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PubMedDate not supplied

Posterior hip dislocation in a five-year-old boy: a case report, review of the literature, and current recommendations.

Traumatic hip dislocation constitutes a true orthopedic emergency, is a relatively rare occurrence in the pediatric population, and may be accompanied by minimal trauma. Long-term morbidity such as avascular necrosis or osteoarthritis of the femoral head may be significant if the diagnosis is not expeditiously confirmed radiographically and prompt reduction employed. A poorer prognosis is conferred by duration of dislocation for longer than 6 h, advanced skeletal maturity of the patient, severe joint injury, or multiple trauma in the affected patient. A case report involving traumatic hip dislocation in a 5-yr-old boy is described followed by a comparative review of the pediatric and adult literature with current recommendations.

Child, Preschool↗
PubMed1989

[Closed injuries of the liver. A series of 70 surgical cases (1983-1988)].

Analysis of a series of 70 cases of closed trauma to the liver seen between 1983 and 1988, confirms the gravity of these lesions even when good transport and reception facilities exist for injured patients. The combined efforts of resuscitation and surgery fail for two reasons: the severity of actual hepatic disruption and the existence of extra-hepatic injury in patients with multiple trauma. The major threat comes from the hemorrhagic syndrome which is responsible for almost half the deaths. The dogma advising emergency surgical intervention still remains, if only to evaluate the exact degree of liver trauma and to deal with coexisting intra-abdominal lesions. The surgical intervention should be adapted to the hepatic lesion without attempting complicated technical procedures. In the absence of coagulopathy, resection should be reserved for massive lesions. Most often direct hemostasis and parenchymal suture are sufficient. This should always be attempted if it appears reasonable. In more severe situations, especially if a coagulopathy exists, packing is a wise and logical procedure. Surgical abstention should especially be reserved for cases of unruptured central or sub-capsular hematoma, in a stable hemodynamic situation, under strict surveillance in a specialised surgical department. In contrast to the high initial mortality (40%), the subsequent course is generally favorable and without specific sequelae even after major disruption or hepatic resection. The use of an appropriate therapeutic strategy will reward the surgeon with a cure in 6 out of 10 cases of closed hepatic trauma.

Adult↗
PubMed1992

Penetrating eye injuries related to assault. The National Eye Trauma System Registry.

From 1985 to 1991, 648 cases of assault-related penetrating ocular injury were reported to the National Eye Trauma System Registry. We examined the circumstances surrounding and initial clinical findings related to this case series of injuries. Eighty-three percent of the patients were male. The median age was 28 years; 77% were younger than age 40 years, and 17% were younger than age 20 years. The ocular injury was part of multiple trauma in 34% of cases. There was evidence of alcohol and illicit drug use by at least 48% and 6% of the injured persons, respectively. Seventeen percent of the injuries involved powder or nonpowder firearms. Fists, glass fragments, metal rods or pipes, knives, and scissors were among the other objects causing injury. Posterior segment trauma, which occurred in 70% of cases, included vitreous hemorrhage (40% of cases), retinal detachment (11%), presence of intraocular foreign bodies (6%), and optic nerve damage (4%). The initial visual acuity after injury was hand motion or worse in 74% of the cases. Strategies to prevent such injuries focus on the origins of violence in general and are more difficult to devise than strategies to prevent eye injuries in other settings. Public health efforts to reduce the use of alcohol, drugs, and firearms may reduce the incidence of these injuries.

Adolescent↗
PubMed1978

Abdominal paracentesis for early diagnosis of closed abdominal injury.

In a 4 year material of closed abdominal injuries consisting of 114 patients, mostly multiple trauma traffic accidents, diagnostic paracentesis with peritoneal lavage was used in 47 cases. The aim of the investigation was to indicate or exclude blood in the abdominal cavity as early as possible and thereby facilitate the priority of treatment and diminish the delay in surgical intervention. The main indication was suspicion of abdominal injury in multiple traumatized, unconscious or shocked patients. The puncture was performed in the emergency room immediately after ordinary lifesaving steps had been taken. If blood was obtained the patients were sent to the operating theatre for laparotomy. If blood was not obtained one litre of an isotonic salt solution was infused and if the returning solution was only slightly blood tinged, the investigation was continued with roentgenographic methods. In our series only two cases were not correctly diagnosed. Diagnostic paracentesis is the most rapid method of demonstrating intraabdominal bleeding, which is found in 90% of all serious intraabdominal organ injuries. In doubtful cases this method must be combined with other diagnostic methods and the patient put under proper clinical observation.

