Search

Introduction: Female blunt urethral injury (FBUI) is much less common than in males. Due to this rarity, studies of FBUI are largely confined to smaller case series. This study analyzes circumstances associated with FBUI and its contribution to mortality in greater detail. Methods: Using the National Trauma Data Bank, we analyzed predictors of FBUI, and tested FBUI as a predictor of mortality. Univariate analysis used Chi-squared for categorical data and T-test for continuous data. Multivariate analysis used multiple logistic regression. Results: A total of 245 (0.021%) of 1 185 904 female blunt trauma patients sustained FBUI, vs. 2242 (0.145%) for males (p15 (p

Our study analyzes imaging results in near-hanging to determine what neuroimaging workup is necessary. We evaluate GCS as a clinical predictor to help guide imaging choice. This is a retrospective study of patients from a level one trauma center and from the National Trauma Data Bank (NTDB). We classified injuries into categories based on the likelihood that CT played an important role in their diagnosis and management. We assessed whether a normal Glasgow Coma Scale (GCS) could exclude clinically important injuries. Chi square was used to test for significance for categorical variables. Multivariate logistic regression was used for multivariate analysis. CT showed structural brain findings in 0% of patients from our facility (local patients) and 11.7% of NTDB patients. Of local patients and NTDB patients, 1.4% and 6.6% had blunt cerebral vascular injury (BCVI) respectively. Of local patients and NTDB patients, 1.4% and 3.3% had a cervical spine fracture or dislocation, respectively. Mortality for patients with GCS 15 versus GCS

Context: Illegal drug use and need for surgery are common in trauma. This allows examination of the effects of perioperative drug use. Aim: The aim was to study the effects of illegal drug use on perioperative complications in trauma. Setting and Design: Propensity-matched analysis of perioperative complications between drug screen-positive (DSP) and drug screen-negative (DSN) patients from the National Trauma Data Bank (NTDB). Methods: The NTDB reports drug screening as a composite. We compared complications for DSP, DSN, and specific chronic drug disorders. Time to first procedure was analyzed to determine whether delay to surgery was associated with reduced complications. Statistics: Logistic regression with 11 predictor variables was used to calculate propensity scores. Categorical and continuous variables were compared using Chi-square and Student’s t-test, respectively. Results: 752,343 patients (21.9%) were tested for illegal drugs. DSP was protective for mortality-relative risk (RR) 0.84 (P < 0.001) and arrhythmia RR 0.87 (P = 0.02). All complications (AC) were higher for DSP with a RR of 1.08 (P < 0.001). Cocaine, cannabis, and opioids were associated with reduced mortality. Cocaine was associated with increased myocardial infarction (MI). All four chronic drug disorders were associated with markedly higher arrhythmia. All except cannabis were associated with higher AC. Mortality was significantly lower for DSP for every time interval until first procedure. Continuous-time until procedure was associated with increased MI and arrhythmia. Conclusions: DSP was protective of mortality and cardiac complications. Drug disorders were protective for mortality but increased arrhythmia and AC. Delay until the surgery does not diminish cardiac or overall risk.

It is well recognized that driving while intoxicated increases the probability of a motor-vehicle collision (MVC). The effect of alcohol on the chance of surviving the MVC is less clear.Using data from the Fatality Analysis Reporting System (FARS) we conducted analyses for the outcome of mortality using alcohol and other variables as predictors. We also selected alcohol positive (AP) and alcohol negative (AN) persons from the same MVC and vehicle to control for confounding characteristics.The odds ratio (OR) for mortality for alcohol positive drivers was 2.57, (p 0.001 for all the following OR). Other harmful predictive factors were age OR 1.01 per year, vehicle age OR 1.05 per year, male sex OR 1.23, avoidance maneuver OR 1.09, speed related OR 2.89, rollover mechanism OR 2.75, and collision with a fixed object OR 6.70. Protective factors were proper restraint use - OR 0.19 and collision with another moving vehicle, OR 0.21. In the multivariate analysis the OR of mortality for AP vs AN was 1.46. Proper restraint use (OR 0.27) remained protective along with collision with another moving vehicle. When AP and AN persons from the same MVC and the same vehicle were compared, the adjusted OR's for mortality were 1.46 and 2.08, respectively.Alcohol is an independent predictor of mortality in an MVC. Proper restraint use is the strongest protective factor. This finding allows a more complete understanding of the risks of driving while intoxicated, not only a higher probability of an MVC, but decreased survival once the MVC occurs. Practical Applications: Identification of alcohol as an independent predictor of mortality in an accident may improve risk assessment and influence drivers to avoid driving while intoxicated.

