CARE OF THE INJURED – PART ONE
TRAUMA TOPICS FOR THE GENERAL SURGEON
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1
INTRODUCTION
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A discussion of general topics pertinent to the care of injured patients by general surgeons will
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occupy two issues of Selected Readings in General Surgery (SRGS) beginning with this issue. The topics
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have been chosen because they are relevant to the practice of general surgery and because they do not
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conveniently pertain to the organ-system-specific issues of SRGS. Principles of care of specific organ in-
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juries and techniques pertinent to the care of specific organ injury are in the issues dealing with the in-
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dividual organ systems. The areas for discussion are introduced, briefly, at this time.
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Trauma systems and trauma centers
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In this first issue, we discuss trauma systems and trauma centers. We will first describe the pro-
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cess of needs assessment that leads to the recognition that trauma care requires improvement in a re-
11
gion. We will then review the available evidence supporting the effectiveness of trauma systems in re-
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ducing the mortality rates of injuries. In subsequent sections, various issues pertinent to the organiza-
13
tion and function of trauma centers will be dealt with. Specifically, we will discuss mechanisms to docu-
14
ment levels of performance and approaches for successful implementation of performance improve-
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ment programs. The effect of trauma center patient volume on performance will be discussed. Ques-
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tions relevant to the data included in trauma registries and the means by which these data can be vali-
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dated and shown to be accurate will be the subject of a subsequent review.
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Injury prevention and control
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The provision of care for patients who have already sustained an injury is, obviously, an example
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of secondary and tertiary preventive efforts. Secondary prevention is designed to minimize the mortality
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and morbidity risks of injuries that have already occurred. Tertiary prevention efforts are designed to
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maximize the potential for full recovery of the injury victim and return of that individual to a role as a
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contributing member of the community. It is appropriate for surgeons to be participants in primary pre-
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vention also. Primary prevention uses education, engineering controls, and legislation to create an envi-
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ronment where the chance is minimized for an injury to occur in the first place. In one section of the
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overview, we will review several primary injury prevention topics and discuss the effectiveness and life
27
preserving potential of these programs.
28
Identifying patients with alcohol and drug abuse related injuries and effective interventions
29
The influence of drug and alcohol use on the frequency and severity of injury is a topic of inter-
30
est for surgeons. Means for detection and treatment of this problem will be dealt with in a separate sec-
31
tion. Surgeons are frequently expected to assume leadership positions in community efforts to prevent
2
1
injury and reduce injury-related mortality and morbidity resulting from alcohol and substance use. One
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section of the overview will deal with the current status of methods of detecting and beginning treat-
3
ment for alcohol and substance abuse. One important finding that has emerged from the recent scien-
4
tific evidence about detection and management of patients, whose injuries are, at least in part, from use
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of alcohol and/or drugs, is that many drug-related episodes of risk taking behavior occur for every injury
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that occurs. This observation serves to underscore the importance of public education in reducing the
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dangerous behaviors fostered by drug and alcohol use. Surgeons have, for the most part, focused on
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interventions directed toward assisting injury victims so that these patients can gain insight into the re-
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lationship between use of drugs and alcohol and their injury. Frequently, the injury event serves to cre-
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ate a mindset that is conducive to gaining such insight. We review the available approaches for identify-
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ing and intervening for patients whose injury event involved alcohol and/or drugs and seek to quantify
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their effectiveness.
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Post-injury psychologic dysfunction
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Post traumatic stress disorder is diagnosed in more than 25% of injury victims. Some subgroups
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of patients are particularly vulnerable. In this section of the discussion the focus will be upon identifica-
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tion of high risk groups, early diagnosis, and effective interventions which may lead to improved out-
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comes and more frequent successful return to full function.
18
Traumatic brain injury
19
Traumatic brain injury is a critically important contributor to trauma-related mortality and mor-
20
bidity. The extent of brain damage is not determined at the time of impact. The physiologic effects of
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brain injury progress over the first days after the injury event. Recognition of this fact has accelerated
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efforts to develop effective means of diagnosing, monitoring, and treating brain injury. We now know
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that patients with the full spectrum of brain injury from mild to severe will sustain medium and long-
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term sequelae that prevent rapid return to full function. In this section, practice guidelines for the man-
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agement of traumatic brain injury are reviewed and data supporting these guidelines presented and
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evaluated.
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Spine and spinal cord injury
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Spine injury is one of the most common skeletal injuries resulting from blunt trauma. Spinal cord
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injury is a devastating injury with a significant mortality risk, especially in older patients. For those pa-
30
tients who survive, paralysis from spinal cord injury is a costly, permanent disability. Newer aspects of
31
diagnosis and management of spine injury are discussed in this section of the overview.
3
1
Pelvic fracture
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Pelvic ring fracture is a reliable marker of heavy force transfer in blunt injury patients. A sub-
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group of patients with severe pelvic fracture will be at risk for life-threatening hemorrhage from arteries
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lacerated during the injury event. Because the production of pelvic fractures that result in hemorrhage
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requires heavy force transfer, these patients will often have multiple potential sources of bleeding and
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this fact has stimulated the development of protocols for the early identification of the bleeding points
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and aggressive efforts to achieve hemostasis. In this section of the overview we discuss articles that de-
8
scribe the current methods of diagnosis and management of pelvic fractures.
