Comparison of autopsy findings and injury severity scores in deaths due to traumatic asphyxia (perthes syndrome)

Abstract Background Treatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma. Methods Our prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14–15) of impaired mental status. Outcome was compared. Results A total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6–12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups. Conclusion This study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.

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Structured and Systematic Team and Procedure Training in Severe Trauma: Going from ‘Zero to Hero’ for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods

World Journal of Surgery ◽

10.1007/s00268-021-05980-1 ◽

2021 ◽

Vol 45 (5) ◽

pp. 1340-1348

Author(s):

Maryam Meshkinfamfard ◽

Jon Kristian Narvestad ◽

Johannes Wiik Larsen ◽

Arezo Kanani ◽

Jørgen Vennesland ◽

...

Keyword(s):

Injury Severity ◽

Trauma System ◽

Severe Trauma ◽

Emergency Procedure ◽

Emergency Thoracotomy ◽

Severity Scores ◽

Time Periods ◽

Low Volume ◽

Time Critical ◽

Over Time

Abstract Background Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. Methods An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. Results Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. Conclusion The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

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Endothelial glycocalyx degradation is associated with early organ impairment in polytrauma patients

BMC Emergency Medicine ◽

10.1186/s12873-021-00446-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Feng Qi ◽

Hao Zhou ◽

Peng Gu ◽

Zhi-He Tang ◽

Bao-Feng Zhu ◽

...

Keyword(s):

Injury Severity ◽

Early Stage ◽

Endothelial Glycocalyx ◽

Control Group ◽

Metabolic System ◽

Metabolic Systems ◽

Organ Systems ◽

Severity Scores ◽

Polytrauma Patients ◽

Trauma Group

Abstract Background Endothelial glycocalyx (EG) abnormal degradation were widely found in critical illness. However, data of EG degradation in multiple traumas is limited. We performed a study to assess the EG degradation and the correlation between the degradation and organ functions in polytrauma patients. Methods A prospective observational study was conducted to enroll health participants (control group) and polytrauma patients (trauma group) at a University affiliated hospital between Feb 2020 and Oct 2020. Syndecan1 (SDC1) and heparin sulfate (HS) were detected in serum sample of both groups. In trauma group, injury severity scores (ISS) and sequential organ failure assessments (SOFA) were calculated. Occurrences of acute kidney injury (AKI), trauma-induced coagulopathy (TIC) within 48 h and 28-day all-cause mortality in trauma group were recorded. Serum SDC1 and HS levels were compared between two groups. Correlations between SDC1/HS and the indicators of organ systems in the trauma group were analyzed. ROC analyses were performed to assess the predictive value of SDC1 and HS for AKI, TIC within 48 h, and 28-day mortality in trauma group. Results There were 45 polytrauma patients and 15 healthy participants were collected, totally. SDC1 and HS were significantly higher in trauma group than in control group (69.39 [54.18–130.80] vs. 24.15 [13.89–32.36], 38.92 [30.47–67.96] vs. 15.55 [11.89–23.24], P < 0.001, respectively). Trauma group was divided into high degradation group and low degradation group according to SDC1 median. High degradation group had more severe ISS, SOFA scores, worse organ functions (respiratory, kidney, coagulation and metabolic system), and higher incidence of hypothermia, acidosis and shock. The area under the receiver operator characteristic curves (AUC) of SDC1 to predict AKI, TIC occurrence within 48 h and 28-day mortality were 0.838 (95%CI: 0.720–0.957), 0.700 (95%CI: 0.514–0.885) and 0.764 (95%CI: 0.543–0.984), respectively. Conclusions EG degradation was elevated significantly in polytrauma patients, and the degradation was correlated with impaired respiratory, kidney, coagulation and metabolic systems in early stage. Serum SDC1 is a valuable predictive indicator of early onset of AKI, TIC, and 28-day mortality in polytrauma patients.

