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BACKGROUND Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE Therapeutic/care management, Level IV.

The purpose of this study was to evaluate trends in agricultural mortality before and after implementation of safety initiatives. Retrospective review of Kansas mortality data from agriculture-related injuries from 1979 to 2018. The 39-year period was stratified into four periods to compare mechanisms of injury and fatality rates between study periods. There were 780 agricultural-related deaths. Mean age significantly increased between study Period I to Period IV from 46.4 to 55.3 years (

Background Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. Methods Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). Results After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. Conclusions Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Police transport (PT) of penetrating trauma patients in urban locations has become routine in certain metropolitan areas; however, whether it results in improved outcomes over prehospital Advanced life support (ALS) transport has not been determined in a multicenter study. We hypothesized that PT would not result in improved outcomes.This was a multicenter, prospective, observational study of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. Police transport and ALS patients were allocated via nearest neighbor, propensity matching. Transport mode also examined by Cox regression.Of 1,618 total patients, 294 (18.2%) had PT and 1,324 (81.8%) were by ALS. After matching, 588 (294/cohort) remained. The patients were primarily Black (n = 497, 84.5%), males (n = 525, 89.3%, injured by gunshot wound (n = 494, 84.0%) with 34.5% (n = 203) having Injury Severity Score of 16 or higher. Overall mortality by propensity matching was not different between cohorts (15.6% ALS vs. 15.0% PT, p = 0.82). In severely injured patients (Injury Severity Score ≥16), mortality did not differ between PT and ALS transport (38.8% vs. 36.0%, respectively; p = 0.68). Cox regression analysis controlled for relevant factors revealed no association with a mortality benefit in patients transported by ALS.Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population.Prognostic and Epidemiologic; Level III.

Tertiary surveys can help identify missed injuries, but how and when to conduct them remains uncertain. This study aimed to evaluate the outcomes of a policy requiring tertiary survey completion within 24 h post-admission.A retrospective review was performed with a pre-intervention time-period of 8/1/2019-1/31/2020, where tertiary surveys were performed prior to discharge (n = 762). During the post-intervention time-period of 8/1/2020-1/31/21 tertiary surveys were performed within 24 h of admission (n = 651).Missed injury (1.6% [n = 12] vs. 1.5% [n = 10]; p = 0.953) and mortality rates (3.1% vs. 3.7%, p = 0.579) were similar between the pre- and post-intervention groups. Tertiary survey completion rates were higher (86.8% vs. 80.2%; p = 0.001) and exams performed earlier (1[1-1] vs. 1 [1-2] day, p 0.001) in the post-intervention group. For those with missed injuries, time to injury identification and number of injuries identified on tertiary survey was unchanged.Requiring tertiary surveys within 24 h of admission can help identify and correct missed injuries, but standardization of the tertiary survey process and documentation may be as important as the timing.

OBJECTIVE: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS), pupil non-reactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS: A prospectively collected multi-center database of 3,279 TBI admissions to 45 different U.S. trauma centers between 2017–2019 was queried to identify patients >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n=150) and the rate of withdrawal of life-sustaining measures was 10% (n=66). A multivariate logistic regression model identified GCS 80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

The purpose of this study was to determine if thromboelastography (TEG) is associated with reduced blood product utilization for trauma patients undergoing massive transfusion protocol (MTP) compared to traditional coagulation tests.A retrospective review was conducted on an intent-to-treat basis of trauma patients undergoing MTP (Pre-TEG = Period I vs. Post-TEG = Period II). Traditional coagulation tests guided transfusion during Period I (n = 20) and the intent was that TEG guided transfusions during Period II (n = 47). Blood product administration and outcomes were compared.Intent-to-treat analysis demonstrated a significant reduction in red blood cell transfusions (11 vs. 6 units, P = 0.001), number of patients receiving fresh frozen plasma (85.0 vs. 17.0%, P 0.001), and platelets (75.0 vs. 38.3%, P = 0.006) in Period II. No difference was seen between Periods I and II in ICU days (7.0 vs. 11.0 days, P = 0.073), hospital length of stay (10.5 vs. 14.0 days, P = 0.618), or mortality (55.0 vs. 31.9%, P = 0.076).Use of TEG-guided transfusion in the critically-ill trauma patient conserved blood product utilization and appears to offer similar outcomes when compared to traditional coagulation tests.

Background Critical access hospitals (CAH) serve a key role in providing medical care to rural patients. The purpose of this study was to assess effectiveness of CAHs in initial care of trauma patients. Methods A 5-year retrospective review was conducted of all adult trauma patients who were transported directly to a level I trauma facility or were transported to a CAH then transferred to a level I trauma facility after initial resuscitation. Results Of 1478 patients studied, 1084 were transferred from a CAH with 394 transported directly to the level I facility. Patients transported directly to the level I hospital were younger and more severely injured. After controlling for injury severity score, age, GCS, and shock, the odds of mortality did not differ between CAH transfer patients and patients transported directly to a level I facility (OR 0.70, P = 0.20). Transfer from CAH was associated with decreased ICU and hospital days, but not associated with increased ventilator days. Conclusion This study demonstrates that use of a CAH for initial trauma care in rural areas is effective.

