Blunt Trauma Victims Research Articles

Traumatic mediastinal hematoma: a potentially fatal condition that may be overlooked by traditional Focused Assessment with Sonography for Trauma

Mediastinal hematoma is an uncommon finding in blunt chest trauma. It may be caused by aortic injury, by mediastinal vascular injury such as aortic injury, and by fractures of the sternum and vertebral column. A huge mediastinal hematoma can result in extrapericardial cardiac tamponade by compressing the adjacent organs. Although Focused Assessment with Sonography for Trauma (FAST) can reliably assess the presence of pericardial effusion in the subxiphoid view, it may overlook mediastinal hematoma. We present a 67-year-old male victim of blunt chest trauma complicated with expanding anterior mediastinal hematoma that was undetectable with standard FAST protocol. The large mediastinal hematoma can only be seen in the parasternal long-axis view. When ultrasound is used to assess for anteriorly located mediastinal hematoma, the transducer should be positioned in the parasternal or precordial area to scan into the pericardium and mediastinum. However, these 2 views (parasternal and precordial) are not included in emergency department's traditional FAST examination. The subxiphoid view of FAST can easily miss a mediastinal hematoma. For trauma patients with probable mediastinal injuries, we suggest doing an extended FAST with parasternal long-axis view. Alternatively, one should consider lowering the threshold of thoracic computed tomographic scan in patients with persistent symptoms because a missed mediastinal hematoma could be insidious and fatal.

Obese Patients Show a Depressed Cytokine Profile Following Severe Blunt Injury

We hypothesized that severely injured obese patients would display increased concentrations of proinflammatory cytokines when compared with patients of normal body mass index (BMI) and that this would be associated with multiple organ failure (MOF). This was a retrospective review of prospectively collected data in the "Inflammation and the Host Response to Injury" trauma-related database. Data were collected prospectively from US level I trauma centers. The subjects were severely injured adult blunt trauma patients. Cytokine concentrations obtained within 12 h of injury and on days 1 and 4 were compared between subjects on the basis of BMI (normal, 18.5-24.9 kg/m, and obese, ≥30 kg/m). Demographic measures, injury severity, cytokine concentrations, and outcome measures were compared between groups. Seventy-four adult blunt trauma victims were evaluated. Relative to patients of normal BMI (n = 34), obese patients (n = 40) demonstrated an overall depressed cytokine response to severe injury, with significantly lower concentrations of several cytokines. Obese patients showed greater incidences of nosocomial infection (60 vs. 45%, not statistically significant) and MOF (63% vs. 44%, not statistically significant) and a later onset of maximum MOF score (5 vs. 3 days, P < 0.04) when compared with those of normal BMI. Despite prior reports suggesting a proinflammatory cytokine profile in obese individuals, obese patients sustaining severe injury show a depressed early cytokine response when compared with patients of normal BMI. This may confer increased susceptibility to nosocomial infection and later MOF. Further study of immune dysfunction in the postinjury obese patient should assess the possibility of early immune suppression.

Modification of the Trauma and Injury Severity Score (TRISS) Method Provides Better Survival Prediction in Asian Blunt Trauma Victims

The objective of the present study was to identify logistic regression models with better survival prediction than the Trauma and Injury Severity Score (TRISS) method in assessing blunt trauma (BT) victims in Japan and Thailand. An additional aim was to demonstrate the feasibility of probability of survival (Ps) estimation without respiratory rate (RR) on admission, which is often missing or unreliable in Asian countries. We used BT patient data (n=15,524) registered in the Japan Trauma Data Bank (JTDB, 2005-2008). We also extracted data on BT patients injured in the Khon Kaen District between January 2005 and December 2008 (n=6,411) from the Khon Kaen Hospital Trauma Registry. For logistic regression analyses, we chose the Injury Severity Score (ISS), age year (AY), Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), RR, and their coded values (c) as explanatory variables, as well as the Revised Trauma Score (RTS). We estimated parameters by the method of maximum likelihood estimation, and utilized Akaike's Information Criterion (AIC), the area under the receiver operating characteristic curve (AUROCC), and accuracy for model comparison. A model having the lower AIC is considered to be the better model. The AIC of the model using AY was lower than that of the model using the coded value for AY (cAY) (used by the TRISS method). The model using ISS, AY and cGCS, cSBP, and cRR instead of the RTS demonstrated the lowest AIC in both data groups. The same trend could be observed in the AUROCCs and the accuracies. In the Khon Kaen data, we found no additional reduction of the AIC in the model using the cRR variable compared to the model without cRR. For better prediction of Ps, the actual number of the AY should be used as an explanatory variable instead of the coded value (used by the TRISS method). The logistic regression model using the ISS, AY, and coded values of SBP, GCS, and RR estimates the best prediction. Information about RR seems to be unimportant for survival prediction in BT victims in Asian countries.