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Non-Selective Thoracic Computed Tomography in Trauma Patients Results in Injury Severity Score Inflation

The American Surgeon ◽

10.1177/00031348211024973 ◽

2021 ◽

pp. 000313482110249

Author(s):

Leonardo Alaniz ◽

Omaer Muttalib ◽

Juan Hoyos ◽

Cesar Figueroa ◽

Cristobal Barrios

Keyword(s):

Computed Tomography ◽

Injury Severity Score ◽

Severity Score ◽

Injury Severity ◽

Treatment Plan ◽

Mortality Prediction ◽

Trauma Patients ◽

Mortality Benefit ◽

Severity Scores ◽

Score Inflation

Introduction Extensive research relying on Injury Severity Scores (ISS) reports a mortality benefit from routine non-selective thoracic CTs (an integral part of pan-computed tomography (pan-CT)s). Recent research suggests this mortality benefit may be artifact. We hypothesized that the use of pan-CTs inflates ISS categorization in patients, artificially affecting admission rates and apparent mortality benefit. Methods Eight hundred and eleven patients were identified with an ISS >15 with significant findings in the chest area. Patient charts were reviewed and scores were adjusted to exclude only occult injuries that did not affect treatment plan. Pearson chi-square tests and multivariable logistic regression were used to compare adjusted cases vs non-adjusted cases. Results After adjusting for inflation, 388 (47.8%) patients remained in the same ISS category, 378 (46.6%) were reclassified into 1 lower ISS category, and 45 (5.6%) patients were reclassified into 2 lower ISS categories. Patients reclassified by 1 category had a lower rate of mortality ( P < 0.001), lower median total hospital LOS ( P < .001), ICU days ( P < .001), and ventilator days ( P = 0.008), compared to those that remained in the same ISS category. Conclusion Injury Severity Score inflation artificially increases survival rate, perpetuating the increased use of pan-CTs. This artifact has been propagated by outdated mortality prediction calculation methods. Thus, prospective evaluations of algorithms for more selective CT scanning are warranted.

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Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury

The American Surgeon ◽

10.1177/000313481508101231 ◽

2015 ◽

Vol 81 (12) ◽

pp. 1272-1278 ◽

Cited By ~ 1

Author(s):

Yann-Leei L. Lee ◽

Jon D. Simmons ◽

Mark N. Gillespie ◽

Diego F. Alvarez ◽

Richard P. Gonzalez ◽

...

Keyword(s):

Injury Severity ◽

Capillary Flow ◽

Severe Trauma ◽

Dark Field ◽

Serum Lactate ◽

Microvascular Perfusion ◽

Trauma Patients ◽

Sidestream Dark Field ◽

Trauma Population ◽

Severity Scores

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

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Intentional Fallers with Complex Pelvic and Acetabular Fractures Do Not have Worse Radiological and Functional Outcomes than Accidental Fallers

10.21203/rs.2.16780/v2 ◽

2020 ◽

Author(s):

Yi-Hsun Yu ◽

Ying-Chao Chou ◽

Yung-Heng Hsu ◽

I-Jung Chen ◽

Lien-Chung Wei

Keyword(s):

Functional Outcomes ◽

Injury Severity ◽

Adjustment Disorder ◽

Acetabular Fractures ◽

Clinical Parameters ◽

Severe Injuries ◽

Severity Scores ◽

Surgical Treatments ◽

Major Diagnosis

Abstract Background: Individuals who fell from heights of >6 m accidentally or intentionally can suffer from complex pelvic and acetabular fractures. The extent to which an intentional fall correlates with prognosis and outcome after osteosynthesis is unclear. We aimed to investigate the clinical outcomes of fallers with pelvic and acetabular fractures after osteosynthesis and to compare the radiological and functional outcomes between intentional and accidental fallers.Methods: Between 2014 and 2017, individuals who fell from heights of >6 m, developed pelvic and acetabular fractures, survived after resuscitation, and completed surgical treatments were enrolled. The fallers were divided into the intentional and accidental fallers, and their clinical parameters were statistically evaluated and compared.Results: Forty-nine fallers who underwent osteosynthesis for pelvic and acetabular fractures were included. Sixteen patients were intentional fallers, whereas the rest of the patients fell accidentally. All patients who fell intentionally had pre-existing mental disorders, and the major diagnosis was adjustment disorder. The group with intentional fallers had female sex predominance, higher injury and new injury severity scores, and longer hospital stay. However, the early loss of fixation (less than three month) and functional outcomes (6- and 12-month follow-up) did not significantly differ between the intentional and accidental fallers. Conclusions: The intentional fallers with pelvic and acetabular fractures might be accompanied by more severe injuries compared to accidental fallers. However, the radiological and functional outcomes of the intentional fallers after osteosynthesis were not inferior to those of the accidental fallers.

