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The case described is that of a 50-year-old housewife, a State Registered Nurse, who was kicked to death. Death was caused by penetration of the left ventricle by two fractured ribs, a relatively rare form of fatal injury.
Seventy-nine belt-protected front seat occupants sustained authentic car-to-car side collisions with impact at front door or B-pillar in which energy equivalent speed (EES) and delta V had a highly significant influence on the occurrence of liver and spleen ruptures. From an EES greater than or equal to 40 km/h the risk of suffering liver and spleen injuries proved to be much higher for occupants on the impact side. Drivers on the impact side often had combined liver and spleen ruptures, front seat passengers had only liver ruptures and combined liver and spleen ruptures. The number of rib fractures on the left or right had a highly significant influence on the occurrence of liver and spleen ruptures. Liver ruptures and combined liver and spleen ruptures were often combined with pelvic ruptures.
A series of deaths due to multiple superficial injuries is reported. These cases represented 5% of a consecutive homicide series in the Northern Territory of Australia. All cases were characterized by extensive superficial injuries, particularly involving soft tissue, which were present over much of the body including the face, head, arms, legs, and trunk. Upper-limb fractures were present in some cases, as were fractured ribs. The internal organs and tissues were pale, but there was either little or no organ damage. No significant volume of free blood was found in any of the body cavities. In one case, fat emboli were identified in moderate numbers in the lung and kidney. Death due to multiple superficial soft tissue injuries has not previously been characterized in the literature.
Twenty autopsy reports, comprising 1 fall, 1 cutting, 1 burn, 1 drowning, 1 strangulation, 3 gunshot wound, and 13 traffic fatalities, were scored by the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS). The codes were adequate for wounds of skin and long bones, and for most wounds of viscera. The autopsy descriptions were more detailed than the coding criteria for craniocerebral, cervicovertebral and muscular trauma, and less detailed for thoracoabdominal visceral, and long bone trauma. Lung contusions and rib fractures received scores that seemed unduly high, possibly reflecting the greater sensitivity of autopsy diagnosis over clinical diagnosis for these lesions. Complete hinge fractures of the skull base scored 4 (severe), which does not reflect the almost universally lethal nature of the accompanying cerebral concussion, which was itself not codeable. AIS scores were low and did not seem to reflect the lethal outcome when the lethal mechanism was purely physiologic and without a striking morphologic derangement, as in instances of cerebral or cardiac concussion, compression of the neck, occlusive airway hemorrhage, and visceral herniation into an adjacent body cavity. The scores were similarly low when therapy was delayed or adverse. Low AIS and ISS scores in a fatality from blunt or penetrating trauma may be useful retrospective clues to the presence of purely physiologic death mechanisms or therapeutic problems.
Lethal and sublethal injuries to infants caused by anteroposterior manual compression can be accompanied by lateral rib fractures, hemorrhage into the viscera, and when severe, rupture of large vessels and solid organs. Abusers may claim that these injuries were sustained in an attempt to perform cardiopulmonary resuscitation (CPR). The difference between injuries caused by CPR and injuries caused by inflicted anteroposterior compression is examined in one sublethal and two lethal cases.
We report the case of a 58-year-old woman who had a 7-year history of multiple myeloma and multiple rib fractures and who presented with dysphagia. She underwent thorough gastrointestinal evaluation to rule out the possibility of amyloidosis. Although upper gastrointestinal biopsies were negative, the rectal biopsy was characterized by extensive smudgy eosinophilic deposits in the submucosa that closely resembled amyloid, except that they were not congophilic. Fibers with serrated borders characteristic of those in elastofibroma were identified and confirmed by means of elastic stain and electron microscopy. Elastofibromatous change of the gastrointestinal tract is a rare lesion that has been reported once previously in association with gastric ulcer. This case illustrates that it may occur as a spontaneous or subclinical finding in the absence of other pathologic lesions. The close resemblance between elastofibromatous change and amyloid deposits necessitates the appropriate histochemical and ultrastructural studies.