Background Clinically occult cervical spine (CS) injuries are well described in blunt trauma, however delay in identifying these injuries and clearing the CS can result in morbidity. Our study examines the ground level fall (GLF) population to analyze whether computed tomography (CT) alone can rule out unstable injury in this group with lower force mechanism. Methods This is a single center, retrospective cohort study. All GLF patients in the institutional trauma registry between 6/1/2012 through 12/31/2019 were included. These comprise all trauma patients evaluated in the emergency department with Injury Severity Score (ISS) > 0, including both activations and consults with both clinical and radiological spine evaluation. Patients who could not be cleared by National Emergency X-ray Utilization Study (NEXUS) criteria underwent CT. Patients with CT or clinical suspicion of cord or ligamentous injury underwent MRI. CT occult injuries were identified by MRI and clinical exam, with MRI identifying all unstable injuries. Results Sixty-nine (2.0%) of patients had CS injury without acute CT abnormality. Of these, 11 (0.3%) required surgery and were considered unstable. All patients who required surgery had a neurologic deficit. Negative predictive value (NPV) of CT for unstable CS injury was 99.7%. The combination of acute CT findings and neurologic deficit ruled out unstable CS injury with 100% NPV. Conclusion In the GLF population, CT alone rules out unstable CS injury with high, but not perfect NPV. The combination of absence of acute CT findings and acute neurologic deficits rules out unstable CS injury with 100% NPV.

Background While blunt extra-peritoneal bladder injury is typically treated non-operatively or with minimally invasive management, the treatment for penetrating bladder injury is generally open surgery. We identify a group of patients with penetrating bladder injury who were treated with minimally invasive management and compare the results with those who underwent traditional open surgical treatment. Methods This retrospective cohort study analyzes penetrating bladder injuries from a single trauma center from 2012 through 2019, and from the National Trauma Data Bank for 2016 and 2017. Mortality, complications, and length of stay were compared for minimally invasive management versus open surgery. We used Chi square to test significance for categorical variables, Mann–Whitney U test for ordinal variables, and T-test for continuous variables. Multivariate analysis was performed with multiple logistic, ordinal, and linear regression. Results Local: 117 (0.63%) had a bladder injury; 30 (25.6%) were penetrating. 6 (20.0%) were successfully treated with minimally invasive management with no complication versus 24 complications in 11 patients (45.8%) for open surgery (p = 0.047). Open surgical management was not a significant independent predictor of mortality or hospital length of stay. National Trauma Data Bank: 5330 (0.27%) had a bladder injury; 963 (19.5%) were penetrating. 97 (10.1%) were treated with minimally invasive management. The minimally invasive management group had 12 complications in 5 patients (4.9%) versus 280 complications in 169 patients (19.7%) for open surgery (p = p = 0.003) and longer hospital length of stay (B = 5.31, p Conclusions Most penetrating bladder injury requires open surgery, however a small proportion can safely be managed with minimally invasive management. Minimally invasive management is associated with lower total complications and shorter hospital length of stay in select patients.

