) is used in emergency orthopedic trauma cases with suspicion of fracture that cannot be detected on X-ray. Also pain during examination in patients with fracture is important for clinicians. We aimed to investigate whether pain severity is indicative of multi-detector CT (MDCT). Methods: A total of 175 patients included in the study. Visual analogue scale (VAS) was used to evaluate pre-examination pain in all patients. The most painful and suitable region for palpation were determined, palpated and the patients were asked to re-score their pain. In this way, the local VAS score was determined. MDCT was performed in all patients with general VAS of > 5. MDCT results were compared with the VAS scores. Results: Fracture detection in MDCT was 61.1% in patients with general VAS score of ≥ 5. Of the 105 patients with the local VAS score of ≥ 7, 90 had fractures. In these patients, the sensitivity, specificity, positive predictive value and negative predictive value of MDCT for detecting fractures were 84.1%, 77.9%, 85.7% and 75.7%, respectively. Conclusion: We believe that MDCT should be performed for suspected fracture if pain severity is high in isolated extremity trauma cases without fracture detection on X-ray.

(471) Nitrous oxide/oxygen compared with fentanyl in reducing pain among adults with isolated extremity trauma: A randomized trial

This study’s objective was to compare the effectiveness of nitrous oxide/oxygen (N(2) O/O(2) ) and fentanyl in relieving pain among patients with an isolated long bone fracture or main joint dislocation of the limbs. Patients with isolated long bone fracture or main joint dislocation with moderate to severe pain were randomized into two groups. For the first group, nitrous oxide/oxygen (50:50) was self-administered until pain relief was achieved up to a maximum of 15 min. Fentanyl (2 μg/kg) as a single dose was administered for the second group. Pain intensity was measured with a visual analogue scale before and at minutes three, six and nine after the start of the drug administration. We also recorded observed adverse effects in these two groups. Results: One hundred patients were enrolled in the study. No statistically significant difference in pain score was detected between the two groups with one exception. The mean visual analogue scale scores at 9 min were 2.2 and 3.1 for nitrous oxide/oxygen and fentanyl, respectively (difference -0.9 [95% CI -1.7--0.1]) (P= 0.006). There was no statistically significant difference between two groups regarding adverse effects. Conclusions: Neither nitrous oxide/oxygen or fentanyl appeared to be superior to the other in relieving moderate to severe pain among emergency patients presenting with isolated limb fracture or dislocation. In an ED, increased use of nitrous oxide might reduce the overall need for opiate analgesia, and in our setting, the need for constant monitoring. This study’s objective was to compare the effectiveness of nitrous oxide/oxygen (N(2) O/O(2) ) and fentanyl in relieving pain among patients with an isolated long bone fracture or main joint dislocation of the limbs. Patients with isolated long bone fracture or main joint dislocation with moderate to severe pain were randomized into two groups. For the first group, nitrous oxide/oxygen (50:50) was self-administered until pain relief was achieved up to a maximum of 15 min. Fentanyl (2 μg/kg) as a single dose was administered for the second group. Pain intensity was measured with a visual analogue scale before and at minutes three, six and nine after the start of the drug administration. We also recorded observed adverse effects in these two groups. Results: One hundred patients were enrolled in the study. No statistically significant difference in pain score was detected between the two groups with one exception. The mean visual analogue scale scores at 9 min were 2.2 and 3.1 for nitrous oxide/oxygen and fentanyl, respectively (difference -0.9 [95% CI -1.7--0.1]) (P= 0.006). There was no statistically significant difference between two groups regarding adverse effects. Conclusions: Neither nitrous oxide/oxygen or fentanyl appeared to be superior to the other in relieving moderate to severe pain among emergency patients presenting with isolated limb fracture or dislocation. In an ED, increased use of nitrous oxide might reduce the overall need for opiate analgesia, and in our setting, the need for constant monitoring.

