Injuries continue to be the leading cause of death and disability for children. The is a paucity of published data on paediatric injuries in our local environment. This study describes the etiological spectrum, injury characteristics and treatment outcome of paediatric injuries in our local setting and provides baseline data for establishment of prevention strategies as well as treatment guidelines.
This was a descriptive cross-sectional study involving paediatric injury patients admitted to Bugando Medical Centre from August 2011 to April 2012. Statistical data analysis was done using SPSS version 17.0 and STATA version 12.0.
A total of 150 patients were studied. The age of patients ranged from 1 month to 10 years with a median age of 5 years. The male to female ratio was 2.3:1. Road traffic accident was the most common cause of injury (39.3%) and motorcycle (71.2%) was responsible for the majority of road traffic accidents. Only 11 (7.3%) patients received pre-hospital care. The head /neck (32.7%) and musculoskeletal (28.0%) were the most frequent body region injured. Open wounds (51.4%), foreign bodies (31.3%) and fractures (17.3%) were the most common type of injuries sustained. The majority of patients 84 (56.0%) were treated surgically. Complication rate was 3.9%. The mean duration of hospitalization was 9.7 ± 13.1 days. Mortality rate was 12.7%. Age of the patient (< 5 years), late presentation and presence of complications were the main predictors of length of hospital stay (P < 0.001), whereas burn injuries, severe head injuries and severity of injury (Paediatric trauma score = 0–5) significantly predicted mortality (P < 0.0001).
Paediatric injuries resulting from road traffic accidents (RTAs) remain a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTAs is necessary to reduce the incidence of paediatric injuries in this region.
Paediatric injuries; Etiological spectrum; Injury characteristics; Treatment outcome; Tanzania
The purpose of our study was to evaluate inter-observer reliability of the Three-Column classifications with conventional Schatzker and AO/OTA of Tibial Plateau Fractures.
50 cases involving all kinds of the fracture patterns were collected from 278 consecutive patients with tibial plateau fractures who were internal fixed in department of Orthopedics and Trauma III in Shanghai Sixth People’s Hospital. The series were arranged randomly, numbered 1 to 50. Four observers were chosen to classify these cases. Before the research, a classification training session was held to each observer. They were given as much time as they required evaluating the radiographs accurately and independently. The classification choices made at the first viewing were not available during the second viewing. The observers were not provided with any feedback after the first viewing. The kappa statistic was used to analyze the inter-observer reliability of the three fracture classification made by the four observers.
The mean kappa values for inter-observer reliability regarding Schatzker classification was 0.567 (range: 0.513–0.589), representing “moderate agreement”. The mean kappa values for inter-observer reliability regarding AO/ASIF classification systems was 0.623 (range: 0.510–0.710) representing “substantial agreement”. The mean kappa values for inter-observer reliability regarding Three-Column classification systems was 0.766 (range: 0.706–0.890), representing “substantial agreement”.
Three-Column classification, which is dependent on the understanding of the fractures using CT scans as well as the 3D reconstruction can identity the posterior column fracture or fragment. It showed “substantial agreement” in the assessment of inter-observer reliability, higher than the conventional Schatzker and AO/OTA classifications. We finally conclude that Three-Column classification provides a higher agreement among different surgeons and could be popularized and widely practiced in other clinical centers.
Inter-observer reliability; Tibial plateau fracture; Classification
The early hemodynamic normalization of polytrauma patients may lead to better survival outcomes. The aim of this study was to assess the diagnostic quality of trauma and physiological scores from widely used scoring systems in polytrauma patients.
In total, 770 patients with ISS > 16 who were admitted to a trauma center within the first 24 hours after injury were included in this retrospective study. The patients were subdivided into three groups: those who died on the day of admission, those who died within the first three days, and those who survived for longer than three days. ISS, NISS, APACHE II score, and prothrombin time were recorded at admission.
The descriptive statistics for early death in polytrauma patients who died on the day of admission, 1–3 days after admission, and > 3 days after admission were: ISS of 41.0, 34.0, and 29.0, respectively; NISS of 50.0, 50.0, and 41.0, respectively; APACHE II score of 30.0, 25.0, and 15.0, respectively; and prothrombin time of 37.0%, 56.0%, and 84%, respectively. These data indicate that prothrombin time (AUC: 0.89) and APACHE II (AUC: 0.88) have the greatest prognostic utility for early death.
The estimated densities of the scores may suggest a direction for resuscitative procedures in polytrauma patients.
“Retrospektive Analysen in der Chirurgischen Intensivmedizin”StV01-2008.
Polytrauma; ISS; NISS; APACHE II; Prothrombin time
Secondary triage protocols have been described in the literature as physiologic (first-tier) criteria and mechanism-related (second-tier) criteria to determine the level of trauma activation. There is debate as to the efficiency of triage decisions based on mechanism of injury which may result in overtriage and overuse of limited trauma resources. Our institution developed and implemented an advanced three-tier trauma alert system in which stable patients presenting with blunt traumatic mechanism of injury would be evaluated by the emergency department (ED) physician rather than the trauma surgeon. The American College of Surgeons Committee on Trauma (ACSCOT) requires that operational changes be monitored and evaluated for patient safety and performance. The primary aim of this study was to evaluate the process, as well as outcomes, of patient care pre and post implementation of the new triage protocol. The secondary aim was to determine predictor variables that were associated with ED dismissal.