The development of simple survival prediction models for blunt trauma victims treated at Asian emergency centers

BackgroundFor real-time assessment of the probability of survival (Ps) of blunt trauma victims at emergency centers, this study aimed to establish regression models for estimating Ps using simplified coefficients.MethodsThe data of 10,210 blunt trauma patients not missing both the binary outcome data about survival and the data necessary for Ps calculation by The Trauma and Injury Severity Score (TRISS) method were extracted from the Japan Trauma Data Bank (2004-2007) and analyzed. Half (5,113) of the data was allocated to a derivation data set, with the other half (5,097) allocated to a validation data set. The data of 6,407 blunt trauma victims from the trauma registry of Khon Kaen Regional Hospital in Thailand were analyzed for validation. The logistic regression models included age, the Injury Severity Score (ISS), the Glasgow Coma Scale score (GCS), systolic blood pressure (SBP), respiratory rate (RR), and their coded values (cAGE, 0-1; cISS, 0-4; cSBP, 0-4; cGCS, 0-4; cRR, 0-4) as predictor variables. The coefficients were simplified by rounding off after the decimal point or choosing 0.5 if the coefficients varied across 0.5. The area under the receiver-operating characteristic curve (AUROCC) was calculated for each model to measure discriminant ability.ResultsA group of formulas (log (Ps/1-Ps) = logit (Ps) = -9 + cISS - cAGE + cSBP + cGCS + cRR/2, where -9 becomes -7 if the predictor variable of cRR or cISS is missing) was developed. Using these formulas, the AUROCCs were between 0.950 and 0.964. When these models were applied to the Khon Kean data, their AUROCCs were greater than 0.91. Conclusion: These equations allow physicians to perform real-time assessments of survival by easy mental calculations at Asian emergency centers, which are overcrowded with blunt injury victims of traffic accidents.

Comparative analysis of injuries observed in motorcycle riders involved in traffic accidents and victims of other blunt trauma mechanisms

To conduct a comparative analysis of the lesions found among motorcycle riders involved in traffic accidents and victims of other mechanisms of blunt trauma. Analysis of data prospectively collected on protocols for trauma patients older than 13 years, admitted from 06/10/2008 to 09/01/2009, victims of blunt trauma. Data collected included trauma mechanism, vital signs at admission, laboratory tests, injuries, and treatment.Stratification of trauma and lesion severity was performed by calculating the trauma index: Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and TRISS. We compared the variables between motorcycle riders (group A) and the others (group B). Severe injuries were considered when AIS > 3. For statistical analysis, we used Student's t, Mann Whitney, chi-square and Fisher's test, with p < 0.05 considered statistically significant. The study included 3,783 blunt trauma victims, aged 14 to 99 years, of which 76.0% were males. The most frequent trauma mechanisms were accidents involving motorcycle riders (24.4%) and pedestrians (22.6%). When comparing the variables between groups A and B, we observed that motorcycle riders were significantly (p < 0.05) younger (28.9 ± 8.5 years vs. 42.4 ± 18.5 years) and had lower mean AIS in the head segment (0.3 ± 0.9 vs. 0.8 ± 1.1), as well as higher mean GCS at admission (14.5 ± 1.9 vs. 14.2 ± 2.2), AIS in the extremities (1.5 ± 1.2 vs. 0.9 ± 1.2), RTS (7.8 ± 0.5 vs. 7.7 ± 0.6) and TRISS (0.98 ± 0.1 vs. 0.97 ± 0.1). Men were significantly more frequent in group A (87.9% vs. 72.6%). When comparing injuries between groups, we observed that the motorcycle riders had significantly (p < 0.05) lower frequency of extradural hematomas (0.6% vs. 2.1%), subdural hematomas (0.9% vs. 2.1%), subarachnoid hemorrhage (0.9% vs. 2.2%), brain injury (1.2 vs. 3.6%), and severe head injuries (4.8% vs. 9.4% ), as well as higher frequency of diffuse axonal injury (1.6% vs. 0.7%), upper- (7.9% vs. 4.4%) and lower-limb fractures (7.7% vs. 5, 2%), and severe extremity lesions (20.6% vs. 12.6%). Compared to victims of other trauma mechanisms, motorcycle riders had a lower frequency and severity of head injuries, as well as increased frequency and severity of lesions in the extremities.