9
Genitourinary injury
10
Injuries to the kidney can result from blunt or penetrating mechanisms. For the patient requiring
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abdominal exploration for penetrating injury, there is often involvement of multiple intraperitoneal and
12
retroperitoneal structures. The decision to explore the injured kidney is based on assessment of the risk
13
of bleeding and urinary extravasation. It is now clear that many injuries can be managed without renal
14
exploration and, for those injuries that are explored, renal repair is often possible. Because surgeons
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now frequently employ techniques to minimize the risk of bleeding, nephrectomy from unexpected
16
hemorrhage has become unusual. Nephrectomy is necessary, for the most part, as a component of
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“damage control” in the patient with multiple injuries and massive blood loss. We review evidence clari-
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fying the bases of decisions to explore the injured kidney and approaches leading to successful renal
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injury management.
20
Ureteral injury is encountered almost exclusively in patients with penetrating injury. Articles dis-
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cussed in this section stress the need for thorough exploration of the ureter and direct repair of injuries.
22
Management of late-developing ureteral leak will be discussed.
23
In the closing section of the overview, bladder and urethral injuries are discussed. Direct repair
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is necessary for intraperitoneal bladder rupture. Extraperitoneal bladder lacerations can frequently be
25
managed with catheter drainage. Urethral injury is an important complication of pelvic fracture and suc-
26
cessful management of the urethral injury has important implications for urinary continence, sexual
27
function, and overall success of operations to permanently stabilize the pelvic fracture. Urethral injury is
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a threat to normal urinary function in females as well as males. Issues of diagnosis and management of
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urethral injuries are reviewed and the evidence supporting successful management approaches re-
30
viewed.
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1
Trauma systems and trauma centers
2
Recognition of the need for improved trauma care is a necessary first step toward the develop-
3
ment of trauma centers and, ultimately, a regional trauma system. Two articles have recently appeared
4
describing this process of recognition of need. The first is by Masella and coauthors1 in the Journal of
5
Trauma in 2008. The report is entitled “Temporal distribution of trauma deaths: quality of trauma care
6
in a developing country.” The authors note that trauma death statistics disclose that 5 million people
7
died, worldwide, from injuries in the year 2000 and 90% of the deaths occurred in low or middle income
8
countries. They go on to cite data from Brazil (their country) that have shown that trauma deaths tend
9
to cluster in young men and that the trauma death rate in Brazil is twofold higher than rates in North
10
America. They identify encouraging trends in their region including the development of a pre-hospital
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care system. These authors undertook study of 238 trauma deaths occurring at their hospital to attempt
12
to determine the temporal distribution of deaths and use these data to determine the level of trauma
13
care currently available in their region. They found that more than half the trauma deaths occurred in
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the pre-hospital setting. Older data from studies authored by Baker (reference 23 in their bibliography)
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and Trunkey (reference 24 in their bibliography) found similar rates of pre-hospital deaths in analyses of
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young trauma systems. These observations led to the time-honored description of the “trimodal” tem-
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poral distribution of deaths from injury.
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As trauma systems in North America have matured, data have accumulated to indicate that the
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maturation of a trauma system results in a change in this temporal distribution of deaths such that the
20
frequency of pre-hospital deaths declines. The authors note other factors that might influence the dis-
21
tribution of times of death, including the age of the population under study, the mechanisms of injury,
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and the body areas most severely injured. These authors confirmed that most pre-hospital deaths in
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their region resulted from penetrating injury mechanisms and the majority of in-hospital deaths resulted
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from blunt mechanisms. The penetrating injury deaths in the pre-hospital phase were largely from as-
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saults and suicide attempts. Although improvements in the level of function in the trauma system might
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not ameliorate the pre-hospital mortality, some improvements might occur. They were able to identify
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deficiencies in the availability of pre-hospital resources and the levels of training of pre-hospital person-
28
nel. There were similar resource availability issues as well as training deficiencies noted as contributing
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to the in-hospital deaths. Deficiencies in critical care training and resources were particularly glaring.
30
They conclude by listing changes occurring in their region that might improve trauma death rates includ-
31
ing education (ATLS courses), improved pre-hospital and in-hospital capabilities, engineering controls for
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traffic management, and improvements in law enforcement.
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1
The second article reviewed is by Eastridge and coauthors2 in the Journal of Trauma in 2006.
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They review trauma care in Iraq during Operations Iraqi Freedom and Enduring Freedom. This article is
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entitled “Trauma system development in a theater of war: experiences from Operation Iraqi Freedom
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and Operation Enduring Freedom.” The authors begin by noting that comparisons of injury death rates
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in previous wars such as the Vietnam conflict permit estimation of change that might have resulted from
6
improvements in prevention and injury care. They stress that the commitment to assess and change,
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where necessary, the combat injury care system in Iraq began with the assignment of a trauma medical
8
director and six trauma nurse coordinators to the combat theatre. These personnel were able to gather
9
data and assess areas of need. They learned that pre-deployment training and personal protective
10
equipment produced improvements in injury death rates. They also were able to identify areas for po-
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tential improvement that included pre-hospital care, appropriate delivery of patients to definitive care
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facilities, practice guidelines, and performance improvement programs driven by trauma registry data.