A retrospective blinded pre/post process change implementation explicit chart review was conducted to compare process and outcomes of minimally injured trauma patients who were field triaged by mechanism of injury. Generalized linear modeling was performed to determine which predictor variables were associated with ED dismissal.
There were no significant differences in minutes to physician evaluation, CT scan, OR/ICU disposition, readmission rates, safety or quality. Significant differences only occurred in time to chest x-ray, length of stay in ED, and ED dismissal rates. Trauma surgeon and ED physician patient groups did not differ on ISS, age, or sex. The only significant predictor for ED dismissal was treatment provider, with ED physicians 3.6 times more likely to dismiss the patient from the emergency department.
ED physicians provided compble care as measured by safety, timeliness, and quality in minimally-injured patients triaged to our trauma center based only on mechanism of injury. Moreover, ED physicians were more likely to dismiss patients from the ED. A three-tiered internal triaging protocol can redirect resource usage to reduce the burden on the trauma service. This may be increasingly beneficial in trauma models in which the trauma surgeons also serve as critical care intensivists.
Critical care; Emergency medicine; Hospitalizations; Physicians; Trauma centers; Triage
Aim of this study was to evaluate prognosis of severely injured patients.
All severely injured patients with an Injury Severity Score (ISS) ≥ 50 were identified in a 6-year-period between 2000 and 2005 in German Level 1 Trauma Center Murnau. Data was evaluated from German Trauma Registry and Polytrauma Outcome Chart of the German Society for Trauma Surgery and a personal interview to assess working ability and disability and are presented as average.
88 out of 1435 evaluated patients after severe polytrauma demonstrated an ISS ≥ 50 (6.5%), among them 23% women and 77% men. 66 patients (75%) had an ISS of 50-60, 14 (16%) 61-70, and 8 (9%) ≥ 70. In 27% of patients trauma was caused by motor bike accidents. 3.6 body regions were involved. Patients had to be operated 5.3 times and were treated 23 days in the ICU and stayed 73 days in hospital. Mortality rate was 36% and rate of multi-organ failure 28%. 15% of patients demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. 25% recovered well or at least moderately. 29 out of 56 survivors answered the POLO-chart. A personal interview was performed with 13 patients. The state of health was at least moderate in 72% of patients. In 48% interpersonal problems and in 41% severe pain was observed. In 57% of patients problems with working ability regarding duration, as well as quantitative and qualitative performance were observed. Symptoms of post-traumatic stress disorder were found in 41%. The more distal the lesions were located (foot/ankle) the more functional disability affected daily life. In only 15%, working ability was not impaired. 8 out of 13 interviewed patients demonstrated complete work disability.
Even severely injured patients after multiple trauma have a good prognosis. The ISS is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score.
Severe multiple trauma; ISS; POLO-chart; Post-traumatic stress disorder
Management of post trauma tibia bone gap varied with orthopedic surgeons’ experience and tools available. Study aims to determine predictive factors for distraction by a monotube fixator (DMF) outcome in post tibia trauma limb length discrepancy.
A prospective descriptive cross sectional study of post traumatized tibia bone gap and limb length discrepancy patients at tertiary hospitals. Patient’s informed consent and institutional ethical committee approval were obtained. Bio-data, clinical and healing indexes were documented. DMF was applied for patient that met inclusion criteria. The Statistic tests used included the Chi-square, the Student’s two-tailed t test, and the Wilcox on rank-sum test when appropriate. Mantel-Haenszel Common Odds Ratio (OR) and 95% confidence intervals for poor outcome potential risk factors were recorded. Bivariate correlation and logistic regression were evaluated. Significance level was set at a p value <0.05.
Thirty-six patients with mean age, 37.2 ± 10.3 year and male/female ratio of 1:1.25 had DMF applied. Motorcycle accident accounted for 50.0% of patients and diaphyseal segment was most commonly affected 25 (69.4%). The mean bone lengthened was 10.1 ± 4.0 cm (range: 5-21 cm) and mean duration of bone transport was 105.6 ± 38.2 days. The means of rate of distraction, healing index and percentage of lengthening were 0.99 ± 0.14 mm/day, 15.6 ± 4.3 days/cm and 38.0 ± 14.3 respectively. The mean follow up was 9.7 ±4.9 months (range: 2–17.0). Per operative complications varied and outcome was satisfactory in 30 (83.3%). Obesity (p <0.0001), multiple surgery (p = 0.012) and transfusion (p = 0.001) correlated to poor outcome. Percentage lengthening ≥ 50%, bone gap >10 cm, anemia, blood transfusion, general anesthesia administration, distraction rate >1 mm/day, osteomyelitis and prolong partial weight bearing were significant predictive factors for poor outcome in post traumatic tibia distraction.
Distraction by a monotube fixator appears effective in achieving correction >38.0% original tibia lengthening following traumatic bone gap. Predictive factors for poor outcome were useful for prognostication.
Bone gap; Bone transport; Limb lengthening; Trauma; Rural Orthopedics Practice
Chest x-rays (CXR) are routinely obtained on blunt trauma patients. Many patients also receive additional imaging with thoracic computed tomography scans for other indications. We hypothesized that in hemodynamically normal, awake and alert blunt trauma patients, CXR can be deferred in those who will also receive a TCT with significant cost savings.