Abdominal Injuries↗
PubMed2005

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma.

BACKGROUND: Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs. OBJECTIVES: To assess the efficiency and effectiveness of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CENTRAL, CCMED, publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and congress abstracts were handsearched. Trials were obtained from the Cochrane Injuries Group's trials register. Authors were contacted for further information and individual patient data. SELECTION CRITERIA PARTICIPANTS: patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury. INTERVENTIONS: diagnostic algorithms comprising emergency ultrasonography (US). CONTROLS: diagnostic algorithms without US ultrasound examinations (e.g. primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]). OUTCOME MEASURES: mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life. STUDIES: randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs). DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate. MAIN RESULTS: We identified two RCTs with US in the experimental arm and another with US in the control group. We also considered two qRCTs. Overall, trials were of moderate methodological quality. Few authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We were able to pool data from two trials comprising 1037 patients for primary endpoint analysis (i.e. mortality). The relative risk in favour of the no-US arm was 1.4 (95% CI 0.94 to 2.08). Because of a lack of details, the meaning of this observation remains unclear. There was a marginal benefit with US-based pathways in reducing CT scans (random-effects RD -0.46; 95% CI -1.00 to 0.13), offset by trials of higher methodological rigour. No differences were observed in DPL and laparotomy rates. AUTHORS' CONCLUSIONS: There is insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

Abdominal Injuries↗
PubMed1993

[Liver injury in abdominal trauma. Review of the literature and personal observations].

In patients who suffered abdominal trauma, the liver is the most frequently involved organ, except the spleen. The % rises from 1520% to 30% if trauma is closed or open. Liver injury may spread from a simple parenchymal contusion to a break in vessels or biliary ducts. Life risk is related to hemorrhage. The mortality is due to: 1) extension of the injured liver surface, 2) possible damage to big vessels, 3) intra or extra abdominal associated injury in case of multiple trauma. It is important to known the kind of injury to choose the best therapy, not necessary surgical. The authors report on 15 patients with thoracoabdominal trauma and liver damage, comparing their cases with literature observations.

Abdominal Injuries↗
PubMed1988

Conjunctival oxygen tension monitoring in emergency department patients.

Conjunctival oxygen tension (PcjO2) was sequentially monitored in 96 medical and surgical patients admitted to the emergency department resuscitation suite during a 6-month period. There were 28 patients with cardiac arrest, 44 with major trauma, and 24 with severe medical problems. A total of 2,392 PcjO2 data points were collected in these patients. In patients with cardiac arrest, PcjO2 showed changes in physiological condition as early as or earlier than measurement of vital signs. Measurement of PcjO2 and the finding of a PcjO2 index (PcjO2/PaO2) less than .5 in normotensive multiple trauma patients allowed rapid detection of hemorrhagic hypovolemia. In critically ill medical patients, low values for PcjO2 were found with hypoxemia as well as in conditions associated with decreased cardiac output and tissue oxygen delivery. These two conditions could be distinguished by measuring PaO2 and calculating the PcjO2 index; a PcjO2 index less than .5 was associated with diminished peripheral perfusion and cardiac output, and a PcjO2 index greater than .5 indicated hypoxemia without any compromise in cardiac output. In the group of critically ill surgical and medical patients included in this study, conjunctival oxygen monitoring provided clinically useful information not available from vital signs and permitted identification of physiological instability associated with abnormalities in peripheral tissue perfusion and oxygenation as early as or earlier than conventional monitoring methods.

Adult↗
PubMed1983

The effects of prehospital trauma care on survival from a 50-meter fall.

One hundred eighty individuals are known to have jumped or fallen from Seattle's Aurora Bridge during the past 49 years. The survival rate has been increasing, as has been the severity of injury experienced by the survivors. Both prehospital resuscitative measures and advances in the overall care of the trauma patients in hospital may have contributed to this. The survival statistics and injury severity scores of this homogeneous group of patients before and after the institution of a sophisticated prehospital emergency medical care program (Medic I) provide historically controlled data on the role of this type of system in the care of trauma patients. More patients who were alive at the scene arrived at the hospital alive after the development of the Medic I program. Overall survival was tripled. Patients with more severe injuries survived. These data demonstrate that prehospital airway control, ventilation, initiation of fluid resuscitation and cardiovascular support by physician-supervised paramedical personnel can significantly benefit multiple trauma patients. In this context, the Medic I approach was superior to the previously existing 'load and go' system.

Accidents↗
PubMed2001

Soluble selectin profiles associated with severe trauma.