Introduction Rectal injuries have been historically treated with a combination of modalities including direct repair, resection, proximal diversion, presacral drainage, and distal rectal washout. We hypothesized that intraperitoneal rectal injuries may be selectively managed without diversion and the addition of distal rectal washout and presacral drainage in the management of extraperitoneal injuries are not beneficial. Methods This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 of all patients who sustained a traumatic rectal injury and were admitted to one of the 22 participating centers. Demographics, mechanism, location and grade of injury, and management of rectal injury were collected. The primary outcome was abdominal complications (abdominal abscess, pelvic abscess, and fascial dehiscence). Results After exclusions, there were 785 patients in the cohort. Rectal injuries were intraperitoneal in 32%, extraperitoneal in 58%, both in 9%, and not documented in 1%. Rectal injury severity included the following grades I, 28%; II, 41%; III, 13%; IV, 12%; and V, 5%. Patients with intraperitoneal injury managed with a proximal diversion developed more abdominal complications (22% vs 10%, p = 0.003). Among patients with extraperitoneal injuries, there were more abdominal complications in patients who received proximal diversion (p = 0.0002), presacral drain (p = 0.004), or distal rectal washout (p = 0.002). After multivariate analysis, distal rectal washout [3.4 (1.4-8.5), p = 0.008] and presacral drain [2.6 (1.1-6.1), p = 0.02] were independent risk factors to develop abdominal complications. Conclusion Most patients with intraperitoneal injuries undergo direct repair or resection as well as diversion, although diversion is not associated with improved outcomes. While 20% of patients with extraperitoneal injuries still receive a presacral drain and/or distal rectal washout, these additional maneuvers are independently associated with a three-fold increase in abdominal complications and should not be included in the treatment of extraperitoneal rectal injuries. Level of evidence Therapeutic study, level III.

Background The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls. Methods A 5-year retrospective review was conducted of adult trauma patients with a diagnosis of dementia at an American College of Surgeons-verified level I trauma center. Patients with dementia were matched with non-dementia patients and compared on mortality, ICU length of stay, and hospital length of stay. Results A total of 195 patients with dementia were matched to non-dementia controls. Comorbidities and complications (11.8% vs 12.4%) were comparable between both groups. Dementia patients spent fewer days on the ventilator (1 vs 4.5, P = 0.031). The length of ICU stay (2 days), hospital length of stay (3 days), and mortality (5.1%) were the same for both groups (P > 0.05). Conclusions Dementia does not appear to increase the risk of mortality in trauma patients. Further studies should examine post-discharge outcomes in dementia patients.

Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability.A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant.Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients.The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs.Prognostic/epidemiologic, level IV.

Background Recent literature suggests the majority of traumatic intracranial hemorrhage does not require intervention. One recently described clinical decision rule was sensitive in identifying patients requiring critical care interventions in an urban setting. We sought to validate its effectiveness in our predominately rural setting. Methods A retrospective study was conducted of adult patients with traumatic intracranial hemorrhage. The rule, based on age, initial Glasgow coma scale score, and presence of a non-isolated head injury, was applied to externally validate the previously reported findings. Results In our population, the rule displayed a sensitivity of 0.923, specificity of 0.251, positive predictive value of 0.393, and negative predictive value of 0.862. The area under curve was 0.587. While our population has a similar adjusted head injury severity score as that from which the rule was developed, significant differences in age and intracranial hemorrhage pattern were noted. Conclusions The rule displayed decreased performance in our population, most likely secondary to differences in age and intracranial hemorrhage patterns. Prospective evaluation and cost-savings analysis are appropriate subsequent steps for the rule.

Survivors of near-hangings suffer anoxic brain injuries, but it remains uncertain whether the incidence of associated injuries warrants extensive workup or trauma activation. An 11-year retrospective review was conducted on adult patients with a hanging mechanism who underwent trauma workup and management. The majority of patients (n = 98) were white (88.8%) males (75.5%) with an average age of 30 ± 12.3 years. Two-hundred fifty-four CT and magnetic resonance scans were performed and eight injuries were uncovered: three thyroid cartilage/hyoid fractures; three vertebral injuries; and two cervical vascular injuries. Anoxic brain injury was diagnosed clinically in 35 patients (35.7%) and was present in all 19 patients (19.4%) who died. Only one patient had intra-abdominal injury requiring surgical intervention. Injuries were more likely in patients with abnormal Glasgow Coma Scale (GCS)