We retrospectively reviewed the charts of trauma patients from 1/1/2010 to 12/31/2010 who received both a CXR and TCT in the trauma room. Billing and cost data were collected from various hospital sources.
239 patients who met inclusion and exclusion criteria and received CXR and TCT between 1/1/2010 and 12/31/2010. The sensitivity of CXR was 19% (95% CI: 10.8% to 31%) and the specificity was 91.7% (95% CI: 86.7% to 95%). The false positive rate for CXR was 35.8% (95% CI: 21.7% to 52.8%) and the false negative rate was 24.5% (95% CI: 18.8% to 31.2%). The precision of CXR was 42.3% (95% CI: 25.5% to 61.1%) and the overall accuracy was 74.1% (95% CI: 68.1% to 79.2%). If routine chest xray were eliminated in these patients, the estimated cost savings ranged from $14,641 to $142,185, using three different methods of cost analysis.
In patients who are hemodynamically normal and who will be receiving a TCT, deferring a CXR would result in an estimated cost savings up to $142,185. Additionally, TCT is more sensitive and specific than CXR in identifying injuries in patients who have sustained blunt trauma to the thorax.
The Journal of Trauma Management and Outcomes welcomes the launch of the UN Decade of Action for Road Safety 2011–2020. More than 100 countries around the world will kick off the first global Decade of Action for Road Safety 2011–2020, a decade that we believe can make a change!
Background and Purpose
Thoracoscopic-assisted ventral stabilisation for thoracolumbar fractures has been shown to be associated with decreased recovery time and less morbidity when compared with open procedures. However, there are a limited number of studies evaluating late clinical and radiological results after thoracoscopic spinal surgery.
We performed an analysis of the late outcomes of thoracolumbar fractures after minimally invasive thoracoscopic ventral instrumentation. Between August 2003 and December 2008, 70 patients with thoracolumbar fractures (T5-L2) underwent ventral thoracoscopic stabilisation. Tricortical bone grafts, anterior plating systems (MACS-System), and cage implants were used for stabilisation. Outcomes measured include radiologic images (superior inferior endplate angle), Visual Analogue Scale (VAS), VAS Spine Score, quality of life scores SF-36 and Oswestry Disability Index (ODI).
Forty seven patients (67%, 47 out of 70) were recruited for the follow up evaluation (2.2 ± 1.5 years). Lower VAS Spine scores were calculated in patients with intra- or postoperative complications (44.7 (± 16.7) vs. 65.8 (± 24.5), p=0.0447). There was no difference in outcome between patients treated with bone graft vs. cage implants. Loss of correction was observed in both bone graft and titanium cage groups.
The present study demonstrates diminished long-term quality of life in patients treated with thoracoscopic ventral spine when compared with the outcome of german reference population. In contrast to the other patients, those patients without intra-operative or post-operative complications were associated with improved outcome. The stabilisation method (bone graft versus spinal cage) did not affect the long-term clinical or radiographic results in this series.
Spine; Thoracoscopic surgery; Thoracolumbar fractures; Outcome
Triage is the process of classifying patients according to injury severity and determining the priority for further treatment. Although the term “major trauma” represents the reference against which over- and undertriage rates are calculated, its definition is inconsistent in the current literature. This study aimed to investigate the effects of different definitions of major trauma on the calculation of perceived over- and undertriage rates in a Norwegian trauma cohort.
We performed a retrospective analysis of patients included in the trauma registry of a primary, referral trauma centre. Two “traditional” definitions were developed based on anatomical injury severity scores (ISS >15 and NISS >15), one “extended” definition was based on outcome (30-day mortality) and mechanism of injury (proximal penetrating injury), one ”extensive” definition was based on the “extended” definition and on ICU resource consumption (admitted to the ICU for >2 days and/or transferred intubated out of the hospital in ≤2 days), and an additional four definitions were based on combinations of the first four.
There were no significant differences in the perceived under- and overtriage rates between the two “traditional” definitions (NISS >15 and ISS >15). Adding “extended” and “extensive” to the “traditional” definitions also did not significantly alter perceived under- and overtriage. Defining major trauma only in terms of the mechanism of injury and mortality, with or without ICU resource consumption (the “extended” and “extensive” groups), drastically increased the perceived overtriage rates.
Although the proportion of patients who were defined as having sustained major trauma increased when NISS-based definitions were substituted for ISS-based definitions, the outcomes of the triage precision calculations did not differ significantly between the two scales. Additionally, expanding the purely anatomic definition of major trauma by including proximal penetrating injury, 30-day mortality, ICU LOS greater than 2 days and transferred intubated out of the hospital at ≤2 days did not significantly influence the perceived triage precision. We recommend that triage precision calculations should include anatomical injury scaling according to NISS. To further enhance comparability of trauma triage calculations, researchers should establish a consensus on a uniform definition of major trauma.
The choice of optimal treatment in traumatic brain injured (TBI) patients is a challenge. The aim of this study was to verify the neurological outcome of severe TBI patients treated with decompressive craniectomy (early < 24 h, late > 24 h), compared to conservative treatment, in hospital and after 6-months.