13
Among the improvements in battlefield care were the implementation of tourniquet use and
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the introduction of hemostatic dressings for control of ongoing bleeding. Improved command and con-
15
trol shortened the interval between injury and arrival at the definitive care site. Practice guidelines in-
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troduced to address the problem of temperature maintenance resulted in a decline in the frequency of
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hypothermia from 7% to less than 1%. Other improvements included the introduction of standard rec-
18
ord formats and standard approaches for antibiotic use. These factors allowed valid data collection that
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could then be used to improve trauma care and enhance pre-deployment training for trauma surgeons.
20
The military drew on the experience of civilian trauma systems to develop the major components of the
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combat injury management system. The trauma registry developed is now producing data driving in-
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theatre research efforts to further improve combat injury care.
23
From the perspective of the editor, these two articles provide confirmatory evidence that the
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design and implementation of a regional trauma system has to be driven by recognition of the im-
25
portance of injury as a public health problem, followed by gathering of valid data to confirm that im-
26
provement is possible. Attention to the facts that integration of pre-hospital, in-hospital, and post-
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hospital resources, personnel, and training required for optimal results are also necessary. In addition,
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valid data collection is essential for continued progress and optimal outcomes. The experience of civilian
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trauma systems has shown that these changes take time, advocacy by surgeons, and attention to politi-
30
cal realities. The benefits of trauma system implementation have become more and more clear. As the
31
discussion in the next section documents, outcomes of injury steadily improve with system maturation.
6
1
Because trauma systems are costly, financial support from government and participating
2
healthcare facilities is essential for trauma systems to survive. Trauma centers and trauma systems are
3
particularly vulnerable to forces shaping the healthcare system. Changes in practice characteristics for
4
several important specialties such as neurosurgery, orthopaedic surgery, ophthalmology, and hand sur-
5
gery have resulted in shortages of specialist coverage for trauma centers that have produced financial
6
stresses and threatened the existence of trauma systems in several states and regions of the United
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States. Funding sources such as federal and state governments have demanded evidence of trauma sys-
8
tem effectiveness. To date, studies of trauma system effectiveness have focused on mortality because
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patient death rates are easily discernable and can be recovered from trauma registries and various ad-
10
ministrative databases. Until 2006, studies of trauma system effectiveness used comparisons of mortali-
11
ty in regions with trauma systems to regions without trauma systems, and comparisons of contempo-
12
rary trauma system mortality rates with historical controls. A systematic review and meta-analysis of
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trauma system effects on mortality was reported in 2006 by Celso and coauthors3 in the Journal of
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Trauma. A -full-text reprint of this article is included in this issue of SRGS. The report is entitled “A sys-
15
tematic review and meta-analysis comparing outcomes of severely injured patients treated in trauma
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centers following the establishment of trauma systems.” Using standard meta-analysis techniques, the
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authors found 14 articles that presented sufficiently rigorous analyses. The requirements for inclusion in
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the meta-analysis were that the report be population based, be published in a peer-reviewed journal,
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use logistic regression analysis, and provide sufficient data to calculate an odds ratio. Eight of the 14 in-
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cluded articles showed a survival advantage for patients triaged to trauma centers after establishment
21
of a trauma system. The overall odds ratio favoring survival was 0.85, indicating a 15% improvement in
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mortality risk, on average, for patients treated in trauma centers. Celso and colleagues note that the
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data reported in this analysis show similar survival advantage to that reported at the Skamania confer-
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ence in 1999 (reference #40 in the bibliography).
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They go on to note that other analyses of trauma system effectiveness have cited the im-
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portance of integration of pre-hospital care and trauma center capability through effective medical con-
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trol and field triage that results in shortening of the interval between injury and definitive care. Im-
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provements in hospital capability are important contributors to lowered mortality risk (reference #44 in
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the bibliography). The authors also cite evidence (reference #35 in the bibliography) that trauma system
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maturation is also a determinant of improved mortality risk. Maturation intervals as long as 10 years
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might be necessary before the full impact of trauma system effectiveness is recognized. The issue of the
7
1
necessary time lapse before trauma center effectiveness is established is discussed in a subsequent sec-
2
tion of the overview.
3
Until 2006, there were very few studies that provided data comparing outcomes for patients
4
treated at trauma centers and nontrauma centers. Available studies did not use statistical techniques to
5
adjust for the systematic bias created because of triage of the most severely injured patients to trauma
6
centers; such triage being a desired outcome in mature trauma systems. This triage bias means that
7
trauma centers will likely have higher crude mortality rates for injuries treated because the most severe-
8
ly injured patients are directed to these centers. Two articles were published in 2006 that used two dif-
9
ferent methods for dealing with the triage bias. The first of these was authored by MacKenzie and coau-
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thors4 in the New England Journal of Medicine and is included as a full-text reprint in this issue of SRGS.