Tourniquet use for peripheral vascular injuries in the civilian setting

BackgroundHaemorrhage in peripheral vascular injuries may cause life-threatening exsanguination. Tourniquets are used extensively by the military, with increased interest in the civilian setting to prevent deaths. This is a retrospective study of trauma patients at two large Canadian trauma centres with arterial injury after isolated extremity trauma. We hypothesized that tourniquet use may decrease mortality rate and transfusion requirements if applied early. MethodsThe study group was all adult patients at two Level 1 Trauma Centres in two Canadian cities in Canada, who had arterial injuries from extremity trauma. The study period was from January 2001 to December 2010. We excluded patients with significant associated injuries. The intervention in this study was prehospital tourniquet use. The main outcome was in-hospital mortality. Secondary outcomes were length of stay, compartment syndrome, amputation, and blood product transfusion. Results190 patients were included in the study, and only 4 patients had a prehospital tourniquet applied. They arrived directly from the scene of injury, had improvised tourniquets by police or bystanders, and showed a trend to be more hypotensive and acidotic. Four other patients had tourniquets applied in the trauma bay within 1h of injury. There were no differences in age, sex, injury severity or physiologic presentation between patients who had an early tourniquet applied and those who died without a tourniquet. However, six patients died without a tourniquet, and all bled to death. Of the eight patients who had early tourniquets applied, none died. ConclusionsTourniquets may prevent exsanguination in the civilian setting for patients suffering either blunt or penetrating trauma to the extremity. Future studies will help determine the utility of deploying tourniquets in the civilian setting, given the rarity of exsanguinating haemorrhage from isolated extremity trauma in this setting.

Takotsubo cardiomyopathy following traumatic hand amputation

Takotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease. We describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point of care ultrasound (POCUS) associated with traumatic hand amputation.&nbsp; The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition ten days later. Emergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.

The missed extremity fractures in emergency department

The purpose of the study was to analyze the accuracy of interpretation of extremity traumas by emergency physicians (EP) to determine the most difficult areas for interpretation in comparison to official radiology reports of direct X-ray. Radiologist reports and EP reports of direct X-rays from isolated extremity trauma patients were retrospectively compared from 01.05.2011 to 31.05.2011. A total of 181 fractures in 608 cases were confirmed. The locations of the misinterpreted fractures were ankle and foot (51.4%), wrist and hand (32.4%), elbow and forearm (5.4%), shoulder and upper arm (5.4%), hip and thigh (2.7%), and knee and leg (2.7%). The diagnostic accuracy of the EPs and radiologists were not significantly different (kappa=0.856, p=0.001). Knowledge about the types of fractures that are most commonly missed facilitates a specifically directed educational effort.

Nitrous oxide/oxygen compared with fentanyl in reducing pain among adults with isolated extremity trauma: A randomized trial

To compare the effectiveness of nitrous oxide/oxygen (N(2)O/O(2)) and fentanyl in relieving pain among patients with an isolated long bone fracture or main joint dislocation of the limbs. Patients with isolated long bone fracture or main joint dislocation with moderate to severe pain were randomized into two groups. For the first group, nitrous oxide/oxygen (50:50) was self-administered until pain relief was achieved up to a maximum of 15 min. Fentanyl (2 µg/kg) as a single dose was administered for the second group. Pain intensity was measured with a visual analogue scale before and at minutes three, six and nine after the start of the drug administration. We also recorded observed adverse effects in these two groups. One hundred patients were enrolled in the study. No statistically significant difference in pain score was detected between the two groups with one exception. The mean visual analogue scale scores at 9 min were 2.2 and 3.1 for nitrous oxide/oxygen and fentanyl, respectively (difference -0.9 [95% CI -1.7- -0.1]) (P=0.006). There was no statistically significant difference between two groups regarding adverse effects. Neither nitrous oxide/oxygen or fentanyl appeared to be superior to the other in relieving moderate to severe pain among emergency patients presenting with isolated limb fracture or dislocation. In an ED, increased use of nitrous oxide might reduce the overall need for opiate analgesia, and in our setting, the need for constant monitoring.

Is Definitive Abdominal Evaluation Required in Blunt Trauma Victims Undergoing Urgent Extra‐abdominal Surgery?