UNLABELLED: Important adverse effects of bystander cardiopulmonary resuscitation (CPR) are well known. We describe the number of nonmedical professional CPR-related complications in patients surviving cardiac arrest, as assessed by chest radiograph. Within 2 yr, all consecutive patients admitted to the department of emergency medicine at a university hospital who had a witnessed, nontraumatic, normothermic cardiac arrest were studied. Radiologically evaluated adverse effects were compared with Mann-Whitney U-tests between patients who received bystander basic life support (Bystander group) and patients who did not receive bystander basic life support before advanced life support was started (ALS group). For assessment of bystander CPR-associated complications, chest radiographs were used. Of 224 patients, 173 were eligible. The median age was 58 yr (interquartile range, 51-71 yr), and 126 patients (73%) were men. The incidence of adverse effects associated with assisted-ventilation maneuvers and external chest compressions did not differ significantly between groups (severe gastric insufflation, 17% vs 18% between the Bystander group [n = 59] and the ALS group [n = 96], respectively; suspicion of aspiration, 22% vs 17%, respectively; soft tissue emphysema, 2% vs 1%, respectively; and serial rib fractures, 8% vs 8%, respectively). CPR administered by nonmedical personnel did not increase the number of life support-related adverse effects in patients surviving cardiac arrest as assessed by means of chest radiograph on admission. IMPLICATIONS: Complications related to cardiopulmonary bypass (CPR) are not increased when CPR is administered by nonmedical personnel, as assessed by chest radiograph. These data may be valuable in motivating lay people to perform basic life support.
Four hundred and twenty-seven patients with severe blunt chest trauma were treated resulting in (1) flail chest, (2) pulmonary contusions, (3) pneumothorax, (4) hemothorax, or (5) multiple rib fracture. The need for endotracheal intubation and mechanical ventilation was determined selectively by standard clinical criteria. Avoidance of fluid overload and vigorous pulmonary toilet was attempted in all patients. Three hundred and twenty-eight patients were treated by nonintubation; 318 patients (96.6%) had a successful outcome, while ten required intubation. Only one patient died. The 99 patients who required intubation and mechanical ventilation had a high mortality because of associated shock and head injury; however, the total mortality for the entire group of patients was 6.5%, with only 1.4% mortality caused by pulmonary injury. The incidence of pneumonia was high (51%), but there was only a 4% incidence of tracheostomy complications. Flail chest and pulmonary contusion without flail chest occurred in 95 and 135 patients, respectively. Half of the flail chest patients were intubated, but 69.5% were intubated less than three days. Twenty per cent of the patients with pulmonary contusion required mechanical ventilation, usually for less than three days. This study demonstrates that patients with severe blunt chest trauma can be managed safely by selective intubation and mechanical, ventilation and that the incidence of complications associated with controlled mechanical ventilation can be greatly reduced.
Twenty-eight patients underwent anterior iliac crest reconstruction after the harvesting of autogenous tricortical graft. The anterior iliac crest was reconstructed using the resected rib from the thoracoabdominal approach. The authors evaluated graft site pain and residual deformity, radiographic evidence of rib incorporation, and the incidence of lateral femoral cutaneous nerve injury. There were no reports of graft site pain greater than "acceptable" levels, requiring nonnarcotic analgesics on an intermittent basis and not interfering with activities of daily living. Four lateral femoral cutaneous nerve neuropraxias were recorded, none of clinical significance. The authors advocate the use of autogenous tricortical anterior iliac crest bone graft when performing reconstructive spinal surgery, followed by reconstruction of the iliac crest with the resected rib from the surgical approach.