11
The report is entitled “A national evaluation of the effect of trauma-center care on mortality.” The au-
12
thors invited 68 trauma centers designated by government agencies or verified by the American College
13
of Surgeons as Level 1 trauma centers to participate in the study. They also invited 124 large nontrauma
14
centers to participate. Eighteen trauma centers and 51 nontrauma centers agreed to participate. Of in-
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terest is the fact that the nontrauma centers were usually smaller than the trauma centers and were less
16
likely to be teaching hospitals. Among the nontrauma centers, however, were 17 institutions with orga-
17
nized trauma teams and 8 of these had full-time trauma medical directors. Adult patients were drawn
18
from administrative discharge databases and confirmed in individual emergency department admission
19
logs. Exclusions included patients with severe burns, patients who did not suffer severe injury, and pa-
20
tients who died within 30 minutes of arrival. A total of more than 18,000 patients were identified. A
21
sample of 8021 surviving patients was compared with the full sample of 1438 patients who died. Medi-
22
cal records were reviewed for 1104 patients who died. Medical record review and telephone interview
23
data were gathered for surviving patients and patients were grouped according to injury severity and
24
age. The final survivor group consisted of 4866 patients; chosen endpoints included death in the hospital
25
and death within 1 year of discharge. Late deaths were ascertained through telephone interviews and
26
examination of the National Death Index. Comorbid conditions were assessed with standard comorbidi-
27
ty assessments and the specific conditions of obesity and coagulopathy were added. Injury severity was
28
assessed with the abbreviated injury scale and these determinations were made by trained nurse ab-
29
stractors.
30
31
To adjust for the systematic bias of triage of the most injured patients to trauma centers, the
propensity score method was used (reference #25 in MacKenzie’s bibliography). The authors noted that
8
1
patients treated in nontrauma centers were older; more often had health insurance, were more often
2
female, and had less severe injuries. As expected, the unadjusted mortality rate was higher in trauma
3
centers than in nontrauma centers. After risk adjustment, the survival advantage for patients treated at
4
trauma centers was more than 20% and this advantage persisted for a full year after discharge. The au-
5
thors note that limitations of their study make assignment of an accurate survival advantage difficult for
6
specific patient groups such as the elderly and children. The overall death rate for children was low and
7
this made statistical confirmation of a survival advantage challenging. Although there was a survival ad-
8
vantage for elderly patients treated at trauma centers, the overall number of such patients was small
9
and this caused a wide 95% confidence interval for these patients that casts doubt on the validity of this
10
11
observation.
The second study that compared outcomes of injured patients treated at trauma centers and
12
nontrauma centers is by Durham and associates,5 from the Annals of Surgery in 2006. The article is enti-
13
tled “Evaluation of a mature trauma system.” A full text reprint of this article is provided with the mailed
14
version of this issue of Selected Readings. The authors report on the results of a comprehensive assess-
15
ment of a trauma system serving one state. The Florida trauma system is administered by the Florida
16
Department of Health Division of Emergency Medical Services and was, at the time the study was com-
17
pleted, 23 years old. The authors note that their study was commissioned by the Governor of Florida to
18
determine whether triage of injured patients to Florida trauma centers conferred a survival advantage.
19
The authors address the difficulties conducting a comparison of outcomes of injury care conducted in
20
trauma centers and nontrauma centers. Data show that there is a “halo effect” that results from im-
21
provements in evacuation times and pre-hospital care (reference 12 in their bibliography). This halo ef-
22
fect produces improved outcomes in all hospitals after institution of a trauma system. They also cite da-
23
ta indicating that shortened response times, improved medical control, and aggressive airway manage-
24
ment by pre-hospital care personnel improves survival for patients triaged to trauma centers as well as
25
nontrauma centers. In this study, the authors assessed outcomes data from a statewide, hospital dis-
26
charge database. Risk adjustment was performed using the ICISS scoring methodology developed by
27
Rutledge and coauthors (reference #16 in their bibliography).
28
Survival risk ratios were determined for patients with discharge ICD-9 diagnosis codes in the
29
800-959 range. Patients were excluded if hospital stays were less than 12 hours, if they were transferred
30
after receiving care in another hospital, if they did not suffer an acute injury, if the patient was over age
31
65 and had a single hip fracture, or if the patient sustained an injury associated with a zero mortality risk
9
1
for the previous 5 years of available data. The authors sought data on mortality and long-term out-
2
comes. Surveys of patients contacted 1-2 years after discharge were done to establish health status and
3
employment. Referral bias was dealt with using the instrumental variables technique, a statistical meth-
4
odology commonly used in economics research. The data disclosed that patients triaged to trauma cen-
5
ters were, as a group, younger, and more severely injured. Patients triaged to trauma centers were
6
more likely to be admitted to an intensive care unit and underwent more procedures compared with
7
patients triaged to nontrauma centers. Hospital charges were higher for patients treated at trauma cen-
8
ters. From their data, these authors concluded that there was a survival advantage of 18% for injured
9
patients triaged to Florida trauma centers after suffering a severe injury. From their survey data, the
10
authors confirmed that 2 years after an injury event, 42% of patients treated in Florida trauma centers
11
had returned to at least part-time employment. Each Florida trauma center sustained an unrecoverable
12
annual cost of nearly $3 million as a result of being a state-designated trauma center. Examination of
13
data relevant to outcomes in specific subgroups of patients (elderly and children) indicated that the data
14
were not robust enough to confirm outcomes advantages in children. There was suggestion from the
15
data, that there was preferential triage of elderly patients to nontrauma centers and that outcomes
16
were worse when this occurred. There was not, however, sufficient statistical power to confirm this sug-
17
gestion.