Background This study’s purpose was to determine if age, fall height, fall mechanism, landing surface, and landing position are associated with injury severity and hospital outcomes among pediatric fall patients. Methods A retrospective review was conducted of patients aged ≤18 years who sustained fall-related injuries admitted to an American College of Surgeons verified Level 1 trauma center from January 1, 2006 through December 31, 2015. Results Patient age, fall mechanism, landing position, and landing surface were associated with the need for surgery. Patient age, fall mechanism, and landing position were also associated with intensive care unit admissions. Fall mechanism was the only variable associated with injury severity. No variables were associated with the need for mechanical ventilation or mortality. Conclusions Patient age, fall mechanism, landing surface, and landing position need to be considered with regard to injury severity and patient outcomes among pediatric fall patients.

BACKGROUND There are no clear guidelines for the best test or combination of tests to identify traumatic rectal injuries. We hypothesize that computed tomography (CT) and rigid proctoscopy (RP) will identify all injuries. METHODS American Association for the Surgery of Trauma multi-institutional retrospective study (2004-2015) of patients who sustained a traumatic rectal injury. Patients with known rectal injuries who underwent both CT and RP as part of their diagnostic workup were included. Only patients with full thickness injuries (American Association for the Surgery of Trauma grade II-V) were included. Computed tomography findings of rectal injury, perirectal stranding, or rectal wall thickening and RP findings of blood, mucosal abnormalities, or laceration were considered positive. RESULTS One hundred six patients were identified. Mean age was 32 years, 85(79%) were male, and 67(63%) involved penetrating mechanisms. A total of 36 (34%) and 100 (94%) patients had positive CT and RP findings, respectively. Only 3 (3%) patients had both a negative CT and negative RP. On further review, each of these three patients had intraperitoneal injuries and had indirect evidence of rectal injury on CT scan including pneumoperitoneum or sacral fracture. CONCLUSION As stand-alone tests, neither CT nor RP can adequately identify traumatic rectal injuries. However, the combination of both test demonstrates a sensitivity of 97%. Intraperitoneal injuries may be missed by both CT and RP, so patients with a high index of suspicion and/or indirect evidence of rectal injury on CT scan may necessitate laparotomy for definitive diagnosis. LEVEL OF EVIDENCE Diagnostic, level IV.

Background This study aimed to determine the incidence of intra-abdominal injuries in elderly patients after a ground-level fall. Methods A 6-year retrospective review was conducted on patients 65 years of age or older involved in a fall from standing and evaluated at a level 1 trauma center. Each patient presented with a pelvic, thoracolumbar, and/or lower rib fracture. Data collection included demographics, injury characteristics, FAST exam results, CT imaging results, and hospitalization outcomes. Results A total of 324 patients met study inclusion criteria. The majority of patients were white (95.1%) females (65.4%) with an average age of 82.0 ± 7.3 years. Only 22 patients (6.8%) reported abdominal pain, although an abdominal CT was performed in 91 patients (28.1%). Only 1 patient (0.3%) was found to have an intra-abdominal injury when no abdominal pain was reported and the FAST exam was negative. This injury was not clinically significant enough to warrant surgical intervention. Conclusion Elderly patients who suffer a ground-level fall do not benefit from PAN-SCAN, even when presenting with rib, thoracolumbar, and/or pelvic fractures.

Agricultural work results in numerous injuries and deaths. Efficacy of farm equipment safety interventions remains unclear. This study evaluated agricultural mortality pre- and postimplementation of safety initiatives. A 31-year retrospective review of mortality data from agriculture-related injuries was conducted. Demographics and injury patterns were evaluated by mechanism of injury. There were 660 deaths (mean age 48.6 years). Female deaths increased from 5.2 to 11.7 per cent (P = 0.032). Mortality associated with tractors decreased (75.6% vs 53.9%; P0.001) and with all-terrain vehicles increased (3.5% vs 22.0%; P0.001) from Period I to III. However, tractors remain the primary cause of mortality. For mechanical equipment-associated mortality, there was a decrease (83.3% vs 50.0%) in "caught in equipment," and an increase (6.7% vs 38.9%) in those killed by "crush injury" from Period I to III. Application of safety devices to enclose and stabilize machinery has led to an overall decrease in mortality associated with tractors and "caught in equipment." Expanded rural education, as well as further development and use of safety devices, is warranted to curtail farm-related injuries and deaths.

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified-Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.