To evaluate the utility of routine abdominal computed tomographic (CT) scanning for abdominal evaluation of blunt trauma patients before urgent extra-abdominal surgery. In this observational cohort study, we prospectively enrolled all blunt trauma patients at least 8 years of age presenting to the emergency department of a Level 1 trauma center who were initially considered to require urgent extra-abdominal surgery within 24 hours of presentation. Patients were excluded if they had any of the following: 1) isolated extremity trauma, 2) signs or symptoms of intra-abdominal injury (including systolic blood pressure < 90 mm Hg; abdominal, flank, or costal margin tenderness; abdominal wall contusion or abrasion; pelvic fracture; and gross hematuria), or 3) unreliable findings on abdominal examination (Glasgow Coma Scale score < 14, paralysis, or mental retardation). Clinical data were documented on a data sheet before abdominal CT scanning. A total of 254 patients, with a mean (+/-SD) age of 32.3 (+/-16.1) years, were enrolled. A total of 201 patients ultimately underwent urgent extra-abdominal surgery for the following procedures: orthopedic, 182 (91%); facial, 17 (8%); laceration, 7 (3%); vascular, 6 (2%); neurosurgical, 3 (1%); urology, 2 (1%); and ophthalmology, 1 (0.4%). Three patients (1.2%; 95% confidence interval = 0.2% to 3.4%) were found to have intra-abdominal injuries. Two patients had splenic injuries that required only observation. One patient (0.4%; 95% confidence interval = 0% to 2.2%) underwent laparotomy. This patient sustained multiple injuries in a motorcycle crash, including splenic, kidney, and pancreatic injuries, and underwent a splenectomy. Abdominal CT scanning has a low yield in trauma patients whose sole indication for diagnostic abdominal evaluation is the need for general anesthesia for urgent extra-abdominal surgery. A small percentage of these patients, however, will have important intra-abdominal injuries such that further refinement of the recommendations for diagnostic study in this select population is needed.

Training of Medical Professionals and the Delivery of Health Care as Related to Cultural Identity Groups

Academic Emergency MedicineVolume 10, Issue 11 p. 1149-1152 Free Access Training of Medical Professionals and the Delivery of Health Care as Related to Cultural Identity Groups First published: 28 June 2008 https://doi.org/10.1197/S1069-6563(03)00481-0Citations: 7AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL References 1 BD Smedley, AY Stith, AR Nelson, (eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington , DC : Institute of Medicine, National Academy Press, 2002. 2 Rosen P, Scott CJ. Ethical issues in emergency medicine. Workshop for Residency Directors. Dallas , TX : American College of Emergency Physicians, 1993. 3 Scott CJ, Ling L, Hogan T. Towards a multicultural environment for the delivery of emergency care services. Workshop. Dallas , TX : American College of Emergency Physicians, 1994. 4 Scott CJ, Martin M, Hogan T. Increasing underrepresented minorities in emergency medicine. Workshop. Dallas , TX : American College of Emergency Physicians, 1995. 5 Scott CJ. Ethnicity, culture, and the delivery of health care services: enhancing system outcomes in a multicultural environment. In: P Rosen, (ed). Emergency Medicine: Concepts and Clinical Practice. St. Louis : Mosby, 1998, pp 2921– 30. 6 Scott CJ. Ethnicity, culture, and the delivery of health care services. In: E Bernstein, J Bernstein, (eds). Case Studies in Emergency Medicine and the Health of the Public. Sudbury , MA : Jones and Bartlett, 1996. 7 Todd KH, Lee T, Hoffman JR. The effect of ethnicity on physician estimates of pain severity in patients with isolated extremity trauma. JAMA. 1994; 271: 925– 8. 8 Task Force on the Core Content for Emergency Medicine Revision. Core content for emergency medicine. Ann Emerg Med. 1997; 29: 792– 811. 9 James T, On Behalf of the SAEM Diversity Interest Group. SAEM diversity position statement. Acad Emerg Med. 2000; 7: 1055. 10 Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978; 88: 251– 8. 11 Lavizzo-Mourey R, Mackenzie ER. Cultural competence: essential measurements of quality for managed care organizations. Ann Intern Med. 1996; 124: 919– 20. 12 Lawson WB. The art and science of the psychopharmacotherapy of African Americans. Mt Sinai J Med. 1996; 63: 301– 5. 13 Moffic HS, Kinzie JD. The history and future of cross-cultural psychiatric services. Community Ment Health J. 1996; 32: 581– 92. 14 Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington , DC : CASSP Technical Assistance Center, Georgetown University Child Development Center, 1989. 15 Denboba KL Bragdon JL, Epstein LG, Grathright K, Goldman TM. Reducing health disparities through cultural competence. J Health Edu. 1998; 29(5 suppl): S47– 53. 16 Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998; 9: 117– 125. 17 Kennedy S, Stubblefield-Tave B, Smith C. Report on Recommendations for Measures of Cultural Competence for the Quality Improvement System for Managed Care. Cambridge , MA : Abt Associates, 1999. 18 Richardson LD. Patients' rights and professional responsibilities: the moral case for cultural competence. Mt Sinai J Med. 1999; 66: 267– 70. 19 Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000; 57 (suppl 1): 181– 217. Citing Literature Volume10, Issue11November 2003Pages 1149-1152 ReferencesRelatedInformation