Escala de coma de Glasgow e qualidade de vida pós-trauma cranioencefálico

OBJETIVO: Avaliar o desempenho de diferentes escores da Escala de Coma de Glasgow (ECGl) observados nas primeiras 72 horas pós trauma perante a qualidade de vida e mudança percebida do estado de saúde, após um ano do evento traumático. MÉTODOS: Estudo de abordagem quantitativa, observacional, longitudinal, descritivo e correlacional com vítimas de trauma cranioencefálico contuso (TCEC) avaliadas, diariamente durante a internação hospitalar, e após um ano por meio do Medical Outcome Study 36-item Short Form Health Survey (SF-36). RESULTADOS: sob as curvas Reciever Operator Characteristics dos valores da ECGl referentes à mudança percebida do estado de saúde não apresentaram diferença significativa e variaram de 0,63 a 0,71. Correlação, estatisticamente significante, porém fraca, foi observada entre os escores da ECGl e alguns dos domínios do SF-36. CONCLUSÃO: Verificou-se que os diferentes valores da ECGl apresentaram limitações para que fossem aplicados na prática clínica para estimar as consequências do TCEC a longo prazo.

Valor diagnóstico da tomografia de coluna cervical em vítimas de trauma contuso

to assess the value of computed tomography in the diagnosis of cervical spine and spinal cord injuries in victims of blunt trauma. we reviewed the charts of blunt trauma victims from January 2006 to December 2008. We analyzed the following data: epidemiology, mechanism of trauma, transportation of victims to the hospital, intra-hospital care, indication criteria for CT, diagnosis, treatment and evolution of the victims. The victims were divided into two groups: Group I - without cervical spine injury, Group II - with cervical spine injury. we gathered medical records from 3,101 victims. Computed tomography was performed in 1572 (51%) patients, with male predominance (79%) and mean age of 38.53 years in Group I and 37.60 years in Group II. The distribution of trauma mechanisms was similar in both groups. Lesions found included: 53 fractures, eight vertebral listeses and eight spinal cord injuries. Sequelae included: paraplegia in three cases, quadriplegia in eight and brain injury in five. There were seven deaths in Group II and 240 in Group I. The average length of hospital stay was 11 days for Group I and 26.2 days for Group II. CONCLUSION. A CT scan of the cervical spine in victims of blunt trauma was effective in identifying lesions of the cervical spine and spinal cord injuries. Thus, despite the cost of neck CT and the low incidence of lesions identified by it, its indication based on the usual criteria seems justified.

Fratura de pelve: um marcador de gravidade em trauma

To assess whether the presence of a pelvic fracture is associated with greater severity and worse prognosis in victims of blunt trauma. A retrospective analysis of protocols and records of victims of blunt trauma admitted from June 2008 to March 2009 was separated into two groups: those with pelvic fracture (Group I) and those without it (Group II). Data were collected from pre-hospital admission rates of trauma, laboratory tests, diagnosed lesions, treatment and outcome. We used the Student t test, Fisher's exact test and chi-square test for statistical analysis, considering p <0.05 as significant. During the study period, 2019 individuals had multiple trauma protocols completed, of which 43 (2.1%) had pelvic fractures. Patients in Group I had significantly lower average blood pressure, higher mean heart rate, lower mean Glasgow Coma Scale, the highest average AIS in the segments head, chest, abdomen and extremities, as well as higher mean ISS and lower mean TRISS and RTS on admission. Group I more frequently presented with traumatic subarachnoid hemorrhage (7% vs. 1.6%), spinal cord injury (9% vs. 1%), thoracic and abdominal injuries, as well as need for laparotomy (21% vs. 1 %), chest drainage (32% vs. 2%) and damage control (9% vs. 0%). Complications were more frequent in group I: ARDS (9% vs. 0%), persistent shock (30% vs. 1%), coagulopathy (23% vs. 1%), acute renal failure (21% vs. 0%) and death (28% vs. 2%). The presence of a pelvic fracture is a marker of greater severity and worse prognosis in victims of blunt trauma.