A total of 186 TBI patients admitted to the ICU of the Emergency Department of a tertiary referral center (Careggi Teaching Hospital, Florence, Italy) from 2005 through 2009 were retrospectively studied. Patients treated with decompressive craniectomy were divided into 2 groups: “early craniectomy group” (patients who underwent to craniectomy within the first 24 hours); and “late craniectomy group” (patients who underwent to craniectomy later than the first 24 hours). As a control group, patients whose intracranial hypertension was successfully controlled by medical treatment were included in the “no craniectomy group”.
Groups included 41 patients who required early decompressive craniectomy, 21 patients treated with late craniectomy (7.7 days after trauma, on average), and 124 patients for whom intracranial hypertension was successfully controlled through conservative treatment. Groups were comparable in age and trauma/critical illness scores, except for a significantly higher Marshall score in early craniectomized patients. The Glasgow Outcome Scale was comparable between groups at ICU, at the time of hospital discharge and at 6 months.
In our sample, a late craniectomy in patients with refractory intracranial hypertension produced a comparable 6-months neurological outcome if compared to patients responder to standard treatment. This data must be reproduced and confirmed before considering as goal-treatment in refractory intracranial hypertension.
Purpose of the presented study is to answer the following questions: Are knee injuries associated with trauma mechanisms or concomitant injuries? Do injuries of the knee region aggravate treatment costs or prolong hospital stay in polytraumatized patients?
A retrospective analysis including 29.779 severely injured patients (Injury Severity Score [greater than or equal to] 16) from the Trauma Registry of the German Society for Trauma Surgery database (1993-2008) was conducted. Patients were subdivided into two groups; the "Knee" group (n=3.458, 11.6% of all patients) including all multiple trauma patients with knee injuries, and the "Non Knee" group (n=26.321) including the remaining patients. Patients with knee injuries were slightly younger, less often male gender and had a significantly increased ISS.
Patients in the Knee group suffered significantly more traffic accidents compared to the Non Knee group (82% vs. 52%, p<0.001). These injuries were more often caused by car or motorbike accidents. Severe thoracic and limb injuries (AIS[greater than or equal to]3) were more frequently found in the Knee group (p<0.001) while head injury was distributed equally. The overall hospital stay, ICU stay, and treatment costs were significantly higher for the Knee group (38.1 vs. 25.5 days, 15.2 vs. 11.4 days, 40,116 vs. 25,336 Euro, respectively; all p<0.001).
Traffic accidents are associated with an increased incidence of knee injuries than falls or attempted suicides. Furthermore, severe injuries of the limbs and chest are more common in polytraumatized patients with knee injuries. At last, treatment of these patients is prolonged and consequently more expensive.
The aim of this survey study was to evaluate the current opinion and practice of trauma and orthopaedic surgeons in the Netherlands in the removal of implants after fracture healing.
A web-based questionnaire consisting of 44 items was sent to all active members of the Dutch Trauma Society and Dutch Orthopaedic Trauma Society to determine their habits and opinions about implant removal.
Though implant removal is not routinely done in the Netherlands, 89% of the Dutch surgeons agreed that implant removal is a good option in case of pain or functional deficits. Also infection of the implant or bone is one of the main reasons for removing the implant (> 90%), while making money was a motivation for only 1% of the respondents. In case of younger patients (< 40 years of age) only 34% of the surgeons agreed that metal implants should always be removed in this category. Orthopaedic surgeons are more conservative and differ in their opinion about this subject compared to general trauma surgeons (p = 0.002). Though the far majority removes elastic nails in children (95%).
Most of the participants (56%) did not agree that leaving implants in is associated with an increased risk of fractures, infections, allergy or malignancy. Yet in case of the risk of fractures, residents all agreed to this statement (100%) whereas staff specialists disagreed for 71% (p < 0.001). According to 62% of the surgeons titanium plates are more difficult to remove than stainless steel, but 47% did not consider them safer to leave in situ compared to stainless steel. The most mentioned postoperative complications were wound infection (37%), unpleasant scarring (24%) and postoperative hemorraghe (19%).
This survey indicates that there is no general opinion about implant removal after fracture healing with a lack of policy guidelines in the Netherlands. In case of symptomatic patients a majority of the surgeons removes the implant, but this is not standard practice for every surgeon.
Osteosynthesis; Implant removal; Survey; Complaints; Fracture healing
Cast bracing (CB) has been a well established method of treating tibial shaft fractures. Majority of the recent literature on treatment of tibial shaft fractures have upheld intramedullary nailing (IMN) as the treatment of choice. Most of these studies are from the west, in public funded health set ups and in hospitals with very low rates of infection. This has lead to bewilderment in the minds of surgeons wishing to opt for conservative treatment in countries with scarcity of health resources. We therefore undertook this study to compare the two modalities in the scenario of the developing world.
Material and methods
Sixty-eight consecutive patients were treated alternately with CB and IMN for high energy, displaced, closed and Gustilo Grade 1 open fractures of the tibial shaft, between 1995 and 2001.