18
Other data have questioned whether elderly patients are adequately served by existing trauma
19
systems. Under triage of elderly patients within designated trauma centers is the focus of an analysis
20
authored by Lehmann and coauthors6 which appeared in the American Journal of Surgery in 2009. The
21
article is entitled “The impact of advanced age on trauma triage decisions and outcomes: a statewide
22
analysis.” These authors used data from the Washington State Trauma Registry and compared several
23
variables related to the efficiency and effectiveness of trauma triage decisions in two groups of patients.
24
One group consisted of patients older than 65 years and the other group was patients younger than 65
25
years. The authors found, as have other investigators, that brain injury with intracranial hemorrhage and
26
fractures are common features of the older age group and this patten, combined with diminished physi-
27
ologic reserve and multiple comorbid conditions characterizes the elderly subgroup. The authors found
28
that elderly patients were less likely to be managed using trauma protocols in the prehospital phase of
29
care. Also, this group was less likely to have full trauma team activation on arrival at the trauma center.
30
Evaluation of prehospital data disclosed that elderly patients were less likely to be hypotensive or tachy-
31
cardic despite severe injury. Whether the lack of signs of shock contributed to under triage of the older
32
patients is a question unanswered by the available data. These two findings were consistent and oc-
10
1
curred in spite of the fact that there was no difference in overall injury severity when the older patients
2
were compared to the younger patients. The complication rate during the initial hospital stay was higher
3
for the elderly patients. The elderly patients who were under triaged had higher mortality rates, were
4
more likely to have Glasgow coma scores <15 at discharge and were less likely to be discharged home
5
when compared to the younger patients as an entire group. This difference persisted when the older
6
patient group was compared to younger patients who were also under triaged. The data from this analy-
7
sis were presented to the annual meeting of the North Pacific Surgical Association. During the discussion
8
that followed the presentation, information from other state trauma systems was offered. Of potential
9
value was the report by one discussant of development of “discretionary” trauma criteria for use by
10
prehospital care providers as a means of identifying potentially severe injuries in patients where stand-
11
ard triage criteria might be undependable. Within the discretionary criteria is age > 55 years. There is,
12
therefore, increasing recognition that older patients may harbor severe injury without displaying the
13
typical prehospital physiologic abnormalities. While refinement of prehospital triage criteria is a valuable
14
effort, attention also needs to be paid to trends identified in other analyses that suggest preferential
15
triage of injured elderly patients to non-trauma centers.
16
Returning to the report by Durham and colleagues5, data analysis disclosed that access to Flori-
17
da trauma centers varied in different geographic regions in Florida. Data from the comprehensive as-
18
sessment document confirmed a worsening motor vehicle crash fatality rate in regions remote from
19
trauma centers (reference #7 in their bibliography). Because of this and because of large areas of the
20
state without trauma centers, these authors made recommendations for improved deployment of
21
trauma centers in Florida.
22
Finally, the cost/life year saved in the Florida trauma system compared favorably with other
23
health interventions such as care of end stage renal disease patients and patients with heart disease.
24
The data were presented to the annual meeting of the Southern Surgical Association in December 2005.
25
In the discussion following the presentation; discussants raised concerns about the accuracy of adminis-
26
trative data. There were also concerns raised about the mechanisms for ensuring adequate financial
27
support for developing trauma centers in underserved areas of Florida.
28
Evaluations of trauma systems have sought to determine which component of the system im-
29
pacts outcomes most. This topic is dealt with in an article by Liberman and coauthors,7 in Surgery, 2005,
30
entitled “The association between trauma system and trauma center components and outcome in a ma-
31
ture regionalized trauma system.” The authors surveyed trauma medical directors in 59 trauma centers
11
1
in the province of Quebec in Canada. They then queried a provincial trauma patient database and ob-
2
tained outcomes data on more than 73,000 patients. After risk adjustment, logistic regression analysis
3
was used and identified trauma system components and trauma center components associated with
4
improved survivals. These authors noted that pre-hospital notification and the presence of a perfor-
5
mance improvement program were independently associated with improved survival. They also ob-
6
served better mortality outcomes in tertiary (equivalent to US Level 1) trauma centers compared to re-
7
sults in primary and secondary centers (equivalent to US Level 3 and 2, respectively). Finally, high-
8
volume centers demonstrated improved mortality outcomes compared with low-volume centers. The
9
authors stress that the volume-outcomes relationship for trauma centers has been controversial; some
10
studies confirm the relationship but others did not observe an association between volume and out-
11
comes.
12
Elderly patients and children comprise two particularly vulnerable injury groups. Data confirm-
13
ing that these groups are adequately served by trauma systems and trauma centers are scarce. Whether
14
a trauma system confers a survival advantage for injured children has been difficult to confirm largely
15
because trauma related mortality for children is low and documenting a significant difference in survival
16
is, therefore, difficult. This topic is dealt with in an article by Pracht and coauthors8 in the Journal of Pe-
17
diatric Surgery, 2008. The article is entitled “Do pediatric patients with trauma in Florida have reduced
18
mortality rates when treated in designated trauma centers?” These authors used a large sample of in-
19
jured children from a statewide administrative database.