BACKGROUND: A shortage of pediatric surgeons exists. The purpose of this study was to evaluate pediatric outcomes using pediatric surgeons vs adult trauma surgeons. METHODS: A review was conducted at 2 level II pediatric trauma centers. Center I provides 24-hour in-house trauma surgeons for resuscitations, with patient hand-off to a pediatric surgery service. Center II provides 24-hour in-house senior surgical resident coverage with an on-call trauma surgeon. Data on demographics, resource utilization, and outcomes were collected. RESULTS: Center I patients were more severely injured (injury severity score = 8.3 vs 6.2; Glasgow coma scale score = 13.7 vs 14.3). Center I patients were more often admitted to the intensive care unit (52.2% vs 33.5%) and more often mechanically ventilated (12.9% vs 7.7%), with longer hospital length of stay (2.8 vs 2.3 days). However, mortality was not different between Center I and II (3.1% vs 2.4%). By logistic regression analyses, the only variables predictive of mortality were injury severity score and Glasgow coma scale score. CONCLUSION: As it appears that trauma surgeons' outcomes compare favorably with those of pediatric surgeons, utilizing adult trauma surgeons may help alleviate shortages in pediatric surgeon coverage. Language: en

The absence of a comprehensive database of grain elevator-associated injuries hinders accurate evaluation of injury prevalence and may lead to discordant information about injury frequencies. The main purpose of this study was to identify the most common mechanisms of injury related to grain elevator events. Comparisons of hospital outcomes between patients who sustained traumatic injuries associated with grain elevators at Occupational Safety and Health Administration (OSHA)-regulated industrial sites versus those on OSHA-exempt farming operations were also made.A retrospective review was conducted of all patients' presenting with grain elevator-related injuries at a level-1 trauma center between January 1, 2003, and December 31, 2013. Data collected included demographics, mechanism of injury, injury severity, hospitalization details, and discharge disposition. Data were summarized, and comparisons were made between the groups.All patients (N = 18) in the study were male, with a mean age of 37 years. Falls and being caught in equipment each accounted for 27.8% of injuries. Among the 18 patients, there were a total of 37 injuries. The majority of injuries were either lower extremity (29.7%) or chest injuries (21.6%). The average hospital length of stay was 4 ± 4.5 days, and one patient required mechanical ventilation. There were no reported deaths.The literature reports entrapments as the leading cause of grain elevator-related injuries; however, this study found that falls and being caught in equipment were the most common mechanisms of injury. This suggests that a greater emphasis should be placed on fall prevention and equipment safety.

Background Children with confirmed brain injury usually undergo follow-up computed tomography (CT) scan of the head within 24 hours of admission. To date, no evidence exists to validate the diagnostic or therapeutic value of these repeat CTs. The purpose of this study was to (1) evaluate progression of traumatic brain injuries, (2) determine if routine repeat imaging changes management, and (3) compare the efficacy of recognizing worsening hemorrhage with serial neurological examination versus repeat imaging. Methods A 5-year retrospective review was conducted of all patients aged under 18 years with blunt traumatic head injury (n = 95). Data included demographics, type and size of intracranial hemorrhage, exam findings, diagnostic and management changes, and hospital outcomes. Results Most patients (68.4%) had at least one repeat CT; of these, 67.7% (n = 44) showed no change or reduced hemorrhage. In only one patient did a repeat CT scan result in a surgical procedure; however, that CT scan was prompted by a change in neurological status. Among patients with more than two repeat head CTs, 42.9% led to a change in management, most frequently an additional CT scan. Presence of neurological symptoms was associated with having repeat CT scans (p = 0.025). Changes in Glasgow Coma Scale score were associated with increased hemorrhage (p = 0.012) but not repeat scans (p = 0.496). In the majority of cases, increased hemorrhage only resulted in an additional head CT and prolonged intensive care unit stay. Excluding patients who arrived with brain death, there was no difference in mortality between patients with and without repeat imaging. Conclusion Findings from this study support a selective approach for repeating head CTs with emphasis on changes in neurological symptoms and Glasgow Coma Scale score. Prospective studies on timing and indications for repeat CT scans are needed to support development of clinical guidelines. Level of evidence Therapeutic study, level III.

Background When retained hemothorax occurs, video-assisted thoracoscopy or thoracotomy is performed, but recently, tissue plasminogen activator (tPA) has been used. This study evaluated intrapleural tPA use for retained traumatic hemothoraces. Methods A retrospective review was conducted of trauma patients treated with intrapleural tPA for retained hemothorax. Data included demographics, past medical and surgical histories, injury details, treatment details, and outcomes. Results Seven patients (median age=47 years, male=6, blunt trauma=6) met study criteria. All patients received a chest tube. Six patients later received computed tomography-guided drains for tPA infusion. Number of tPA treatments per patient varied from 1 to 5. Median total tPA dosage was 24 mg. Median time from injury to chest tube placement was 11 days and from chest tube placement to first tPA treatment was 4 days. No patients required a video-assisted thoracoscopy; however, 1 patient required thoracotomy. There were no deaths or bleeding complications attributed to intrapleural tPA. Conclusion Although future studies are needed to identify optimum treatment guidelines, intrapleural tPA appears to be a safe and efficacious treatment option.

Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality.We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome.From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p0.001), Revised Trauma Score (RTS, p0.001), and head Abbreviated Injury Scale (AIS) score (p0.05). Factors significantly associated with mortality were RTS (p0.001), head AIS score (p0.001), total number of operations (p0.001), and age (p0.05). An injury located in Zone III was independently associated with mortality (p0.001).GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines.Therapeutic/care management, level III.

BACKGROUND Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. METHODS Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. RESULTS A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). CONCLUSION While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study. LEVEL OF EVIDENCE Prognostic study, level III.

Background This study analyzed outcomes and cost of splenic embolization compared with surgery for the management of blunt splenic injury. Methods We performed a retrospective chart review of all patients admitted with isolated, blunt splenic injury. An intent-to-treat analysis was initially conducted. Outcomes and cost/charges were compared in patients treated with embolization and surgical treatment. Results Of 236 patients admitted with isolated, blunt splenic injury, 190 patients were ultimately managed by observation, 31 by splenic embolization, and 15 by surgical management. Comparing outcomes and cost data for splenic embolization versus surgical management, there was no significant difference in intensive care unit use, hospital stay, complications, or re-admission. Surgical management patients required more blood transfusions and incurred higher procedure charges. Conversely, splenic embolization patients underwent more radiologic evaluations and charges. Total procedure-related charges were higher for surgical management when compared with splenic embolization ($28,709 vs $19,062; P = .016), but total hospital cost and total hospital charges were not significantly different. Conclusions Nonsurgical treatment of blunt splenic injury is safe and cost effective. Angioembolization was statistically similar to surgical therapy regarding cost.

Use of damage control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen.Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development.During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77%) sustaining blunt trauma (66%) with a mean age of 37.1 years±1.2 years and median Injury Severity Score of 27 (interquartile range=20-41). Injury patterns included 81 (40%) small bowel, 37 (18%) colonic, and 86 (42%) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17%) abscesses, 15 (7%) leaks, and 11 (5%) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3% leak rate; right colon, 3%; transverse colon, 20%; left colon, 45%). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p=0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p=0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ for trend, p=0.01), with closure after day 5 having a four times higher likelihood of developing leak (3% vs. 12%, p=0.02).Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.

The use of computed tomography (CT) to identify injury after penetrating torso trauma has become routine in the hemodynamically stable patient. The diaphragm has been a historically difficult structure to evaluate, however, and missed injuries to the diaphragm may result in significant morbidity. With the increasing use of multidetector row CT (MDCT), we hypothesized that CT would be an accurate detection modality to identify patients with diaphragm injuries.We retrospectively reviewed the admission CT of consecutive patients admitted for penetrating injury to the torso during a 4-year period. The CT scans were reviewed and classified into three categories: positive (P), negative (N), or equivocal (Eq). Data from the medical records of these patients were abstracted to identify demographics, injury-specific data, length of stay, length of follow-up (LOFU), and operative findings.There were 803 patients who met inclusion criteria. Mechanism of injury was gunshot wound in 36% and stab wound in 64%. Mean length of stay was 4 days (+/-6.6) and mean length of follow-up was 43 days (+/-184). CT was read as P in 57, N in 710, and Eq in 36 patients. Diaphragm injury was detected in 67 patients overall and was excluded in 736. For the entire study population, sensitivity and specificity were calculated as 94.0% (95% CI = 88.4-99.7) and 95.9% (94.5-97.4) with an overall accuracy of 95.8% (94.4-97.2) if the CT scan was used to exclude diaphragm injury ([P and Eq] vs. N). Sensitivity and specificity were 82.1% (72.9-91.3) and 99.7% (99.4-100) if CT was used to detect diaphragm injury (P vs. [N and Eq]). One hundred and forty-eight patients underwent operative procedures in which the diaphragm was evaluated. Diaphragm injury was identified in 50 (38 P, 4 N, 8 Eq) and was surgically excluded in 104 patients (2 P, 93 N, 9 Eq). Three hundred and eighty-four patients were lost to follow-up; including 348 who had negative finding on CT. There were no known missed diaphragm injuries during the study period or in follow-up.Injuries to the diaphragm occur commonly after penetrating torso trauma. MDCT scan is an accurate test to detect diaphragm injury. When MDCT is equivocal, further investigation is required to evaluate the diaphragm.