An average follow up at 4.3 years revealed no statistical difference in the final functional outcome as per Johner and Wruhs' criteria with modification to Indian lifestyle. IMN group had a) slightly shorter time to fracture union (mean 21.3 weeks versus 23.1 weeks for CB, p > 0.05), (b) lesser time off work (mean 17.6 weeks versus 25.6 weeks for CB, p <0.01), (c) fewer outpatient visits (mean 6.2 versus 9.7 for CB, p < 0.05), (d) less limb length discrepancy (mean 4.3 mm versus 6.6 mm for CB, p < 0.05). The difference in residual antero-posterior angulation (mean 3.2 degrees for IMN versus 4.9 degrees for CB, p = 0.14) and varus-valgus angulation (mean 3.7 degrees for IMN versus 5.1 degrees for CB, p = 0.7) were not statistically significant. However CB group had no deep infections as compared to two in the IMN group. The average cost of hospital treatment of CB group was less than half incurred by the IMN group (average USD 831 versus USD 2071 for nailed group, p < 0.05).
Treating tibial shaft fracture either with IMN or CB provided equally gratifying results with no statistical difference in final functional outcome. The economic cost to the patient in Indian conditions is significantly less with CB and therefore stands as an equally reliable treatment option, especially in countries with fewer resources.
Fracture shaft tibia; Treatment methods; Plaster cast brace; Intramedullary nail
Despite a widespread shift to selective non-operative management (SNOM) for blunt splenic trauma, there remains uncertainty regarding the role of adjuncts such as interventional radiological techniques, the need for follow-up imaging, and the incidence of long-term complications. We evaluated the success of SNOM (including splenic artery embolization, SAE) for the management of blunt splenic injuries in severely injured patients.
Retrospective review (1996-2007) of the Alberta Trauma Registry and health records for blunt splenic trauma patients, aged 18 and older, with injury severity scores of 12 or greater, admitted to the Foothills Medical Centre.
Among 538 eligible patients, 150 (26%) underwent early operative intervention. The proportion of patients managed by SNOM rose from 50 to 78% over the study period, with an overall success rate of SNOM of 87%, while injury acuity remained unchanged over time. Among SNOM failures, 65% underwent surgery within 24 hours of admission. Splenic arterial embolization (SAE) was used in only 7% of patients managed non-operatively, although at least 21% of failed SNOM had contrast extravasation potentially amenable to SAE. Among Calgary residents undergoing SNOM, hospital readmission within six months was required in three (2%), all of whom who required emergent intervention (splenectomy 2, SAE 1) and in whom none had post-discharge follow-up imaging. Overall, the use of post-discharge follow-up CT imaging was low following SNOM (10%), and thus no CT images identified occult hemorrhage or pseudoaneurysm. We observed seven cases of delayed splenic rupture in our population which occurred from five days to two months following initial injury. Three of these occurred in the post-discharge period requiring readmission and intervention.
SNOM was the initial treatment strategy for most patients with blunt splenic trauma with 13% requiring subsequent operative intervention intended for the spleen. Cases of delayed splenic rupture occurred up to two months following initial injury. The low use of both follow-up imaging and SAE make assessment of the utility of these adjuncts difficult and adherence to formalized protocols will be required to fully assess the benefit of multi-modality management strategies.
Splenic injury; Surgery; Resuscitation; Diagnostic imaging; Angiography
An intensivist-directed Intensive Care Unit is a closed-model unit in which a physician formally trained in critical care plays a leadership role in patient management. In the last decade, there has been a move toward closed Intensive Care Units. The purpose of this evaluation was to assess the association of changes in the use of intensivists to a closed-model with mortality outcomes in injured patients seen in a long-established urban Level I Trauma Center.
This analysis used data from the Scottsdale Healthcare Osborn Medical Center trauma registry from January 1, 2002-December 31, 2008. Mortality prior to hospital discharge was compared in the pre-intensivist (intensivists were not employed and did not provide care), partial intensivist (intensivists were employed and provided care during some Intensive Care Unit shifts) and full-time intensivist (intensivists were employed and provided care in the Intensive Care Unit full time) periods. Multiple logistic regression analysis was used to estimate odds ratios for mortality adjusting for patient characteristics and injury severity for the partial intensivist and full-time intensivist periods compared with the pre-intensivist period.
Of 18,918 patients, 365 (1.9%) died before hospital discharge. After adjustment for demographic factors and injury severity score, for all patients, odds ratios comparing the partial intensivist and full-intensivist periods with the pre-intensivist period were 0.84 (95% confidence interval 0.64-1.11) and 0.99 (95% confidence interval 0.69-1.41). In patients with an injury severity score 16-24, the adjusted OR for death was 0.20 (95% CI 0.07-0.58) comparing the partial-intensivist with the pre-intensivist period and 0.30 (95% CI 0.11-0.88) comparing the full-time intensivist period with the pre-intensivist period. For patients age 65 + years, compared with the pre-intensivist period, odds ratio were 0.51 (95% confidence interval 0.31-0.84) and 0.61 (95% confidence interval 0.32-1.16) for the partial and full-time intensivist periods respectively.
In our setting, a change to a closed Intensive Care Unit model was associated with improved mortality outcomes in patients with less severe injuries and patients age 65+ years.
Data on clinical characteristics and outcomes in regard to hip fracture (HF) type are controversial. This study aimed to evaluate whether clinical and laboratory predictors of poorer outcomes differ by HF type.