Digital processing, storing, and interpretation of scintigraphic images from a PACS system has been postulated as an efficient, cost-saving measure that may obviate the need for analog film. In order to replace analog film, documentation that images can be interpreted from a digital video display with accuracy at least equal to film must be obtained. Analog film was compared with video images in 28 patients with cancer suspected to be metastatic to bone. Images were acquired with a gamma camera and processed in 256 x 256 word mode by the use of the Medical Data Systems A3 computer. Adjustment of gray scales provided operator-controlled digital contrast enhancement. Video and film images were independently interpreted by two experienced nuclear medicine physicians, each blinded to the other modality. A linear four-color scale was then substituted for the gray scale, and images again interpreted. Lesions were interpreted as positive or equivocal and verified through follow-up scans over a minimum of six months. Of the 28 patients, 22 proved to have metastases, in whom 129 lesions were confirmed by follow-up scintigrams. 124 of these lesions (96.1%) were detectable on both analog film and video images. An additional three proven metastatic lesions on video images were absent or equivocal on analog studies, increasing sensitivity for video images to 98.4%. Five further lesions seen on the video screen represented rib fractures and regressed on follow-up examination. All lesions seen on black-and-white video were also seen when the color scale was applied.(ABSTRACT TRUNCATED AT 250 WORDS)
A technique for measuring the gaseous environment during the reconstitution of a large bone defect is described. Extensive testing of this system over the past 10 years has demonstrated its validity in measuring the average extracellular tissue pO-2 and pCO-2. Histology of the tissue surrounding the tonometer was obtained and correlated with the gaseous measurements. New bone formation in the healing segmental bone defects has been shown to take place under hypoxic conditions. The oxygen consumption of the surrounding tissue was determined and correlated with the histology and tissue gas measurements. It was demonstrated that the oxygen consumption was not elevated during the period of new bone formation, reflecting a state of anaerobic metabolism. The hypoxic conditions persist until the vascularity increases to match the cellularity. Thephysiological role of oxygen in osseous repair is presented. The present technique as well as the previously published microelectrode technique have demonstrated bone formation in vivo can take place under hypoxic conditions but the mechanism is not known and requires further investigation.
The CT studies in 63 patients in which rib abnormality was identified or excluded were retrospectively analyzed. The CT features were detailed and correlated with other available radiographic findings as well as clinical data. Contiguous spread of tumor to rib or metastasis to rib characteristically showed subtle or complete segmental lytic rib destruction. An accompanying extrapleural soft tissue mass was frequently seen with metastatic disease and myeloma. In nine patients CT showed rib destruction that had been obscured on chest radiography by heart, diaphragm, mass, or pleural effusion. Other imaging studies prompted consideration of neoplasm in seven patients in whom CT clearly showed benign post-traumatic or developmental lesions. Six patients had a clinically suspected chest wall mass excluded, leading to the diagnosis of Tietze syndrome. The ribs should be carefully inspected on all CT studies of the thorax and upper abdomen. Computed tomography is helpful when other imaging techniques, such as rib films or isotopic bone scans, have not resolved the question of clinically or radiographically suspected rib abnormality.
The value of endotracheal intubation and internal stabilization in severe chest injuries is well known. Recent reports have proposed that many such patients can be managed without intubation. To determine which patients need intubation we reviewed 140 patients with three or more rib fractures who presented to our hospitals from 1 January 1979 through 31 December 1983: 119 nonintubated patients (Group A); 13 patients intubated on admission (Group B); five patients intubated after hospital day 1 (Group C); and three patients intubated questionably on admission (Group D). The purpose of this report was to identify the factors which indicated severe pulmonary injury necessitating intubation. The need for intubation was correlated with five risk factors: 1) initial respiratory rate of over 25 min; 2) pulse greater than 100 min; 3) systolic blood pressure less than 100 mm Hg; 4) poor initial arterial blood gas; 5) the presence of other injuries. There was no correlation between severity of pulmonary injury and number of fractures, bilateral and/or segmental fractures, flail chest, contusion of lung, or age of patient. There was a greater percentage of complications and deaths in intubated patients (Groups B, C, and D). Group C patients all had poor initial blood gases and were erroneously not intubated early, even though 60% of them had three or more risk factors, as did Group B patients. Only 4% of patients who did not need intubation (Group A) had three or more risk factors. Group D patients were intubated without apparent indication. They had good initial blood gas levels and only one risk factor.(ABSTRACT TRUNCATED AT 250 WORDS)
The incidence, diagnosis, and impact on surgical management of myocardial contusion (MC) are incompletely defined. During a 12-month period, all patients admitted to a Level I trauma center with blunt trauma were prospectively evaluated for MC (n = 1,110). Those with anterior chest wall contusions, sternal or anterior rib fractures, or pain/tenderness of the anterior chest (n = 140, 13%) underwent immediate and daily ECG, and CPK isoenzymes were measured at admission and every 6 hours in the first 24 hours. Eighty-nine of these patients underwent gated ventricular angiography (GVA) and 66 underwent two-dimensional echocardiography (2D ECHO). MC was considered present if either: 1) CPK-MB was greater than or equal to 5% of total CPK, or 2) an abnormal admission ECG reverted to normal before patient discharge. Fifty-six patients (5% of admissions, 40% of those with apparent chest trauma) were positive by one or both criteria. Thirty patients (54%) were positive by CPK alone, 23 (41%) by both CPK and ECG, and three (5%) by ECG alone. Of the 53 with elevated CPK-MB, 14 (26%) were normal on admission with the remainder becoming elevated in the first 24 hours. 2D ECHO was abnormal in only three of 21 positive patients (14%), and GVA was abnormal in only three of 40 positive patients (7%). Surgical procedures requiring general anesthesia were performed in 37 (66%) of the positive patients. No significant arrhythmias developed under general anesthesia.