Background Head injuries are common in the pediatric population, but when an isolated skull fracture is found, there are no guidelines for repeat imaging. This study evaluated the need for repeat head computed tomography (CT) for isolated skull fracture. Methods A 10-year retrospective review was conducted of patients 17 years and younger with isolated skull fractures. Data included demographics, injury severity score (ISS), fracture location, clinical indicators of head trauma, intracranial hemorrhage, and mortality. Results Of the 65 patients in this study, mean age was 4.2 years, ISS was 7.2, and head/neck abbreviated injury score was 2.3. Most injuries were from falls (69.2%) and motor vehicle collisions (23.1%). The most common clinical indicators associated with skull fractures were nonfrontal scalp hematoma (40.0%), severe mechanism (30.8%), and loss of consciousness (30.8%). One patient who developed intracranial hemorrhage after the initial head CT showed no bleed. There were no deaths. Conclusion Isolated skull fractures in the pediatric population do not necessitate a repeat head CT as long as they do not develop worsening clinical indicators of head injury.

BACKGROUND: Motor vehicle collisions (MVCs) are the second leading cause of injury among octogenarians. Physicians and families lack outcomes-based data to assist in the decision-making process concerning injury treatment in this population. The purpose of this study was to evaluate 1-year postdischarge mortality in octogenarian MVC patients, cause of death, and patterns predictive of mortality. METHODS: A 10-year retrospective review was conducted of trauma patients 80 years and older who were involved in an MVC and were subsequently discharged alive. Data collected included demographics, injury severity and patterns, hospitalization details, and outcomes. State death database and hospital records were queried to determine cause of death for patients who died within 12 months of hospital discharge. Analyses were conducted to explore if a relationship existed between severity of injury and injury patterns to 12-month postdischarge mortality. RESULTS: Among the 199 patients included in this study, mean (SD) age and Injury Severity Score (ISS) was 84.2 (3.3) years and 9.3 (8.2), respectively. Twenty-two patients (11.1%) died within 12 months. Among these patients, cause of death was directly related to trauma in nine (40.9%), likely related to trauma in seven (31.8%), and unrelated to trauma in six (27.3%). More severely injured patients (ISS >15, p = 0.0041) and those admitted to the intensive care unit (ICU) (p = 0.0051) were more likely to die within 12 months of discharge. Results indicated a trend toward higher mortality in patients with pneumonia. Rib, hip, and pelvic fractures; spinal injuries; intubation upon hospital arrival; and need for mechanical ventilation were not associated with higher postdischarge mortality rates. CONCLUSION: The commonly held belief that the majority of octogenarians with MVC-related trauma die within 1 year of hospital discharge is refuted by this study. Only injury severity, ICU admission, and ICU duration were predictive of mortality within 12 months following discharge. LEVEL OF EVIDENCE: Prognostic study, level III. Language: en

Background While percutaneous tracheostomy (PT) is becoming the procedure of choice for elective tracheostomy, there is little late complication data. This study compared incidence of, and factors contributing to, tracheal stenosis following PT or open tracheostomy (OT). Methods A 10-year review was conducted of trauma patients undergoing tracheostomy. Data on demographics, injury severity, tracheostomy type, complications, and outcomes were compared between patients receiving PT or OT and for those with or without tracheal stenosis. Results Of 616 patients, 265 underwent OT and 351 underwent PT. Median injury severity score was higher for PT (26 vs 24, P = .010). Overall complication rate was not different (PT = 2.3% vs OT = 2.6%, P = .773). There were 9 tracheal stenosis, 4 (1.1%) from the PT group and 5 (1.9%) from the OT group ( P = .509). Mortality was higher in OT patients (15.5% vs 9.7%, P = .030). Patients developing tracheal stenosis were younger (29.8 vs 45.2 years, P = .021) and had a longer intensive care unit length of stay (28.3 vs 18.9 days, P = .036). Conclusion Risk of tracheal stenosis should not impact the decision to perform an OT or PT.

Traumatic brain injury remains one of the most prevalent and costly injuries encountered within the discipline of trauma and represents a leading cause of morbidity and mortality within our society. The purpose of this study was to compare the safety of intracranial pressure (ICP) monitor placement by general surgery residents and neurosurgeons.A retrospective chart review of all trauma patients requiring ICP monitor placement at an American College of Surgeons-verified Level 1 trauma center during a 10-year period was performed. Comparison of demographic variables, injury severity, intracranial injuries, incidence of ICP monitor-related complications, and outcomes were made between general surgery residents, trauma surgeons, and neurosurgeons.There were 546 patients included in the study. The average age of the cohort was 37.6 years, with an average hospital length of stay being 16.0 days and an Injury Severity Score of 27.7. Mechanisms of injury varied, but 58.8% was a result of motor vehicle and motorcycle collisions, and an additional 19.2% was a result of falls. No significant difference was found in terms of procedure-related complications between subgroups, including intracranial hemorrhage, infection, malfunctions, dislodgment, or death.Our results demonstrate that the placement of ICP monitors may be performed safely by both neurosurgeons and non-neurosurgeons. This procedure should thus be considered a core skill for trauma surgeons and surgical residents alike, thereby allowing initiation of prompt medical treatment in both rural areas and trauma centers with inadequate neurosurgeon or fellow coverage.Therapeutic study, level IV.