Blunt traumatic diaphragmatic rupture

Traumatic injury of the diaphragm ranges from 0.6 to 1.2% and rise up to 5% among patients who were victims of blunt trauma and underwent laparotomy. Clinical suspicion associated with radiological assessment contributes to early diagnosis. Isolated diaphragmatic injury has a good prognosis. Generally worse outcomes are associated with other trauma injuries. Bilateral and right diaphragmatic lesions have worse prognosis. Multi detector computed tomography (MDCT) scan of the chest and abdomen provides better diagnostic accuracy using the possibility of image multiplanar reconstruction. Surgical repair via laparotomy and/ or thoracotomy in the acute phase of the injury has a better outcome and avoids chronic complications of diaphragmatic hernia. The authors present the case of a young male patient, victim of blunt abdominal trauma due to motor vehicle accident with rupture of the diaphragm, spleen and kidney injuries. The diagnosis was made by computed tomography of the thorax and abdomen and was confirmed during laparotomy.

8 Does Chest CT Detect Clinically Significant Injuries Missed on Chest X-Rays in Blunt Trauma Patients?

Although computed tomography (CT) has been shown to detect more injuries than plain radiography in blunt trauma patients, it is unclear whether these injuries truly change patient management. We sought to determine the proportion of blunt trauma patients who have a management-changing chest injury (MCCI) as a result of a chest CT, when the CXR showed no significant intrathoracic injury (SITI). At 2 urban Level I trauma centers, blunt trauma victims over 14 years of age who received ED chest imaging as part of their evaluation were enrolled. An expert panel, consisting of 2 emergency medicine attending physicians and an attending trauma surgeon, determined a priori 2 definitions, significant intrathoracic injury (SITI) and management-changing chest injury (MCCI). SITI was defined as any of the following injuries on official radiology reports: pneumothorax, hemothorax, mediastinal hematoma, pneumomediastinum, sternal fracture, aortic injury, ruptured diaphragm, 2 or more rib fractures, or pulmonary contusion. MCCI was defined as interventions that were deemed by expert panel to qualify as a management change for injuries detected by CT alone. Of the 2509 subjects that were enrolled, 1943 (77.4%) had a CXR alone and 566 (22.6%) had both a CXR and chest CT. 10.7% (265/2509) of all subjects were determined to have SITI: 26.4% were detected on CXR alone, 44.5% by both CXR and CT, and 29.1% on CT alone (where CXR missed the injury). In 13.6% (77/566) of patients who had a chest CT, SITI was missed on the CXR. 42.8% (33/77) of the missed injuries were from multiple rib fractures, of which 25.9% (20/77) were from pulmonary contusion. Of those patients with missed injuries on CXR and seen on CT, 31/77 (40%) patients had injuries that qualified as a management changing chest injury (MCCI). Of 33 missed multiple rib fractures, 24 led to MCCI. Although chest CT frequently detects injuries missed on CXR in blunt trauma patients, it rarely changes patient management. In 13.6% of cases in which it was performed, chest CT detected SITI not seen on plain CXR. Of these cases, 40% (31/77) led to a management changing chest injury. Therefore, in all cases where chest CT was performed, 5.5 % (33/566) of cases led to an MCCI that was not seen on plain CXR. Given this low yield of 5.5%, and the concerns of radiation, cost, and ED crowding, we are developing a clinical decision instrument for selective chest CT in blunt trauma.

Coagulopathy is Prevalent and Associated with Adverse Outcomes in Transfused Pediatric Trauma Patients

To evaluate coagulopathy in pediatric trauma patients on presentation to the emergency department, and to quantify the relationship with mortality. Pediatric trauma patients requiring a blood transfusion (red blood cells, fresh frozen plasma, platelets, or cryoprecipitate) within 24 hours of arrival were included. Coagulation values on emergency department arrival were analyzed, as were clinical details and outcome. A total of 102 children (mean age, 6 years; mean injury severity score 22, mean Glascow Coma Scale 7, 80% blunt trauma victims) were studied over a 4 year period. An abnormal prothrombin time was found in 72%, partial thromboplastin time in 38%, fibrinogen in 52%, hemoglobin in 58%, and platelet count in 23%. An abnormal prothrombin time, partial thromboplastin time, and platelet count were strongly associated with mortality (P=.005, .001, and <.0001, respectively) and remained significantly associated in multivariate analysis after adjusting for injury severity score. Coagulopathy is prevalent in pediatric trauma patients ill enough to require a transfusion and is strongly associated with mortality. Studies are needed to determine whether early coagulation factor replacement and the institution of massive transfusion protocols may improve outcomes in these patients.