20
More than 27,000 injured children had risk stratification done using the ICISS method (referred
21
to above) and outcomes of patients treated in trauma centers were compared with outcomes of pa-
22
tients treated in nontrauma centers. There was an overall survival advantage of 3.15% for patients aged
23
0-19 triaged to designated trauma centers. For children aged 0-15 years, no statistically significant sur-
24
vival advantage could be demonstrated. Statistical significance was achieved when patients aged 15-19
25
were added to the younger patient group. Assessing an advantage in terms of mortality alone might un-
26
derestimate the true long-term effects of treatment of injured children at designated trauma centers
27
having pediatric capability. They stress those long-term outcomes studies will be necessary to determine
28
the full range of outcomes benefits for injured children.
29
Another important question about the effects of trauma system implementation is concerned
30
with the time interval necessary to achieve the observed mortality benefit after establishment of a
31
trauma center. This question is dealt with in another article by Pracht and coauthors9 in Surgery, 2006.
12
1
The article is entitled “Analysis of trends in the Florida trauma system (1991-2003): changes in mortality
2
after establishment of new centers.” The article analyzed data from a large administrative database and
3
grouped injured patients by age. Logistic regression analysis was performed to determine changes in
4
outcomes for patients treated at trauma centers during the first three years after trauma center desig-
5
nation. The authors found that improved mortality risk for adults and children treated at trauma centers
6
was realized in the third year after designation. The data presented in this report confirmed the sugges-
7
tive trend identified in the study authored by Durham and coauthors (discussed previously) that hospi-
8
talization rates and mortality rates for elderly injured patients increased over the interval of this study.
9
From the perspective of the editor, it is now clear that trauma system implementation achieves
10
a survival advantage for injured patients. This occurs because of improved pre-hospital care, improved
11
outcomes of care in trauma centers, and overall improvement of results in all hospitals treating emer-
12
gent conditions within the region served by the trauma system. The benefit comes with significant cost.
13
There are “sunken” costs (costs which are incurred whether or not patient care is delivered) to hospitals
14
that become trauma centers that cannot be recovered from patients. Legislative bodies have not con-
15
sistently recognized the need for durable funding of trauma systems and this inconsistency continues to
16
endanger regional systems. It is clear that the data gathered into national and regional trauma data-
17
bases are useful for documenting results and charting future efforts at performance improvement.
18
These issues, relevant to the trauma system and the individual trauma centers, are discussed in the next
19
two sections of the overview.
20
An example of the use of trauma system data to implement a regional performance improve-
21
ment effort is the topic of the next two articles discussed. The first article identifies a problem and the
22
second describes a data-driven regional performance improvement program. The first article is by Styl-
23
ianos and coauthors10 in the Journal of the American College of Surgeons, 2006, entitled “Variation in
24
treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemina-
25
tion of American Pediatric Surgical Association benchmarks and guidelines.” The authors analyzed data
26
from four state hospital discharge databases and identified more than 3000 patients who sustained
27
spleen injury alone or spleen injury in combination with other injuries. Patients with traumatic brain in-
28
jury were excluded. The authors sought to determine whether splenectomy rates were consistent with
29
guidelines promulgated by the American Pediatric Surgical Association (APSA recommends that splenec-
30
tomy rates should range between 5-11% in the setting of multiple injuries and from 0-3% for isolated
31
injuries). The data analyzed disclosed that trauma centers had lower rates of splenectomy for spleen
13
1
injuries in the multiple injury patient compared with nontrauma centers (15.3% vs 19.3%) and this dif-
2
ference persisted when patients with isolated spleen injury were analyzed (9.2% vs 18.5%). The authors
3
point out that the splenectomy rates for trauma centers and nontrauma centers are higher than the
4
rates recommended by APSA. They discovered that independent risk factors for splenectomy included
5
multiple injury, spleen injury severity, and older age (15-19 years). The authors noted that triage of in-
6
jured children to trauma centers is increasing within regional trauma systems. They recommend that
7
dissemination and discussion of the APSA guidelines to trauma surgeons in these centers could decrease
8
the splenectomy rate in injured children.
9
A regional quality improvement strategy directed at lowering the splenectomy rate among in-
10
jured children through dissemination of the APSA guidelines and acceptance of these guidelines by the
11
trauma surgeon community is the topic of an article by Bowman and coauthors11 in the Journal of Trau-
12
ma, 2008. The article is entitled “Impact of a statewide quality improvement initiative in improving the
13
management of pediatric spleen injury in Washington State.” Data were gathered confirming that sple-
14
nectomy rates in Washington trauma centers exceeded the APSA recommended rates. Splenectomy
15
rates were lower in pediatric trauma centers than in general trauma centers. The authors presented the
16
data they had gathered to statewide trauma system control committees and trauma medical directors
17
agreed to undertake education of trauma surgeons and trauma center medical staff members in an ef-
18
fort to improve splenectomy rates.