The open abdomen is a requisite component of a damage control operation and treatment of abdominal compartment syndrome.Enteral nutrition (EN) has proven beneficial for patients with critical injury, but its application in those with an open abdomen has not been defined. The purpose of this study was to analyze the use of EN for patients with an open abdomen after trauma and the effect of EN on fascial closure rates and nosocomial infections.We reviewed patients with an open abdomen after injury from January 2002 to January 2009 from 11 trauma centers.During the 7-year study period, 597 patients required an open abdomen after trauma. Most were men (77%) sustaining blunt trauma (72%), with a mean (SD) age of 38 (0.7) years, an Injury Severity Score of 31 (0.6), an abdominal injury score of 3.8(0.1), and an Abdominal Trauma Index score of 26.8 (0.6). Of the patients, 548 (92%) had an open abdomen after a damage control operation, whereas the remainder experienced an abdominal compartment syndrome. Of the 597 patients, 230 (39%)received EN initiated before the closure of the abdomen at mean (SD) day 3.6 (1.2) after injury. EN was started with an open abdomen in one quarter of the 290 patients with bowel injuries. For the 307 patients without a bowel injury, logistic regression indicated that EN is associated with higher fascial closure rates (odds ratio [OR], 5.3; p G 0.01), decreased complication rates(OR, 0.46; p = 0.02), and decreased mortality (OR, 0.30; p = 0.01). For the 290 patients who experienced a bowel injury,regression analysis showed no significant association between EN and fascial closure rate (OR, 0.6; p = 0.2), complication rate (OR, 1.7; p = 0.19), or mortality (OR, 0.79; p = 0.69).EN in the open abdomen after injury is feasible. For patients without a bowel injury, EN in the open abdomen is associated with increased fascial closure rates, decreased complication rates, and decreased mortality. EN should be initiated in these patients once resuscitation is completed. Although EN for patients with bowel injuries did not seem to affect the outcome in this study,prospective randomized controlled trials would further clarify the role of EN in this subgroup.

Significant resources are expended on the assessment of trauma patients who arrive at the trauma center based solely on mechanism of injury. We hypothesized that rollover motor vehicle crashes (ROMVC) are not an independent predictor for trauma center care. All patients seen between January 1, 2001, and December 31, 2005, involved in a ROMVC, were reviewed. Patients with any confounding factors were removed, leaving those transported to the trauma center based on mechanism only. Five hundred sixty-nine patients were transported to our center for the mechanism of ROMVC. Of the 569 patients, 369 (65%) were evaluated and discharged with minimal Injury Severity Score and regional Abbreviated Injury Scale scores. Of the remaining 200 (35%) patients admitted, 130 required surgery, predominantly for closed extremity and facial fractures. Six patients required immediate surgery for life-threatening injuries: 3 splenectomies, 1 subdural evacuation, and 2 vascular repairs (1.1%). Of the remaining 123 (4.2%) patients requiring surgery, 24 required urgent surgery (2 craniotomies, 9 laparotomies, and 13 spinal fixations). None of the patients with spinal injury had neurologic deficit. Eight patients were admitted to the intensive care unit for neurologic monitoring (1.4%). Only 6.7 per cent benefited from initial Trauma Triage Criteria. Therefore, ROMVC is not an independent predictor of the need for trauma center evaluation or admission. The majority of these patients could be safely evaluated and treated at nontrauma centers or transferred later.

Daily multidisciplinary discharge rounds have been shown to decrease length of stay (LOS), increase patient volumes, and virtually eliminates "bypass" (inability to accept admissions). Originally, these were attended by senior house staff from each trauma team. Implementation of the 80-hour workweek precluded house staff participation, raising concerns that these rounds would loss their benefits. Certified nurse practitioners (CRNPs) were added to the trauma teams to assist in patient care and represent the team on discharge rounds, replacing the fellows. We hypothesized that this would offset any potential negative effects.A senior trauma physician leads discharge rounds, focusing on each patient's plan of care. Rounds cover 90 inpatient beds and last approximately 60 minutes. CRNPs from each trauma team, orthopedics, and neurosurgery as well as the teams' discharge planner, hospital bed manager, unit nursing staff, and physical, occupational, and speech therapists participate in discharge rounds.The results are stratified by time period: June 1998 to May 1999 is before discharge rounds, June 1999 to May 2001 is during the house staff period, and June 2001 to May 2004 is when CRNPs replaced fellows and residents. During the 5-year period, 1999 to 2004, daily discharge rounds maintained their efficacy. We have increased admissions, whereas LOS has remained the same. Admissions of greater than 24 hours have increased, whereas average injury severity score has statistically remained the same. Bypass has virtually been eliminated.Adding CRNPs to discharge rounds has allowed us to have the continued benefits of decreased LOS and increased patient volume. Bypass remains rare. CRNPs can effectively replace some house staff functions.