Prospective evaluation of 761 consecutively admitted patients (mean age 82.3 ± 8.8 years; 74.9% women) with low-trauma non-pathological HF. Clinical characteristics and short-term outcomes were recorded. Haematological, renal, liver and thyroid status, C-reactive protein, cardiac troponin I, serum 25(OH) vitamin D, PTH, leptin, adiponectin and resistin were determined.
The cervical compared to the tronchanteric HF group was younger, have higher mean haemoglobin, albumin, adiponectin and resistin and lower PTH levels (all P < 0.05). In-hospital mortality, length of hospital stay (LOS), incidence of post-operative myocardial injury and need of institutionalisation were similar in both groups. Multivariate analysis revealed as independent predictors for in-hospital death in patient with cervical HF male sex, hyperparathyroidism and lower leptin levels, while in patients with trochanteric HF only hyperparathyroidism; for post-operative myocardial injury dementia, smoking and renal impairment in the former group and coronary artery disease (CAD), hyperparathyroidism and hypoleptinaemia in the latter; for LOS > 20 days CAD, and age > 75 years and hyperparathyroidism, respectively. Need of institutionalisation was predicted by age > 75 years and dementia in both groups and also by hypovitaminosis D in the cervical and by hyperparathyroidism in the trochanteric HF.
Clinical characteristics and incidence of poorer short-term outcomes in the two main HF types are rather similar but risk factors for certain outcomes are site-specific reflecting differences in underlying mechanisms.
Hip fracture type; Clinical characteristics; Predictors of outcomes
Road traffic crash is of growing public health importance worldwide contributing significantly to the global disease burden. There is paucity of published data on road traffic crashes in our local environment. This study was carried out to describe the injury characteristics and outcome of road traffic crash victims in our local setting and provide baseline data for establishment of prevention strategies as well as treatment protocols.
This was a prospective hospital based study of road traffic crash victims carried out at Bugando Medical Centre in Northwestern Tanzania between March 2010 and February 2011. After informed consent to participate in the study, all patients were consecutively enrolled into the study. Data were collected using a pre-tested questionnaire and analyzed using SPSS computer software version 15.0.
A total of 1678 road traffic crash victims were studied. Their male to female ratio was of 2.1:1. The patients ages ranged from 3 to 78 years with the mean and median of 29.45 (± 24.22) and 26.12 years respectively. The modal age group was 21-30 years, accounting for 52.1% patients. Students (58.8%) and businessmen (35.9%) were the majority of road traffic crash victims. Motorcycle (58.8%) was responsible for the majority of road traffic crashes. Musculoskeletal (60.5%) and the head (52.1%) were the most common body region injured. Open wounds (65.9%) and fractures (26.3%) were the most common type of injuries sustained. The majority of patients (80.3%) were treated surgically. Wound debridement was the most common procedure performed in 81.2% of the patients. The complication rate was 23.7%. The overall average length of hospital stay (LOS) was 23.5 ± 12.3 days. Mortality rate was 17.5%. According to multivariate logistic regression analysis, patients who had severe trauma (Kampala Trauma Score II ≤ 6) and those with long bone fractures stayed longer in the hospital and this was significant (P < 0.001) whereas the age of the patient, severe trauma (Kampala Trauma Score II ≤ 6), admission Systolic Blood Pressure < 90 mmHg and severe head injury (Glasgow Coma Score = 3-8) significantly influenced mortality (P < 0.001).
Road traffic crashes constitute a major public health problem in our setting and contribute significantly to unacceptably high morbidity and mortality. Urgent preventive measures targeting at reducing the occurrence of road traffic crashes is necessary to reduce the morbidity and mortality resulting from these injuries. Early recognition and prompt treatment of road traffic injuries is essential for optimal patient outcome.
Road traffic crashes; Victims; Injury characteristics; Outcome; Tanzania
Rapid economic growth in Vietnam over the last decade has led to an increased frequency of road traffic injury (RTI), which now represents one of the leading causes of death in the nation. Various efforts toward injury prevention have not produced a significant decline in the incidence of RTIs. Our study sought to describe the geographic distribution of RTIs in Hanoi, Vietnam and to evaluate the accessibility of trauma centers to those injured in the city.
We performed a cross-sectional study using Hanoi city police reports from 2006 to describe the epidemiology of RTIs occurring in Hanoi city. Additionally, we identified geographic patterns and determined the direct distance from injury sites to trauma centers by applying geographical information system (GIS) software. Factors associated with the accessibility of trauma centers were evaluated by multivariate regression analysis.
We mapped 1,271 RTIs in Hanoi city. About 40% of RTIs occurred among people 20-29 years of age. Additionally, 63% of RTIs were motorcycle-associated incidents. Two peak times of injury occurrence were observed: 12 am-4 pm and 8 pm-0 am. "Hot spots" of road traffic injuries/fatalities were identified in the city area and on main highways using Kernel density estimation. Interestingly, RTIs occurring along the two north-south main roads were not within easy access of trauma centers. Further, fatal cases, gender and injury mechanism were significantly associated with the distance between injury location and trauma centers.
Geographical patterns of RTIs in Hanoi city differed by gender, time, and injury mechanism; such information may be useful for injury prevention. Specifically, RTIs occurring along the two north-south main roads have lower accessibility to trauma centers, thus an emergency medical service system should be established.