19
There was, in addition, a commitment to maintain records of pediatric splenectomy rates and
20
this information was made a required dataset for submission at the time of trauma center re-
21
designation. A post-intervention study was then performed and the data from that study are presented
22
in this report. In the post-intervention study the authors observed a significant decline in splenectomy
23
rates across the entire trauma system. In addition, they observed an increase in the number of injured
24
children triaged to pediatric trauma centers in the post-intervention period.
25
A significant difference in splenectomy rates remained when pediatric trauma centers were
26
compared with general trauma centers in the post-intervention study. The authors concluded that their
27
data confirm the value of education to change trauma surgeon practice. They noted the importance of
28
seeking data to confirm behavioral change and they stress the importance of the trauma system as an
29
environment where quality improvement can be documented.
14
1
Designated trauma centers enable trauma systems to produce improved outcomes so that ef-
2
fective secondary and tertiary prevention of trauma morbidity and mortality can occur. In this discus-
3
sion, we focus on characteristics of trauma centers that lead to improved outcomes. When a hospital
4
makes the commitment to establish a trauma team and to put in place the organizational components
5
leading to trauma center designation, improved outcomes occur. This topic is dealt with in an article
6
authored by Cornwell and coauthors12 in Archives of Surgery, 2003. The authors analyzed data from an
7
institutional trauma registry for two three-year intervals before and after the implementation of a for-
8
mally organized trauma clinical service. Process measures analyzed included time from arrival to transfer
9
out of the emergency treatment area. Outcomes measures included overall mortality and length of stay.
10
The authors observed significant reductions in time spent by injured patients in the emergency depart-
11
ment and in the observation area. There was a trend toward decreased overall mortality and head injury
12
mortality but these did not reach statistical significance. After risk adjustment, logistic regression analy-
13
sis disclosed a significant reduction in the risk of death in the post-intervention period. Their organiza-
14
tional plan included 24/7 in-house coverage by trauma attendings. They cite several reports supporting
15
the positive effects on processes and outcomes associated with in-house attending coverage. They also
16
note that there are at least two reports that identified no relationship between in-house attending cov-
17
erage and improved trauma mortality. A report by Durham and coauthors13 documented a significant
18
reduction in preventable and potentially preventable mortality and morbidity after implementation of
19
in-house attending coverage in a Level 1 trauma center.
20
The trauma center designation process requires that trauma centers comply with certain struc-
21
tural, organizational, and process requirements. Within most trauma systems in the United States, des-
22
ignation requirements draw on the principles established by the trauma center consultation and verifi-
23
cation program of the Committee on Trauma of the American College of Surgeons. This program assess-
24
es the structures and processes that can be established in trauma centers to facilitate optimal out-
25
comes. Requirements for verification are contained in the document entitled Optimal Resources for the
26
Care of the Injured published by the American College of Surgeons.
27
A relevant question about trauma center designation/verification is: do trauma center designa-
28
tion levels and the subsequent increase in trauma case load at the designated centers result in improved
29
trauma outcomes? This topic is addressed in an article by Demetriades and coauthors14 in Annals of Sur-
30
gery, 2005, entitled “The effect of trauma center designation and trauma volume on outcome in specific
31
severe injuries.” These authors analyzed data from the National Trauma Data Bank and selected patients
15
1
who sustained severe injuries to the heart, major vessels, liver, and spinal cord. In this study, the au-
2
thors assessed in-hospital mortality and level of disability at discharge.
3
They found that designated/verified Level 1 trauma centers consistently demonstrated lower
4
mortality rates and discharge disability rates overall. Subgroup analysis showed that this difference was
5
most pronounced for patients with cardiac, major vascular and liver injuries. These authors were not
6
able to show a relationship of trauma center patient volume to outcomes. In the discussion section of
7
their report, they review several articles that examine the volume/ outcomes relationship for trauma
8
centers. They note that available studies are nearly equally divided between those confirming a vol-
9
ume/outcomes relationship and those that did not. Demetriades and coauthors suggest that the volume
10
outcomes relationship may be most important in subgroups of patients at particularly high risk for mor-
11
tality and/or complications. In support of this assertion they cite an article (reference #17 in their bibli-
12
ography) that showed a volume outcomes relationship for elderly patients but not for all patient groups.
13
Additional data supporting a volume outcomes relationship for certain high-risk groups of pa-
14
tients is the topic of an article by Nathens and coauthors15 in the Journal of the American Medical Asso-
15
ciation, 2001. The authors analyzed data submitted by 31 academic Level 1 and 2 trauma centers that
16
participated in the University Healthsystem Consortium Trauma Benchmarking Study. Outcomes were
17
analyzed in 478 patients with penetrating abdominal trauma and 541 patients with multisystem blunt
18
trauma. A volume outcomes relationship was evident for patients sustaining penetrating abdominal
19
trauma who arrived at the hospital in shock. Patients arriving in shock at a high volume center had sig-
20
nificantly lower overall mortality rates. Similarly, a volume/outcomes relationship was demonstrated
21
showing better mortality rates for patients sustaining multiple blunt injuries with coma. Patients not in
22
shock or with no diagnosis of coma showed no relationship of outcomes to trauma center volume.