Patient: Female, 83-year-old Final Diagnosis: Eosinophilic gastroentritis • jejunal diverticulosis Symptoms: Abdominal pain • obstruction Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare coexistence of disease or pathology Background: Eosinophilic gastroenteritis is a broad classification of disease characterized by eosinophilic infiltration of the gastrointestinal tract in the absence of a stimulatory cause. Given the ability of eosinophilic gastroenteritis to affect the entire gastrointestinal tract, it can present in a variety of ways, from chronic intermittent pain to mechanical obstruction. We present a rare case in which eosinophilic gastroenteritis of the jejunum led to small bowel diverticulosis and volvulus, requiring surgery. Case Report: An 83-year-old woman with a history of chronic abdominal pain, nausea, and early satiety presented to our clinic after a thorough gastrointestinal workup and radiologic diagnosis of partial midgut volvulus. She underwent an exploratory laparotomy and was found to have normal rotational anatomy with prominent small bowel diverticulosis. A section of 70 cm of proximal jejunum was resected, encompassing all visible diverticula, and a primary anastomosis was performed. The patient recovered without complication. She was seen at follow-up with complete resolution of her presenting symptoms. Conclusions: We propose that this patient’s pathology was caused by chronic intermittent obstructions related to eosinophilic gastroenteritis, leading to repeated periods of increased intraluminal pressure and severe small bowel diverticulosis. This case highlights the importance of maintaining an index of suspicion for small bowel diver-ticulosis in the setting of chronic eosinophilic gastroenteritis.

Our study analyzes imaging results in near-hanging to determine what neuroimaging workup is necessary. We evaluate GCS as a clinical predictor to help guide imaging choice.This is a retrospective study of patients from a level one trauma center and from the National Trauma Data Bank (NTDB). We classified injuries into categories based on the likelihood that CT played an important role in their diagnosis and management. We assessed whether a normal Glasgow Coma Scale (GCS) could exclude clinically important injuries. Chi square was used to test for significance for categorical variables. Multivariate logistic regression was used for multivariate analysis.CT showed structural brain findings in 0% of patients from our facility (local patients) and 11.7% of NTDB patients. Of local patients and NTDB patients, 1.4% and 6.6% had blunt cerebral vascular injury (BCVI) respectively. Of local patients and NTDB patients, 1.4% and 3.3% had a cervical spine fracture or dislocation, respectively. Mortality for patients with GCS 15 versus GCS 15 was 0 versus 26.9% for local patients (p = 0.004) and 0 versus 43.8% for NTDB (p 0.001). Structural brain injury for patients with GCS 15 versus GCS 15 for isolated hanging was 0 versus 14.9% for NTDB (p 0.001). GCS 15 was an independent predictor of survival and freedom from brain injury (p 0.001), but not neck injury.GCS 15 is a significant independent predictor of survival and freedom from brain injury in near-hanging. GCS 15 rules out intracranial injury likely to require intervention with negative predictive value of 100%. GCS of 15 does not rule out critical neck injury.

Study objective Trauma has historically been considered a disorder of the young and healthy, with a low risk of cardiac ischemia; hence most research on myocardial infarction in trauma has focused on direct cardiac damage from blunt chest trauma. However, the age and comorbidity of trauma patients are increasing, making the trauma population more vulnerable to myocardial infarction (MI). Cardiac risk assessment has emphasized morbidity and mortality in an elective surgical setting, but it is also important in acute trauma. Our study analyzes the risk factors for MI in a trauma population to create a scoring system to predict the risk of MI. Design Retrospective cohort analysis of a national trauma registry over a five-year period. Potential predictors of MI in trauma patients were identified and tested with univariate and multivariate statistics. A numerical score was created to predict the risk of MI based on these criteria. Setting The National Trauma Data Bank (NTDB) is a large registry of selected trauma centers in the United States. Data include demographic, injury, treatment, and outcome variables pertaining to the index admission of each patient. The institutions range from community hospitals through level 1 trauma centers. The time period is the entire inpatient hospital admission from arrival from the field, through the emergency department, ICU, and floor up to discharge. Patients 3,437,959 trauma patients aged 18 years and older from various US trauma centers. 62.8% were male. The median age is 50 years with a standard deviation of 21.25. The median Injury Severity Score is 9 with a standard deviation of 9.04. Measurements Demographic, traumatic, and comorbidity variables were collected from the NTDB. The primary outcome was MI during the initial trauma admission. Multivariate analysis was performed with logistic regression. Main results Over 8010 (0.23%) suffered an MI. The strongest risk factors for MI were a history of MI with an adjusted odds ratio (OR) of 7.0, and angina with an OR of 3.4. A procedure under general anesthesia (GA) conferred an OR of 2.3. Minor risk factors included torso injury and 10-year age interval over 50, both with an OR of 1.7, a 20-point interval of the Injury Severity Score (ISS) with OR 1.6, male gender with OR of 1.5, and various chronic disease comorbidities with OR ranging from 1.4 to 1.9. A Trauma Cardiac Risk Index (TCRI) was derived from these risk factors. The model showed good discrimination with a C statistic of 0.85. Conclusions Overall the trauma population has a low risk of MI. However, the risk is much higher for older patients with chronic comorbidity. The TCRI can be used to assess cardiac risk in trauma patients to help direct monitoring, testing, and risk reduction measures to those at the highest risk.