Nonoperative management of splenic injury has become the standard of care in the hemodynamically stable patient. The time period of observation and the utility of follow-up scanning remain an area of debate. This study examined the utility of follow-up abdominal CT for detection of delayed vascular injury in patients with low-grade splenic injury. A retrospective review of all patients with low-grade splenic injuries undergoing nonoperative management from June 2000 to June 2004 was performed. Patients underwent follow-up abdominal CT 48 to 72 hours after admission to rule out delayed vascular injury and were discharged if the results were negative. Charts were reviewed for demographic data, abdominal CT results, and splenic salvage. A total of 472 patients underwent nonoperative management for splenic injury, with 140 patients treated with simple observation during this protocol. All patients were successfully managed with simple observation with no nonoperative failures; there were two instances of delayed vascular injury on follow-up CT. Both patients with progression of injury had decreasing hematocrit levels during admission prior to follow-up abdominal CT scan. Overall, the injury severity score was 22 points and the American Association for the Surgery of Trauma (AAST) splenic injury severity score was 1.8 points. Length of hospital stay was 2.8 days for patients with predominately splenic injury and 10 days for the overall cohort. Follow-up abdominal CT confers no benefit in patients with low-grade splenic injury, and a stable hematocrit level and abdominal exam.

Objectives: The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. Methods: We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. Results: A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. Conclusion: Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.

Injury from personal watercraft has continued to increase. Prior attempts to delineate patterns of injury and relative frequencies have yielded varied results. We retrospectively reviewed Trauma Registry data and charts of all patients who suffered personal watercraft injury treated at the R. Adams Cowley Shock Trauma Center between August 1996 and January 2001. Patient demographics included mechanism of injury, injuries sustained, and outcomes. Attempts were made to correlate events around the injury and injury pattern. During the study period 24 patients were treated. Mechanisms consisted of direct collision, fails from the watercraft, handlebar straddle injuries, axial loading, and hydrostatic jet injury. Traumatic brain injury was most common occurring in 54 per cent of patients. Spinal injury was also common occurring in 29 per cent of patients. Axial loading from falls while wave jumping seemed to correlate with skeletal injury. Thoracolumbar spine injury were often skeletally unstable requiring either brace or operative fixation. Inexperience and reckless behavior were found to be the greatest contributing factors. Substance abuse did not influence injury.

Background: The potential for ligamentous injury of the cervical spine (C-spine) may mandate prolonged neck immobilization via a hard cervical collar in the blunt trauma victim (BTV) with altered sensorium. We investigated the incidence of ligamentous C-spine injuries, and whether applying (post hoc) the practice management guidelines from the Eastern Association for the Surgery of Trauma (three radiograph views plus computed tomographic scan of Cl-C2) would have detected the injuries. Methods: The study was a 3-year retrospective review of BTVs admitted to the state's Primary Adult Resource Center for trauma from 1996 to 1998. Unreliable patients were defined as those with admission Glasgow Coma Scale score < 15. A rigorous algorithm to clear the C-spine was used. Pure ligamentous C-spine injury was defined as a C-spine having abnormal anatomic alignment, dislocation, subluxation, or listhesis, but without fracture. Demographics, diagnostic studies, presence of neurologic deficit, therapy, survival, and disposition were analyzed. Results: There were 14,577 BTVs with 614 (4.2%) patients having C-spine injury. There were 2,605 (18%) unreliable patients, with 143 (5.5%) of these having C-spine injury, 129 (90%) having fracture and 14 (10% of BTVs; 0.5% of unreliable patients) having no fracture. Of the 14 unreliable patients with pure ligamentous C-spine injury, 13 had initial diagnosis by supine cross-table lateral radiograph. The one exception had a normal three-view radiographic series, but atlanto-occipital dislocation was diagnosed by computed tomographic scan. Eight patients had upper level injury (C0-C4) and six were lower (C4-C7). Four patients died within 30 minutes after admission, 4 underwent cervical fusion, and 6 were treated with collar only. Five (50%) of the survivors had no apparent neurologic deficit attributed to the C-spine at admission. Nine patients remained institutionalized after discharge and one was discharged home. Conclusion: Ligamentous injuries without fracture of the C-spine are rare. Application of the practice management guidelines developed by the Eastern Association for the Surgery of Trauma for identifying C-spine instability is effective and should facilitate early removal of the cervical collar in unreliable patients.