Blunt Breast Trauma: Is There a Standard of Care?

The incidence of female blunt breast trauma (FBBT) is unknown, and there are no established treatment guidelines. The purpose of this study was to establish the incidence of FBBT, define associated injuries, and develop a treatment algorithm. This is a retrospective analysis of FBBT at a Level I trauma center from October 2000 through December 2008. The incidence, mechanism, and severity of injury, associated injuries, therapeutic interventions, and clinical outcomes were evaluated. A total of 14,499 patients were evaluated. Of these, 13,637 were blunt trauma victims and 5,305 were female blunt trauma victims. One hundred and eight (2%) were diagnosed with FBBT. Although the average injury severity score (ISS) was 12.3 for all FBBT patients, 60 per cent of patients had an ISS > 15. Ninety-four per cent were caused by motor vehicle crashes, with the most common injuries being long bone fractures (45%) and rib fractures (44%). One hundred and one (93.5%) of the injuries were simple hematomas managed expectantly; seven patients (6.5%) had expanding hematomas with radiological evidence of active bleeding that ultimately required invasive procedures, with six of them undergoing arteriogram and four successfully embolized. One patient was taken directly to the operating room for surgical ligation of a bleeding vessel. These data represent the largest series of breast injuries ever reported. Because FBBT is a marker for severe associated injuries, our treatment algorithm recommends that women with radiological evidence of active bleeding who are hemodynamically stable be evaluated with a chest arteriogram plus or minus embolization. However, unstable patients with no other source of hemorrhage should undergo definitive urgent operative repair. All other patients should be managed expectantly.

Correlation of fat embolism severity and subcutaneous fatty tissue crushing and bone fractures

Pulmonary fat embolism (PFE) is frequently encountered in blunt trauma. The clinical manifestation ranges from no impairment in light cases to death due to right-sided heart failure or hypoxaemia in severe cases. Occasionally, pulmonary fat embolism can give rise to a fat embolism syndrome (FES), which is marked by multiorgan failure, respiratory disorders, petechiae and often death. It is well known that fractures of long bones can lead to PFE. Several authors have argued that PFE can arise due to mere soft tissue injury in the absence of fractures, a claim other authors disagree upon. In this study, we retrospectively examined 50 victims of blunt trauma with regard to grade and extent of fractures and crushing of subcutaneous fatty tissue and presence and severity of PFE. Our results indicate that PFE can arise due to mere crushing of subcutaneous fat and that the fracture grade correlated well with PFE severity (p = 0.011). The correlation between PFE and the fracture severity (body regions affected by fractures and fracture grade) showed a lesser significant correlation (p = 0.170). The survival time (p = 0.567), the amount of body regions affected by fat crushing (p = 0.336) and the fat crush grade (p = 0.485) did not correlate with the PFE grade, nor did the amount of body regions affected by fractures. These results may have clinical implications for the assessment of a possible FES development, as, if the risk of a PFE is known, preventive steps can be taken.

Fatores associados à amnésia pós-traumática de longa duração

OBJETIVO: Identificar fatores relacionados à amnésia pós-traumática de longa duração. MÉTODO: Estudo prospectivo, longitudinal, com 187 vítimas de trauma cranioencefálico contuso, idade &gt;14 anos, atendidos em hospital de referência para trauma. As variáveis independentes foram: idade, sexo, gravidade do trauma cranioencefálico, local e tipo de lesão, número de lesões encefálicas e uso de medicação com atividade em sistema nervoso central ou corticoides. RESULTADO: O modelo de regressão logística múltipla ajustado pela variável área de lesão (intra/extra axial) evidenciou: Escala de Coma de Glasgow inicial &lt;12 (OR=20,17); Maximum Abbreviated Injury Scale/cabeça &gt;3 (OR=2,80) e uso de Fenitoína (OR=2,60), Midazolan (OR=2,83) ou ambas as drogas (OR=3,83). CONCLUSÃO: O uso do Midazolan e da Fenitoína, além da gravidade do trauma cranioencefálico, destacaram-se como fatores relacionados à amnésia de longa duração.