Care process in tertiary trauma centers consists of a chain of care phases in different departments from the emergency department (ED) to post-operative rehabilitation. The historical evolution of healthcare systems and organizations has led to variations in trauma patient processes in different countries. The present study is aimed at revealing differences in the throughput and productivity of trauma patient processes between German (UKB) and Finnish (HUS) tertiary trauma centers. Problems related to the comparison of different healthcare systems were also identified. The share of patients discharged was used as a control measure.
The biggest differences between the hospitals were found in the use of resources in the ED and in post-operative care. Despite problems in defining comparable patients and resources, ED productivity was significantly higher in UKB. Post-operative care was, on average, 41% shorter in HUS. However, the share of patients discharged was significantly higher in UKB (96.5% vs. 68.9%). Differences were also found in the pre-operative length of stay of patients with proximal femoral fractures (UKB: 0.97 days, HUS: 1.57 days). The productivity of the operating unit was quite similar in the hospitals. In terms of ED mortality, no statistically significant differences were found.
The results of the present study showed significant differences in the use of resources and throughput times in trauma patient processes between Finnish and German hospitals. However, due to system-level differences between German and Finnish healthcare, the results cannot be directly transformed into development proposals for the organizations. On the other hand, in spite of certain differences regarding the healthcare systems, the demographic data of the trauma patients and medical procedures are comparable. Based on the present study, the ED process of severe trauma, pre-operative care, and operating unit processes were the most comparable parts of trauma care between the hospitals. The study also showed that the international benchmarking approach could be used to reveal bottlenecks in system-level policies and practices.
Triage and interhospital transfer are central to trauma systems. Few studies have addressed transferred trauma patients. This study investigated transfers of variable distances to OUH (Oslo University Hospital, Ullevål), one of the largest trauma centres in Europe.
Patients included in the OUH trauma registry from 2001 to 2008 were included in the study. Demographic, injury, management and outcome data were abstracted. Patients were grouped according to transfer distance: ≤20 km, 21-100 km and > 100 km.
Of the 7.353 included patients, 5.803 were admitted directly, and 1.550 were transferred. The number of transfers per year increased, and there was no reduction in injury severity during the study period. Seventy-six per cent of the transferred patients were severely injured. With greater transfer distances, injury severity increased, and there were larger proportions of traffic injuries, polytrauma and hypotensive patients. With shorter distances, patients were older, and head injuries and injuries after falls were more common. The shorter transfers less often activated the trauma team: ≤20 km -34%; 21-100 km -51%; > 100 km -61%, compared to 92% of all directly admitted patients. The mortality for all transferred patients was 11%, but was unequally distributed according to transfer distance.
This study shows heterogeneous characteristics and high injury severity among interhospital transfers. The rate of trauma team assessment was low and should be further examined. The mortality differences should be interpreted with caution as patients were in different phases of management. The descriptive characteristics outlined may be employed in the development of triage protocols and transfer guidelines.
Injury; Trauma System; Interhospital Transfer; Norway
HIV infection in a patient with burn injuries complicates the care of both the patient and the treating burn team. This study was conducted to establish the prevalence of HIV among burn patients in our setting and to compare the outcome of these patients who are HIV positive with those who are HIV negative.
This was a prospective cohort study involving burn injury patients admitted to Mulago Hospital between November 2005 and February 2006. Patients were stratified into HIV positive (exposed) group and HIV-negative (unexposed) group. Data was collected using a pre-tested coded questionnaire and analyzed using SPSS statistical computer software version 11.5.
Of the 130 patients included in the study, 17 (13.1%) patients tested HIV positive and this formed the study (exposed) group. The remaining 113 patients (86.9%) formed the control (unexposed) group. In the HIV positive group, females outnumbered males by a ratio of 1.4:1 and the mean age was 28.4 ± 21.5 years (range 3 months-34 years). 64.7% of HIV positive patients reported to have risk factors for HIV infection. Of these, multiple sexual partners [Odds Ratio 8.44, 95% C.I. (3.87-143.23), P = 0.011] and alcoholism [Odds Ratio 8.34, 95% C.I. (5.76-17.82), P = 0.002] were found to be independently and significantly associated with increased risk to HIV infection. The mean CD4 count for HIV positive and HIV negative patients were 394 ± 328 cells/μL and 912 ± 234 cells/μL respectively which is statistically significant (P = 0.001). There was no difference in the bacteria cultured from the wounds of HIV positive and negative patients (P = 0.322). Patients with clinical signs of sepsis had lower CD4+ counts compared to patients without sepsis (P < 0.001). ). Skin grafting was carried out in 35.3% of HIV negative patients and 29.4% of HIV positive patients with no significant difference in skin graft take and the degree of healed burn on discharge was the same (P = 0.324). There was no significant difference in hospital stay between HIV positive and negative patients (P = 0.674). The overall mortality rate was 11.5%. Using multivariate logistic regression analysis, mortality rate was found to be independently and significantly related to the age of the patient, HIV positive with stigmata of AIDS, CD4 count, inhalation injury, %TBSA and severity of burn (p-value < 0.001).