Severe trauma acts as a trigger for the complex cascade of postinjury events leading to the release of different mediators and the development of generalized inflammation. Selectins are a family of adhesion proteins that are responsible for the adherence of polymorphonuclear neutrophils to the endothelium. This interaction plays an important role in the development of severe complications after multiple trauma. The aim of the present study is to follow the sequential alterations in circulating selectin levels after severe injury and to evaluate the clinical significance of these mediators in monitoring prognosis and outcome. Thirty four severely traumatized patients were entered into the study. Serum sE-selectin, plasma sP-selectin and sL-selectin concentrations were measured and an APACHE II score was calculated on admission to the intensive care unit and during the subsequent 5 days. The patients were divided into survivors and nonsurvivors. Initial soluble P- and E-selectin concentrations were significantly elevated in all trauma patients. The highest values of these adhesion molecules were measured in all the observed days in patients with poor prognosis and outcome. In survivors we found a systematic decrease in the sP-selectin concentrations. On admission, the sL-selectin concentrations in all trauma patients were decreased. There were stable, very low values in nonsurvivors and a slow increase in circulating L-selectin in patients who survived. The pattern of soluble selectins in patients with severe trauma is characterized by increased levels of P- and E-selectin and a decreased concentration of L-selectin. These findings suggest a widespread microvascular endothelial activation on injury in the early posttraumatic period, which may be associated with increased neutrophil-endothelial adhesion, neutrophil extravasation and migration. We suppose that these parameters of endothelial cell activation/injury may be useful as another early prognostic factor in severe trauma.

Adult↗
PubMed1989

[Treatment of splenic injuries. Retrospective study of 101 cases].

101 patients with splenic trauma were treated during the period 1978 to 1988. They included 76 men and 25 women aged between 16 and 85 years, with a mean age of 38 years 6 months. Exclusively splenic lesions were present in 33 cases (32.67%) and bony or visceral lesions were also present in 68 cases (67.33%). 61 cases (60.39%) suffered from multiple trauma. 97 patients underwent laparotomy, 86 (85.1%) subsequently underwent total splenectomy and 11 (10.8%) conservative surgical treatment (10 partial splenectomies and 1 splenorrhaphy). Four patients did not undergo surgery and were kept under surveillance in a surgical ward for 3 weeks. The majority of partial splenectomies were carried out after 1985 though the first was performed in 1981. There was no operative mortality and post-operative mortality was 9.9% (10 deaths). The overall mean duration of hospitalisation was 20.2 days: 15.6 days for patients who underwent partial splenectomy, 19.6 days for patients who underwent total splenectomy and 21 days for cases involving simple surveillance. Operative complications occurred in 28 patients who underwent laparotomy. Complications did not occur in the 4 patients who received simple surveillance. The most frequent complications were sepsis, pneumonia, thrombo-embolic complications and four patients required reoperation for hemoperitoneum. Conservative surgical treatment is increasingly being used in splenic trauma. The criteria for avoidance of surgical intervention remain difficult to define at the present time.

Accidents↗
PubMed2006

Chest injury in victims of Bam earthquake.

OBJECTIVE: To analyze the data of trauma patients with thoracic injury in the earthquake of Bam admitted to hospitals of Tehran University of Medical Science (TUMS) for better understanding the type and consequence of thoracic injuries in a major earthquake. METHODS: After Bam earthquake registering 6.5 on the Richter scale, 526 trauma patients were admitted to hospitals of TUMS. Among them, 53 patients sustained thoracic injury. RESULTS: This group was composed of 21 females (39.6%) and 32 males (60.4%). Fifteen patients (28.3%) had isolated chest injuries. Rib fracture (36.4%) was the most common injury in our patients and haemo/pneumothorax (25.5%) followed. Superficial injury was the most common accompanying injury. Multiple-trauma patients with chest injury had higher injury severity score (ISS) versus patients with isolated chest injury (P=0.003). CONCLUSIONS: Chest wall injuries and haemo/pneumothorax comprise a considerable number of injuries in survival victims of earthquakes. Consequently, the majority of these patients can be treated with observation or tube thoracostomy. We should train and equip the health workers and members of rescue teams to treat and manage these patients in the field.

Adolescent↗
PubMedDate not supplied

The evaluation of blunt abdominal trauma: the evolving role of ultrasound.