Blunt Thoracic Aortic Injuries: An Autopsy Study

The objective of this study was to identify the incidence and patterns of thoracic aortic injuries in a series of blunt traumatic deaths and describe their associated injuries. All autopsies performed by the Los Angeles County Department of Coroner for blunt traumatic deaths in 2005 were retrospectively reviewed. Patients who had a traumatic thoracic aortic (TTA) injury were compared with the victims who did not have this injury for differences in baseline characteristics and patterns of associated injuries. During the study period, 304 (35%) of 881 fatal victims of blunt trauma received by the Los Angeles County Department of Coroner underwent a full autopsy and were included in the analysis. The patients were on average aged 43 years±21 years, 71% were men, and 39% had a positive blood alcohol screen. Motor vehicle collision was the most common mechanism of injury (50%), followed by pedestrian struck by auto (37%). A TTA injury was identified in 102 (34%) of the victims. The most common site of TTA injury was the isthmus and descending thoracic aorta, occurring in 67 fatalities (66% of the patients with TTA injuries). Patients with TTA injuries were significantly more likely to have other associated injuries: cardiac injury (44% vs. 25%, p=0.001), hemothorax (86% vs. 56%, p<0.001), rib fractures (86% vs. 72%, p=0.006), and intra-abdominal injury (74% vs. 49%, p<0.001) compared with patients without TTA injury. Patients with a TTA injury were significantly more likely to die at the scene (80% vs. 63%, p=0.002). Thoracic aortic injuries occurred in fully one third of blunt traumatic fatalities, with the majority of deaths occurring at the scene. The risk for associated thoracic and intra-abdominal injuries is significantly increased in patients with thoracic aortic injuries.

Motion Within the Unstable Cervical Spine During Patient Maneuvering: The Neck Pivot-Shift Phenomenon

Cervical extrication collars are applied to millions of blunt trauma victims despite the lack of any evidence that a collar can protect against secondary injuries to the cervical spine. Cadaver studies support that in the presence of a dissociative injury, substantial motion can occur within the occipitocervical spine with collar application or during patient transfers. Little is known about the biomechanics of cervical stabilization; hence, it is difficult to develop and test improved immobilization strategies. Severe unstable injuries were created in seven fresh whole human cadavers. Rigid collars were applied with the body in a neutral position. Computed tomographic examinations were obtained before and after tilting the body or backboard as would be done during patient transport or to inspect the back. Relative displacements between vertebrae at the site of the injury were measured from the Computed tomographic examinations. The overall relative alignment between body and collar was assessed to understand the mechanisms that may facilitate motion at the injury site. Intervertebral motion averaged 7.7 mm±6.8 mm in the axial plain and 2.9 mm±2.5 mm in the cranial-caudal direction. The rigid collars appeared to create pivot points where the collar contacts the head in the region under the ear and where the collar contacts the shoulders. Rigid cervical collars appear to create pivot points that shift the center of rotation lateral to the spine and contribute to the intervertebral motions that were measured. Immobilization strategies that avoid these neck pivot-shift phenomena may help to reduce secondary injuries to the cervical spine. The whole cadaver model with simulation of patient maneuvers may provide an effective test method for cervical immobilization.

3D reconstruction of emergency cranial computed tomography scans as a tool in clinical forensic radiology after survived blunt head trauma—Report of two cases

When requested to evaluate surviving victims of blunt head trauma the forensic expert has to draw mainly on medical documentation from the time of hospital admission. In many cases these consist of written clinical records, radiographs and in some cases photographic documentation of the injuries. We report two cases of survived severe blunt head trauma where CT images, which had primarily been obtained for clinical diagnostic purposes, were used for forensic assessment. 3D reconstructions of the clinical CT-images yielded valuable information regarding the sequence, number and direction of the impacts to the head, their gross morphology and the inflicting weapon. We conclude that computed tomography and related imaging methods, along with their 3D reconstruction capabilities, provide a useful tool to approach questions in clinical forensic casework.