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Motorcyclist Traffic Accidents and Risk Factors: A Singapore Study

Asia Pacific Journal of Public Health ◽

10.1177/101053959000400106 ◽

1990 ◽

Vol 4 (1) ◽

pp. 34-38 ◽

Cited By ~ 20

Author(s):

Tze Wai Wong ◽

Wai-On Phoon ◽

James Lee ◽

Ivy Po Chu Yiu ◽

Kam Pui Fung ◽

...

Keyword(s):

Public Education ◽

Traffic Accidents ◽

Injury Severity ◽

Driving Experience ◽

Factors Associated ◽

Singapore General Hospital ◽

Breath Testing ◽

Severity Scores ◽

One Year ◽

Drunken Driving

Motorcyclist accidents cause significant morbidity and mortality in Singapore. To elucidate personal and environmental factors associated with such accidents, we studied 198 motorcyclists who were hospitalized in Singapore General Hospital between April 1986 and June 1987. The patients were mostly young and almost exclusively male with a high proportion of Malays. Most accidents occurred on Sundays and at night. Ten percent of the victims took alcohol before the accident. Most had low injury severity scores (ISS). Less experienced drivers had a significantly higher ISS than those with one year or longer of driving experience. Vigorous control of drunken driving, through public education and intensive breath testing, should reduce the incidence of traffic accidents.

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Suburban geriatric trauma: the experiences of a level I trauma center

American Journal of Critical Care ◽

10.4037/ajcc1995.4.5.379 ◽

1995 ◽

Vol 4 (5) ◽

pp. 379-382 ◽

Cited By ~ 9

Author(s):

F DeKeyser ◽

D Carolan ◽

A Trask

Keyword(s):

Trauma Center ◽

Functional Outcomes ◽

Injury Severity ◽

The Elderly ◽

Mortality Rates ◽

Geriatric Trauma ◽

Trauma Patients ◽

Younger Patients ◽

Severity Scores ◽

Trauma Scores

BACKGROUND: As the mean age of the US population increases, so does the incidence of geriatric trauma. Investigators have shown that the elderly have high morbidity and mortality rates associated with traumatic injuries. OBJECTIVE: To compare the severity of injury, mortality, and functional outcomes of geriatric patients with younger patients admitted to a suburban trauma center. METHOD: A convenience sample of trauma patients who were 65 years old or older was compared with trauma patients who were 35 to 45 and 55 to 64 years old. Demographic data, injury data, Injury Severity Scores, Revised Trauma Scores, length of stay, and functional ability outcomes were abstracted from a trauma registry in aggregate form and then analyzed. RESULTS: The sample consisted of 766 subjects (age 35-45, n = 223; age 55-64, n = 135; age 65 and older, n = 408) with a mean age of 64.6 years. A larger percentage of the elderly were victims of falls; younger trauma patients were more likely to be victims of motor vehicle crashes. Significant differences were found between age groups on Glasgow Coma Scale scores. Revised Trauma Scores, and length of stay. Significant differences were not found on Injury Severity Scores, mortality rates, or functional outcomes. CONCLUSIONS: Although anatomic injury severity of elderly patients was similar to that of younger patients, the elderly demonstrated greater physiologic compromise and longer hospital stays. Mortality rates were lower for the elderly group, but this result might be because a larger proportion of elderly patients were hospitalized with minor or moderate injuries.

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