There is a growing body of literature pertaining to the use of ultrasound in the evaluation of patients with blunt abdominal trauma. Multiple studies have looked at the use of this modality as a screening examination for the detection of intra-abdominal fluid and as a means of diagnosing specific organ injuries. Although ultrasound has been used extensively in Europe and Asia, it has only recently been used in the United States. In many centers, ultrasound is now being performed by emergency medicine physicians and trauma surgeons as part of the initial trauma evaluation. This paper summarizes the recent literature on the use of ultrasound in evaluating blunt abdominal trauma as an adjunct or an alternative to diagnostic peritoneal lavage and abdominal computed tomography.

Abdominal Injuries↗
PubMed2004

Burn epidemiology: the patient, the nation, the statistics, and the data resources.

Throughout the years, bum care treatment in the United States has made major strides in the ability to save the lives of those once rendered helpless as a result of an extensive bum injury. Bum care professionals are able to assist these individuals to live as normal a life as possible as they heal from one of the most devastating injuries a human being can endure. The only way to remedy the suffering and the costs in health care resources and in productivity is to reduce the incidence of bum injuries and death. Communities must be concerned with consistently establishing preventive measures and with the proactive treatment of bums to help decrease incidence. Activities on the community, state, and national level to obtain accurate data regarding the epidemiologic characteristics must be implemented to provide a more accurate picture of bum injuries in the United States. Addressing issues surrounding the persons at high risk of bum injury will help to decrease the incidence of bum trauma. Funding must be strengthened to ensure the continued existence of bum programs that truly provide high-quality standards of care. In these programs, the burn victim is given every opportunity to become a survivor. In light of the recent terrorist activity in the United States, the nation must address another area that might affect the history of bum care and treatment, the multiple-trauma victim with an extensive burn injury caused by massive explosions, chemical warfare,missiles, and weapons of mass destruction. One out-come from the recent terrorist attack was recognition of the need for facilities to be capable of providing care for this type of patient. Efforts to strengthen these programs and bum care facilities must be continued to maintain and strengthen the care needed for bum patients of the future.

Accident Prevention↗
PubMed2005

September 11, 2001, revisited: a review of the data.

HYPOTHESIS: The September 11, 2001, World Trade Center (WTC) attack was a disaster of epic proportion in New York City, NY. It was unprecedented in terms of the number of people who were killed in the bombings, as well as in terms of the volume of patients received at local (New York City) hospitals. The strain on local emergency medical services, hospitals, and the citywide trauma system is still felt today as the hospitals, physicians, and agencies involved struggle to train for similar events that may occur in the future, cope with the psychological and social aftermath, and even pay for the response to the bombing. The objective of this review of the data was to determine the major causes of morbidity (ie, hospital visits) during the hours immediately after the September 11, 2001, WTC attack, as well as to detail the costs involved in the medical response to a disaster of this scale and to identify some lessons learned with respect to the hospital's response to an event of this magnitude. DESIGN: Review of records and cost data submitted by Saint Vincent's Hospital, Manhattan, NY, to the state of New York and federal sources for financial relief from the September 11, 2001, WTC attack. SETTING: Saint Vincent's Hospital is an academic medical center of New York Medical College and a New York City-designated level I trauma center. PATIENTS: All medical records for the patients registered at Saint Vincent's Hospital on September 11, 2001, after 8:50 am were reviewed. RESULTS: The major cause of morbidity for the September 11, 2001, patients was smoke inhalation (30.0%); followed closely by chemical conjunctivitis and corneal abrasions (16%); lacerations, abrasions, and soft-tissue injuries (15.5%); isolated orthopedic complaints (12%); and psychiatric complaints (10%). Multiple-trauma patients were 3% of the patients seen. There were 5 fatalities at Saint Vincent's Hospital. CONCLUSIONS: The WTC disaster was a source of major morbidity and mortality to the people of New York City. The possibility that Saint Vincent's will again serve in that role is in the forefront of the minds of everyone involved in updating our contingency plan.

Academic Medical Centers↗
PubMed2000

Pediatric trauma made simple.

At present, similar to the adult, conventional management in the child following TBI appropriately attempts to lessen the second insults that occur after the injury and the effects of the secondary physiologic events. Many of the treatment modalities used for the child after severe TBI have been extrapolated from the adult data, as there is little literature that primarily involves children. Though children as a group overall have a better outcome than adults, there are many factors that influence prognosis in the pediatric population. The age at injury, mechanism of injury, injury severity, multiple trauma, second insults, and/or the extent of secondary injury can all impact on the final outcome. It is clear that many of the poor outcomes observed are best prevented by preventing either the initial impact or the second insults that typically occur following TBI. Interestingly, very young and preschool children have worse outcomes both in mortality and long-term disability than older children and adolescents. The deficits observed are often persistent and severe in the long term even with aggressive management. Continued aggressive intervention to prevent secondary injury and, in the future, mechanistically targeted therapeutic modalities in the acute setting will hopefully improve the mortality rates and functional recovery in these children.