Regional Block Anaesthesia - How Effective is it for Extremity Trauma?

Regional block anaesthesia (RBA) techniques are eclipsed by the widespread use of general anaesthesia (GA), especially in trauma surgery. This is despite the numerous advantages that regional blocks have to offer. We conducted a study to evaluate efficacy, safety and feasibility of RBA in isolated extremity trauma in war scenario. A prospective study was carried out over a period of eight months. There were a total of 96 patients with splinter, mine blast and gun shot wounds. Supraclavicular or axillary brachial block was employed for upper extremity surgery. 3 in 1 femoral block with classical sciatic block at hip or popliteal fossa was administered for lower limb operations. All patients were stabilized prior to the procedure. A combination of lignocaine 3 mg/kg of 2% and bupivacaine 1.5 mg/kg of 0-5% with dilution to make a volume of 0.75 ml/kg was employed. Assessment was made for onset, duration and degree of anaesthesia. Haemodynamic parameters and oxygen saturation were measured during the peritraumatic period. 92.5% cases had good motor and sensory anaesthesia and permitted unhindered surgery without supplementation. The rest required GA/dissociative anaesthesia (DA). Post operative pain relief lasted for an average of 4-5 hours. No patient had derangement of haemodynamic parameters or oxygen saturation. There was no systemic drug toxicity, local complications or mortality in our series. We found RBA for isolated extremity trauma to be simple, safe and effective with consistent results.

Clinically significant changes in pain along the visual analog scale

Study Objective: We sought to test the hypothesis that the change in visual analog scale (VAS) associated with a clinically significant change in pain is related to the initial VAS score. Methods: A convenience sample of adults with isolated extremity trauma was enrolled. A VAS score was obtained on entry into the study. Descriptions of change in pain (“lot less,” “little less,” “about the same,” “little more,” or “lot more”) and VAS scores were then obtained every 30 minutes until the patient was free of pain or discharged or a total of 2 hours had passed. Patients were divided into 3 cohorts on the basis of the initial VAS score: VAS score of less than 34, VAS score of 34 to 66, and VAS score of 67 or greater. The absolute values of VAS changes associated with pain descriptions of a “little less” or “little more” (defined as clinically significant), “about the same” (defined as clinically insignificant), and “lot less” or “lot more” were calculated. Results: The change in VAS associated with clinically significant changes in pain in the cohort with VAS scores of less than 34 was 13±14 (mean±SD), which was significantly lower than that of the cohort with VAS scores of 67 or greater (28±21). There was no statistically significant difference in clinically significant changes in pain between the middle cohort and either the upper or lower cohorts (P =.07 and P =.29, respectively). There was no significant change in VAS for clinically insignificant changes in pain among the 3 cohorts (3±4, 6±6, and 8±16, respectively). Conclusion: Patients with greater pain require a greater change in VAS score to achieve clinically significant pain relief. [Bird SB, Dickson EW. Clinically significant changes in pain along the visual analog scale. Ann Emerg Med. December 2001;38:639-643.]