Normal Presenting Vital Signs Are Unreliable in Geriatric Blunt Trauma Victims

Normal vital signs are typically associated with improved outcomes in trauma patients. Whether this association is true for geriatric patients is unclear. A Level 1 trauma center retrospective chart review of vital signs on presentation (heart rate [HR] and blood pressure) in young (aged 17-35 years) and geriatric (aged 65 years or older) blunt trauma victims from September 2003 to September 2008 was preformed. Generalized nonlinear using piecewise regression for the linear portion of standard logistic models was used to model risk of mortality as a function of HR and blood pressure. Independent models were selected for elderly and young trauma patients based on blood pressure and HR. Models of the same complexity were then fit within each gender and age. There were 2,194 geriatric and 2,081 young patients. Two hundred fifty-one (11.4%) geriatric and 49 (2.4%) young patients died. At all points of "normality," the mortality of the geriatric patients was higher than the young group. Mortality increases considerably in the elderly patients for HRs >90 beats per minute (bpm), an association not seen until HR of 130 bpm in the young group. Mortality significantly increases with systolic blood pressure (SBP) <110 mm Hg in the geriatric patients but not until a SBP of 95 mm Hg in the young patients. HR and mortality association was most variable in the male geriatric patients. Vital signs on presentation are less predictive of mortality in geriatric blunt trauma victims. Geriatric blunt trauma patients warrant increased vigilance despite normal vital signs on presentation. New trauma triage set points of HR >90 or SBP <110 mm Hg should be considered in the geriatric blunt trauma patients.

Mortes evitáveis em pacientes de trauma associadas a não adesão às diretrizes de atendimento

To evaluate patients treated for traumatic injuries and to identify adherence to guidelines recommendations of treatment and association with death. The recommendations adopted were defined by the committee on trauma of the American College of Surgeons in advanced trauma life support. Retrospective cohort study conducted at a teaching hospital. The study population was victims of trauma > 12 years of age with injury severity scores > 16 who were treated between January 1997 and December 2001. Data collection was divided into three phases: pre-hospital, in-hospital, and post-mortem. The data collected were analyzed using EPI INFO. We analyzed 207 patients, 147 blunt trauma victims (71%) and 60 (29%) penetrating trauma victims. Trauma victims had a 40.1% mortality rate. We identified 221 non adherence events that occurred in 137 patients. We found a mean of 1.61 non adherence per patient, and it occurred less frequently in survivors (1.4) than in non-survivors (1.9; p=0.033). According to the trauma score and injury severity score methodology, 54.2% of deaths were considered potentially preventable. Non adherence occurred 1.77 times more frequently in those considered potentially preventable deaths compared to other non-survivors (95% CI: 1.12-2.77; p=0.012), and 92.9% of the multiple non adherence occurred in the first group (p=0.029). Non adherence occurred more frequently in patients with potentially preventable deaths. Non adherence to guidelines recommendations can be considered a contributing factor to death in trauma victims and can lead to an increase in the number of potentially preventable deaths.

Application of imaging guidelines in patients with suspected cervical spine trauma: retrospective analysis and literature review

Safe and efficient clearance of cervical spine injury in blunt trauma patients has been a controversial topic among health professionals. The increased availability of CT scanners in major trauma centers seems to be a factor that has led to increased number of unnecessary cervical spine imaging using this imaging modality. The objective of this study was to investigate the applicability and efficacy of a pre-test clinical criterion in order to stratify post-blunt trauma victims based on their risk of sustaining cervical spine injury and in turn recommend an appropriate imaging modality accordingly. Goergen's criteria (Australas Radiol 48(3):287, 2004), a pre-investigation diagnostic algorithm was retrospectively applied to 106 blunt trauma victims who presented to a level1 trauma center in Sydney, Australia, and had a CT scan of cervical spine as part of their initial management. Overall, nine (8.5%) of patients sustained a significant cervical spine injury. All nine patients would be classified as high-risk victims according to the algorithm investigated in this study, warranting CT scanning. No patients with low-risk injuries were demonstrated to have a significant cervical spine injury. There was a statistically significant greater proportion of acute cervical spine injuries detected in the high-risk group (p value = 0.0024). Hence, using Goergen's diagnostic algorithm could reduce the number of unnecessary cervical spine CT scans ordered, while not compromising the quality of care in post-blunt trauma victims.