HIV infection is prevalent among burn injury patients in our setting and thus presents an occupational hazard to health care workers who care for these patients. All burn health care workers in this region need to practice universal precautions in order to reduce the risk of exposure to HIV infection and post-exposure prophylaxis should be emphasized. The outcome of burn injury in HIV infected patients is dependent upon multiple variables such as age of the patient, inhalation injury and %TBSA and not the HIV status alone.
HIV seroprevalence; outcome; burn injuries; Uganda
Maxillofacial injuries pose a therapeutic challenges to trauma, maxillofacial and plastic surgeons practicing in developing countries. This study was carried out to determine the etiology, injury characteristics and management outcome of maxillofacial injuries at our teaching hospital.
Patients and Methods
A prospective hospital based study of maxillofacial injury patients was carried out at Bugando Medical Centre from November 2008 to October 2009. Data was collected using a structured questionnaire and analyzed using SPPS computer software version 11.5.
A total of 154 patients were studied. Males outnumbered females by a ratio of 2.7:1. Their mean age was 28.32 ± 16.48 years and the modal age group was 21-30 years. Most injuries were caused by road traffic crushes (57.1%), followed by assault and falls in 16.2% and 14.3% respectively. Soft tissue injuries and mandibular fractures were the most common type of injuries. Head/neck (53.1%) and limb injuries (28.1%) were the most prevalent associated injuries. Surgical debridement (95.1%) was the most common surgical procedures. Closed reduction of maxillofacial fractures was employed in 81.5% of patients. Open reduction and internal fixation was performed in 6.8% of cases. Complications occurred in 24% of patients, mainly due to infection and malocclusion. The mean duration of hospital stay was 18.12 ± 12.24 days. Mortality rate was 11.7%.
Road traffic crashes remain the major etiological factor of maxillofacial injuries in our setting. Measures on prevention of road traffic crashes should be strongly emphasized in order to reduce the occurrence of these injuries.
Maxillofacial injuries; etiology; injury characteristics; treatment outcome; Tanzania
This case series report discusses patients presenting with hemorrhage and hemodymanic compromise due to severe pelvic fractures and undergoing intraoperative angioembolization (IAE) with other resuscitative procedures.
We used portable digital subtraction fluoroscopy units for IAE in patients with severe pelvic hemorrhage and hemodynamic instability (5/03-4/09). Data was collected on demographics, injury severity, resource utilization, and outcomes at our Level 1 trauma center.
There were 6,538 adult admissions with 912 having pelvic fractures and 65 of these undergoing pelvic angioembolization. Twelve hemodynamically compromised patients (10 males, 2 females) had intraoperative pelvic angiography (age: 22-79 years; mean 51.3 ± 17.4). Injury severity score (ISS) was 37.5 ± 8.4 (22-50). Mean emergency department (ED) length of stay (LOS) was 57.4 min ± 47.9 with 10 patients transported directly to the OR and 2 to the SICU prior to OR. Ten of 12 patients underwent exploratory laparotomy followed by angioembolization. Mortality was 50%. Among the 6 survivors (ISS 22 - 50), all had a pre-op CT scan, five had an initial base deficit <13, and four were transfused ≤ 6 units pre-incision/pre-procedure. Four of the 6 survivors had unilateral embolization. In contrast, all 6 non-survivors (ISS 29-41) required massive transfusion prior to OR (>6 units PRBCs) with 4 having a based deficit >13. Three of these patients bypassed CT and five underwent bilateral internal iliac embolization (BIIE).
IAE for severe pelvic hemorrhage can be successfully performed concurrently with exploratory laparotomy, pelvic packing or other resuscitative procedures. Patients most likely to benefit have a base deficit <13, and do not require massive transfusion prior to IAE or suffer from a vertically unstable pelvis fracture.
Injuries from skiing and snowboarding became a major challenge for emergency care providers in Switzerland. In the alpine setting, early assessment of injury and health status is essential for the initiation of adequate means of care and transport. Nevertheless, validated standardized protocols for on-slope triage are missing. This article can assist in understanding the characteristics of injured winter sportsmen and exigencies for future on-slope triage protocols.
Six-year review of trauma cases in a tertiary trauma centre. Consecutive inclusion of all injured skiers and snowboarders aged >15 (total sample) years with predefined, severe injury to the head, spine, chest, pelvis or abdomen (study sample) presenting at or being transferred to the study hospital. Descriptive analysis of age, gender and injury pattern.
Amongst 729 subjects (total sample) injured from skiing or snowboarding, 401 (55%, 54% of skiers and 58% of snowboarders) suffered from isolated limb injury. Amongst the remaining 328 subjects (study sample), the majority (78%) presented with monotrauma. In the study sample, injury to the head (52%) and spine (43%) was more frequent than injury to the chest (21%), pelvis (8%), and abdomen (5%). The three most frequent injury combinations were head/spine (10% of study sample), head/thorax (9%), and spine/thorax (6%). Fisher's exact test demonstrated an association for injury combinations of head/thorax (p < 0.001), head/abdomen (p = 0.019), and thorax/abdomen (p < 0.001).
The data presented and the findings from previous investigations indicate the need for development of dedicated on-slope triage protocols. Future research must address the validity and practicality of diagnostic on-slope tests for rapid decision making by both professional and lay first responders. Thus, large-scale and detailed injury surveillance is the future research priority.
skiing; snowboarding; triage; prehospital care; injury