The Effect of Ethnicity on Physician Estimates of Pain Severity in Patients with Isolated Extremity Trauma

Division of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia and the Emergency Medicine Center and Department of Medicine, UCLA School of Medicine, Los Angeles, California

The Effect of Ethnicity on Physician Estimates of Pain Severity in Patients With Isolated Extremity Trauma

To determine whether physician estimates of pain severity are influenced by patient ethnicity. Prospective cohort study. UCLA Emergency Medicine Center, a level I trauma center, Los Angeles, Calif. Hispanic and non-Hispanic white patients presenting to the emergency department with extremity trauma when research assistants were present. Exclusion criteria were patient refusal, altered mentation, or severe injury interfering with the interview process. The difference between patient and physician estimates of pain severity as assessed on a visual analog scale for Hispanics and non-Hispanic whites. A total of 138 non-Hispanic white and 69 Hispanic patients participated in the study. The groups differed in language use, insurance status, and proportions suffering occupational injury. There were no differences between non-Hispanic white and Hispanic patients in patient pain assessments (mean, 39.8 mm vs 39.0 mm, respectively; P = .86), physician pain assessments (mean, 33.6 mm vs 29.7 mm; P = .23), or the disparity between patient and physician pain assessments (mean 6.1 mm vs 9.4 mm; P = .38). The degree of disparity between patient and physician pain assessments remained similar for both groups even after controlling for multiple potential confounders. Physician ability to assess pain severity does not differ for Hispanic and non-Hispanic white patients. Other explanations for a difference in analgesic practice as a function of ethnicity should be explored.

The effect of ethnicity on physician estimates of pain severity in patients with isolated extremity trauma

The effect of ethnicity on physician estimates of pain severity in patients with isolated extremity trauma

Relative bradycardia in patients with isolated penetrating abdominal trauma and isolated extremity trauma

A relative bradycardia is sometimes seen in patients with hemorrhagic shock. The phenomenon of relative bradycardia in civilian patients with isolated penetrating abdominal trauma and isolated severe extremity trauma who presented to an urban trauma center was studied retrospectively. Relative bradycardia was defined as a pulse rate of less than 100 with a concomitant systolic blood pressure of less than 100 mm Hg. There were 256 patients with isolated penetrating abdominal trauma and 938 patients with isolated severe extremity trauma. The incidence of relative bradycardia was 3.1% (eight of 256) in the group with abdominal trauma and 1.8% (17 of 938) in the group with extremity trauma. A pulse rate less than 100 was documented in 35.2% of all patients presenting with a systolic blood pressure less than 100 mm Hg (25 of 71). A pulse rate of less than 100 was documented in 45.8% of all patients presenting with a systolic blood pressure less than 90 mm Hg (11 of 24). No increased mortality was seen in the patients who evidenced relative bradycardia. The effect of intraperitoneal bleeding on the normal tachycardic response to hemorrhage also was studied. After controlling for volume status using various operational definitions of shock, no statistically significant (P less than .01) difference in pulse rates was noted between patients with isolated penetrating abdominal trauma and isolated extremity trauma. This result suggests that the previously theorized vagal-mediated bradycardia unique to intraperitoneal bleeding may not exist.

Postoperative Obstruction and Ileus

Haemorrhage in peripheral vascular injuries may cause life-threatening exsanguination. Tourniquets are used extensively by the military, with increased interest in the civilian setting to prevent deaths. This is a retrospective study of trauma patients at two large Canadian trauma centres with arterial injury after isolated extremity trauma. We hypothesized that tourniquet use may decrease mortality rate and transfusion requirements if applied early.The study group was all adult patients at two Level 1 Trauma Centres in two Canadian cities in Canada, who had arterial injuries from extremity trauma. The study period was from January 2001 to December 2010. We excluded patients with significant associated injuries. The intervention in this study was prehospital tourniquet use. The main outcome was in-hospital mortality. Secondary outcomes were length of stay, compartment syndrome, amputation, and blood product transfusion.190 patients were included in the study, and only 4 patients had a prehospital tourniquet applied. They arrived directly from the scene of injury, had improvised tourniquets by police or bystanders, and showed a trend to be more hypotensive and acidotic. Four other patients had tourniquets applied in the trauma bay within 1 h of injury. There were no differences in age, sex, injury severity or physiologic presentation between patients who had an early tourniquet applied and those who died without a tourniquet. However, six patients died without a tourniquet, and all bled to death. Of the eight patients who had early tourniquets applied, none died.Tourniquets may prevent exsanguination in the civilian setting for patients suffering either blunt or penetrating trauma to the extremity. Future studies will help determine the utility of deploying tourniquets in the civilian setting, given the rarity of exsanguinating haemorrhage from isolated extremity trauma in this setting.