Brain Injuries↗
PubMed1996

Elevated selectin levels after severe trauma: a marker for sepsis and organ failure and a potential target for immunomodulatory therapy.

UNLABELLED: Severe injury is frequently complicated by sepsis and organ failure. Activated neutrophils adherent to inflamed endothelia have been implicated in the pathogenesis of these complications. Identification of high-risk patients to target immunomodulatory therapy, however, remains an elusive goal. We postulated that (1) patients at risk for sepsis and organ failure could be identified by measuring shed selectin adhesions molecules as a marker of endothelial activation after injury and reperfusion, and (2) these elevated selectin levels would correlate with injury severity, shock, major complications, and mortality. METHODS: Blood samples were drawn from 50 patients with multiple trauma every 2 hours after admission for the first 24 hours, and every 6 hours for the subsequent 24 hours, and assayed for levels of shed E- and P-selectin. Patients were then stratified according to Injury Severity Score (ISS), presence or absence of shock, presence or absence of organ failure and/or infectious complications, and finally, death versus survival. RESULTS: Trauma patients who had ISS < 30, who did not develop shock, sepsis, or organ dysfunction, had minimal increase in circulating E- and P-selectin over admission levels. In patients who subsequently developed infectious complications, organ dysfunction, or both, or subsequently went on to die, elevated levels of E-selectin levels were evident by 36 hours, and in some cases, earlier. Differences between nonsurvivors and survivors was statistically significant. There was also a trend toward increased levels of P-selectin in the same group of patients, although these differences were not significant. There was no differentiation in either of the two selections when patients were stratified according to ISS or presence of shock. CONCLUSION: A subset of major trauma patients manifest increased levels of circulating E-selectin adhesion molecules after resuscitation. These patients seem to be at increased risk of death and possibly at risk for infections complications and organ failure. Selectin blockade is a potential new immunomodulatory strategy in this subgroup of patients.

Adjuvants, Immunologic↗
PubMedDate not supplied

[The diagnosis of traumatic cervical lesions: a decade of evidence-based change].

The growing awareness of the need for emergency centers specializing in the care of trauma patients, together with advances in diagnostic imaging technology, have led to the occasional indiscriminate use of diagnostic methods to the detriment of ordering diagnostic tests based on the risk of fracture and of the clinical examination itself. In many institutions, this practice is carried out without appropriate controls and without analyzing the risks and benefits of a particular clinical conduct. This is particularly true in cases of multiple trauma with suspected traumatic lesions of the cervical spine. For many years, radiological examination was based on plain-film radiography, with CT playing a complementary role. Over the last decade, since the introduction of helical CT, and more recently multidetector CT scanners, the diagnostic approach has undergone rapid, significant changes. This article summarizes the experience based on publications centered on establishing the diagnostic effectiveness of CT in comparison to plain-film radiography and the importance of recognizing risk factors when determining the diagnostic strategy. On the other hand, the importance of avoiding unnecessary tests and excessive radiation in providing appropriate and efficient medical care is stressed. In general, the evidence indicates that CT should be the first-line approach in high-risk patients and plain-film radiography should be reserved for the initial evaluation of patients with a low risk of traumatic lesions.

Cervical Vertebrae↗
PubMed2001

Traumatic posterior dislocation of hip in children.

Traumatic posterior dislocation of the hip joint in children is an uncommon injury. It constitutes a true orthopedic emergency. It makes up over 80% of pediatric hip dislocations. In children, it can occur as a result of minimal trauma, which is attributed to a soft pliable acetabulum and ligamentous laxity. In skeletally mature adolescents, a greater force is required to dislocate the hip joint. Delay in reduction is associated with long-term complications such as avascular necrosis and degenerative arthritis. Avascular necrosis is related to the duration of dislocation. A poorer prognosis is associated with delay in reduction beyond 6 hours, advanced skeletal maturity, or multiple traumas. Prompt reduction minimizes complications. We report two cases of traumatic posterior dislocation of hip in children aged 3 and 14 years. Both were reduced within 6 hours of dislocation, and review at 6 months revealed normal examination and no evidence of any post-traumatic changes. Post-reduction treatment remains without a consensus. This review highlights the clinical presentation, management, and time-sensitive complications of the injury.

Adolescent↗