Traumatic uterine rupture is rare, occurring in 0.6% of blunt trauma cases, and usually results from very violent accidents in which patients usually also sustain other major injuries. Following severe blunt abdominal trauma, fetal loss can result from maternal hypotension or hypoxemia, placental abruption, maternal death, and uterine rupture. Although less common, fetal loss can also occur in minor injuries. We report a patient who sustained an isolated anterior uterine rupture with fetal demise without any associated abdominal or pelvic injuries. This case report highlights the importance of proper seat belt usage and placement because both can reduce maternal and fetal morbidity and mortality in motor vehicle accidents.

Background: Previous studies have shown that ICU patients receive only a fraction of their calculated nutritional goals, and that cumulative caloric deficit in the ICU has been correlated with poor outcome. One reason for this underfeeding is the frequent interruption of enteral nutrition. Many ICU patients receive enteral feeding formula via a nasogastric (NG) tube. Feeding is typically held for several hours prior to procedures due to the theoretical risk of aspiration. An alternative is to continue feeding up until the procedure begins, then stop the feeding and place the NG to suction. This evacuates the contents of the stomach and minimizes the risk of aspiration, while reducing the interruption of feeding that can result in malnutrition. Methods: This study is a review of prospectively gathered data including 55 sequential patients who underwent bedside percutaneous endoscopic gastrostomy (PEG) placement in a mixed ICU under a reduced fasting protocol. This was compared with a historical cohort of 33 critically ill trauma patients who fasted for at least 8 hours prior to the procedure. Under the reduced fasting protocol, enteral feeding via NG was continued up until the time of the procedure. The NG was then placed to suction, and sedation was given. The NG was left in place until the esophagus was cannulated, then it was removed. The PEG was placed in standard fashion, and feeding was resumed via the PEG immediately following the procedure. Results: We have documented no peri-procedural vomiting or aspiration. New diagnosis of pneumonia within 3 days occurred in 2/55 of the feeding group and 4/33 of the fasting group. Overall mortality was higher for the feeding group: 13/55 vs. 1/33, however when adjusted for baseline characteristics, the difference was no longer significant. Under our protocol, the interruption of feeding averaged approximately one hour, rather than the 8 or 9 hour interruption required by standard protocols. This saved an average of approximately 700 kilocalories per patient. Conclusion: We believe that continuing feeding via NG up until the time of bedside PEG is safe and advantageous for intubated patients in the ICU. Since there was minimal gastric content, it may also be safe for other procedures.