To investigate the role of the IVP, we studied 139 patients with blunt abdominal trauma and hematuria. Multivariate analysis of clinical parameters was utilized in attempt to predict which patients would have abnormal IVP's and which would eventually require genitourinary operation. Thirty-four patients (25%) demonstrated abnormalities on IVP; however, no combination of clinical findings (including degree of hematuria) could reliably predict which patients would have abnormal IVP's. On the other hand, in 90% of the patients, the necessity for genitourinary operation could be reliably predicted based on: presence of blood at the urethral meatus, degree of hematuria, patient age, Injury Severity Score, and number of rib fractures. We conclude that to detect IVP abnormalities, IVP's need to be performed on all blunt trauma patients with hematuria. However, patients likely to have injuries requiring operative repair can be predicted. Those patients unlikely to have genitourinary injury requiring repair, therefore, may have IVP performed on a nonurgent basis.
Of 174 multiple trauma patients undergoing abdominal CT examination for suspected abdominal trauma, 65 patients had 109 chest injuries detected by abdominal CT, chest film, or both examinations. Forty-one patients had 55 chest injuries at the base of the thorax which were not detected on the initial chest film. The most frequent chest injuries detected only by CT were pneumothroax, fracture (rib, thoracic spine, and sternum), lung contusion, aspiration pneumonia, hemothorax, and post-traumatic atelectasis. Seven patients whose chest injury initially was seen only at abdominal CT required treatment of the injury, suggesting that a variety of chest injuries which may vitally affect patients can be detected early in multiple trauma patients by abdominal CT, and that all abdominal trauma CT scans should be scrutinized for signs of a chest injury.
Rib fractures and other chest wall injuries can lead to weak ventilation, atelectasis, and even death. Whereas such injuries in young patients are usually well tolerated, relatively minor chest wall trauma can be serious in elderly patients. Epidural analgesia, by improving pain control and ventilatory function, might improve morbidity and mortality rates compared to other forms of analgesia. Stepwise logistic regression was used to compare thoracic trauma patients more than 60 years of age treated with either epidural or parenteral (IV/IM) analgesia. In spite of more severe thoracic trauma in epidural patients as measured by the Abbreviated Injury Score for the chest (epidural = 3.3 +/- 0.1, IV/IM = 2.8 +/- 0.1; p less than 0.05) the use of epidural analgesia was an independent predictor of both decreased mortality (p = 0.0035) and a decreased incidence of pulmonary complications (p = 0.0088). Epidural analgesia has a positive effect on outcome in elderly trauma victims with chest wall injury and is useful in high-risk patients. Increased costs associated with epidural analgesia are minimal and are justified by improvements in outcome.
The records of obese and nonobese victims of blunt trauma were compared to determine if obese individuals are predisposed to a specific injury pattern. Prospectively collected data on 6368 adults admitted to a level I trauma center over a 4-year period were analyzed. Twelve percent (743 patients) met Body Mass Index (weight/height2) criteria for obesity (greater than or equal to 30 kg/m2). The obese group was older (p less than 0.01) and had lower ISSs (p less than 0.05) and higher GCS scores (p less than 0.01). More obese patients were injured in vehicular crashes (62.7% vs. 54.1% [p less than 0.01]). The obese victims were more likely to have rib fractures, pulmonary contusions, pelvic fractures, and extremity fractures and less likely to have incurred head trauma and liver injuries (p less than 0.05). Obese people injured in vehicular crashes had a similar injury pattern with no difference in seating position, direction of impact, seat belt use, and ejection.