Electronic cigarettes (also known as e-cigarettes or e-cigs) are becoming a popular method of recreational nicotine use over recent years. The growth of new brands and devices has been outpacing the FDA's ability to regulate them. As a result, some of these devices fail without warning, most likely from malfunction of the lithium-ion batteries that are in close proximity to volatile compounds within the device. Failures have occurred during both use and storage of the devices or their components. The subsequent injuries from several of these events, including full thickness burns requiring grafting and blast injuries, have been observed at Arrowhead Regional Medical Center, a regional trauma and burn center in southern California. One severe case resulted in several maxillofacial fractures, blurred vision, and pneumocephalus after a device failed catastrophically during use. The patient required close monitoring with serial imaging by neurosurgery in the intensive care unit and multiple procedures by oral maxillofacial surgery to reconstruct his facial bones and soft tissue. Ultimately, the patient recovered with minimal permanent damage, but the potential for further injury or even death was apparent. Cases such as this one are becoming more frequent. It is important to increase awareness of this growing problem for both medical professionals and the general public in order to curb this concerning new trend. ((West J Emerg Med. 2016;17(6)805-7.)

Biopiling is an ex situ bioremediation technology that has been extensively used for remediating a wide range of petrochemical contaminants in soils. Biopiling involves the assembling of contaminated soils into piles and stimulating the biodegrading activity of microbial populations by creating near optimum growth conditions. Phytoremediation is another very successful bioremediation technique and involves the use of plants and their associated microbiomes to degrade, sequester or bio-accumulate pollutants from contaminated soil and water. The objective of this study was to investigate the effectiveness of a combined phytoremediation/biopiling system, termed Ecopiling, to remediate hydrocarbon impacted industrial soil. The large scale project was carried out on a sandy loam, petroleum impacted soil (1613 mg Total Petroleum Hydrocarbons (TPH) kg-1 soil). The contaminated soil was amended with chemical fertilisers, inoculated with TPH degrading bacterial consortia and then used to construct passive biopiles. Finally, a phyto-cap of perennial rye grass (Lolium multiflorum) and white clover (Trifolium repens) was sown on the soil surface to complete the Ecopile. Monitoring of important physico-chemical parameters was carried out at regular intervals throughout the trial. Two years after construction the TPH levels in the petroleum impacted Ecopiles were below detectable limits in all but 1 subsample (152mg TPH kg-1 soil). The Ecopile system is a multi-factorial bioremediation process involving bio-stimulation, bio-augmentation and phytoremediation. One of the key advantages to this system is the reduced costs of the remediation process, as once constructed, there is little additional cost in terms of labour and maintenance (although the longer process time may incur additional monitoring costs). The other major advantage is that many ecological functions are rapidly restored to the site and the process is aesthetically pleasing.

Objective : Trauma victims with hypotension require a rapid and reliable localization of bleeding and expedient surgical tri-age. Our hypothesis is that emergent abdominal sonography (EAS) is a rapid and accurate test of the need for urgent laparotomy in blunt trauma victims with hypotension. Methods : Among 400 blunt trauma victims entered in a prospective blind study of EAS, a subgroup of 69 (17%) patients had a systolic blood pressure ≤90 mm Hg during their initial assessment. Although the EAS results [(+) = fluid, (-) = no fluid] were not used in clinical decision making, the potential contribution of EAS to patient care was examined. Results : The mean Injury Severity Score was 32. Twenty-two (32%) patients were EAS (+), of which 19 required an acute laparotomy. No laparotomies were performed in the 47 EAS (-) patients. The EASs required 19 ± 5 seconds in the EAS (+) group and 154 ± 13 seconds in the EAS (-) group. Twenty of the 22 positive EASs had free fluid in Morison's pouch. All 13 patients with an ultrasound score ≥3 had a laparotomy. The primary etiology of hypotension was blood loss in 42 patients, hemoperitoneum in 18, and retroperitoneal hemorrhage in 12. Conclusion : EAS is a rapid and accurate indicator of the need for urgent laparotomy in the hypotensive blunt trauma victim. Further, a negative EAS can hasten the search for other causes of hypotension. Diagnostic peritoneal lavage may become obsolete in centers with EAS capabilities.

Background: Trauma patients continue to improve after discharge from the trauma center, but the completeness of this recovery remains uncertain. The purpose of this study was to compare the characteristics of patients who do and who do not return to work after blunt trauma. Methods: Consecutive survivors of blunt trauma discharged from a regional trauma center over a 1-year interval (July of 1994 to June of 1995) were included in the study. Patients completed the SF-36 Health Survey and some additional questions related to employment status both at discharge and again after 1 year. Our principal analysis compared patients who were employed and unemployed at 1-year follow-up. Results: Complete data were available for 195 patients. The typical patient was a young man who had been in a motor vehicle collision and had an injury severity score of 25. At 1-year follow-up, 101 patients had returned to work and 94 remained unemployed. Employed individuals were younger (31 vs. 44 years, p < 0.0001), less severely injured (mean injury severity score 23 vs. 27, p < 0.001), and more likely to hold professional jobs (50 vs. 16%,p < 0.0001). Patterns of injury and operative procedures were similar for employed and unemployed patients. However, the average employed patient had fewer days in the intensive care unit (2 vs. 5 days, p < 0.001), a shorter total hospitalization (19 vs. 28 days, p < 0.01), and was more likely to be discharged to home (62 vs. 39%, p < 0.01). At discharge, those who went on to employment had marginally better SF-36 Health Survey scores on seven of the eight scales (all except general health). During the year after discharge, both groups improved significantly, although employed individuals to a greater extent on all scales of the SF-36 Health Survey. Conclusions: Almost one half of the multiple system blunt trauma patients remain unemployed 1 year after hospital discharge. Those patients who return to work are usually young professionals with a lower severity of injury. Functional status at discharge predicts future employment status, but underestimates the extent of long-term recovery.

Although there is an interest in emergent abdominal sonography (EAS), the clinical utilization of EAS in North America is minimal. The purpose of this study was to develop a new diagnostic algorithm for blunt abdominal injury based on a prospective blinded comparison of EAS, diagnostic peritoneal lavage (DPL), and computed tomography (CT). EAS (+ = fluid, - = no fluid) was performed before the DPL or CT, in 400 patients with a mean Injury Severity Score of 26; 293 had a CT and 107 had a DPL. The EASs required 2.6 +/- 1.2 minutes with 82% < or = 3 minutes. The accuracy of EAS for free fluid was 94% with a positive and negative predictive value of 82 and 96%, respectively. Only 1 of 338 patients with EAS- had an acute therapeutic laparotomy. Three patients with EAS- had a delayed laparotomy based on evolving clinical findings. The radiologists interpretation of the EAS video disagreed with the clinician sonographer in only 3% of cases. Based on these results, a diagnostic algorithm was developed using EAS as a screening test with selective use of DPL and CT. Emergent abdominal sonography performed by clinician sonographers is a rapid and accurate test for peritoneal fluid in blunt trauma victims, and the need for laparotomy in patients with a negative EAS is rare. Our study supports the routine use of EAS as a screening test in a diagnostic algorithm for the evaluation of blunt abdominal trauma.

In North America, the role of emergent abdominal sonography [ultrasonography (US)] after blunt trauma requires further definition. The purpose of this prospective study was to compare US to the gold standards, diagnostic peritoneal lavage (DPL), and computed tomography (CT), in a population of adults after blunt trauma. In 206 adults who required either CT or DPL to assess possible abdominal injury, US was performed, before DPL or CT, and was aimed at the detection of intraperitoneal fluid. The mean Injury Severity Score and Glasgow Coma Scale score were 24.0 and 11.9, respectively. One hundred thirty-seven patients (67%) had CT and 69 (33%) had DPL. The positive and negative predictive values of US for intraperitoneal fluid were 90% and 97%, respectively. The sensitivity, specificity, and accuracy of US for free fluid were 81%, 98%, and 96%, respectively. Of the six false-negative USs, only one required surgery. The US examinations required 2.6 +/- 1.4 min. Emergent abdominal sonography is an accurate, rapid test for the presence of intraperitoneal fluid in adult blunt trauma victims and in these patients may prove valuable as a screening test for abdominal injury.