23
The authors were able to show that outcomes began to improve for these high-risk groups when
24
trauma center annual admissions surpassed 650 patients. In the discussion of the article, they make the
25
interesting observation that the trauma centers with moderate volume had the best overall mortality
26
outcomes. They raise the question that very high volume centers may not consistently have good out-
27
comes because resources are overwhelmed by large volumes of patients with non-life-threatening inju-
28
ries. In fact, the improvements in outcomes for complex elective operations with progressive increases
29
in volume occur in ever smaller increments as volume increases. It is entirely possible that this same
30
phenomenon is occurring at trauma centers and that at some level of volume, stress on the institutional
16
1
resources will result in decrements of outcomes with additional increases in volume. This fact, if con-
2
firmed, has important implications for trauma system planners.
3
In the final article considered in this section of the overview, Glance and coauthors16 describe an
4
analysis of data from the National Trauma Data Bank. They performed their study focusing on adult pa-
5
tients with injury severity scores greater than 15 (this injury severity score is generally accepted as the
6
score dividing severely injured patients who have higher scores from less severely injured patients with
7
lower scores). These authors emphasize that research that analyzes trauma patient outcomes and re-
8
lates these to trauma center volume has shown inconsistent results. They provide a clear and valuable
9
critique of the studies that have shown a volume/outcomes relationship and they stress that methodo-
10
logic shortcomings in these studies prevent a clear cut conclusion that a volume/outcomes relationship
11
exists for any of these.
12
It seems likely, that at some level of volume, there is benefit realized for selected high-risk pa-
13
tient groups but that a clear volume outcomes relationship cannot be reliably demonstrated for all pa-
14
tient groups. The bothersome possibility that incremental improvements in outcomes for high-risk pa-
15
tients progressively decrease as volumes increase requires confirmation. It is reasonable to expect that
16
some level of volume will stress the institutional resources, and past this point outcomes will deterio-
17
rate. Consistent data acquisition and careful analysis is required to establish the presence and magni-
18
tude of this risk.
19
The processes of monitoring trauma center quality and using the data gathered to facilitate
20
trauma center performance improvement are believed to be major drivers of improved outcomes. For
21
quality assessment and performance improvement to be successful, valid measures of quality and de-
22
pendable data are essential. In the two sections that complete this section of the overview we will dis-
23
cuss methods of assessing quality, defining complications, identifying correctable deficiencies, and mak-
24
ing certain that trauma registry data are accurate and valid. The success of the trauma registry and the
25
trauma quality improvement program within a designated trauma center are valid measures of institu-
26
tional commitment to trauma care. Unless the institution is willing to allocate personnel and technologic
27
resources to this effort, quality assessment and performance improvement efforts will fail. This fact is
28
the basis for inclusion of a requirement for documentation of the success of quality assessment and per-
29
formance improvement programs at the time of re-designation and/or re-verification of the center.
17
1
Quantification of trauma center quality requires valid and reproducible quality measures. This
2
topic is addressed in the first article reviewed in this section. This report is by Glance and coauthors17 in
3
the Journal of Trauma, 2004. The authors analyzed patient data from the National Trauma Databank for
4
the year 1999; patients who sustained brain or spinal cord injury were excluded. The authors measured
5
trauma center quality using two models. The first was TRISS (injury severity score, revised trauma score,
6
and age). The second model combined mortality with functional status at discharge. Functional status at
7
discharge was assessed using the FIMMTOS (the functional independence measure adapted for the Na-
8
tional Trauma Databank). The functional status at discharge is a required entry for patient records
9
placed in the National Trauma Data Bank. In this report, the hypothesis was that hospitals would not
10
11
only seek to maximize survival but also to maximize functional status.
The stimulus for broadening the scope of analysis of optimal health outcomes to include func-
12
tional outcomes is in line with recent initiatives from the Institute of Medicine. Using this conceptual
13
approach, it is reasonable to expect that trauma centers successful at maximizing both survival and
14
functional status at discharge would be more likely to be high-quality outliers. The report points out the
15
fact that survival and good functional outcomes may not be correlated for a single trauma center be-
16
cause aggressive efforts to achieve maximal survival might result in a patient group where functional
17
status is suboptimal. The authors used logistic regression statistical techniques to compare survival out-
18
comes using TRISS as the survival predictor. They then combined probability of survival with probability
19
of good functional status to produce a second model for comparing trauma center performance.
20
The results of this analysis showed no good agreement between quality assessment using mor-
21
tality and the combination of mortality and functional outcomes. In the discussion section of this article,
22
the authors emphasize certain limitations of the study, including functional status measured at dis-
23
charge resulting in isolated data points that do not measure functional status over time. Another limita-
24
tion is that the TRISS outcome predictor variable was developed using data that are now nearly 20 years
25
old. Changing outcomes of injury could well have made this outcome predictor unreliable. Furthermore,
26
functional status may not be the best variable to determine trauma center performance. They cite stud-
27
ies that have looked at quality of surgical and medical care for various conditions (references #38-40 in
28
their bibliography). The results of these studies suggest that measuring complications rather than mor-
29
tality might be a superior method for judging hospital quality. Finally, the authors note that mortality
30
and functional outcomes may well reflect two different and, possibly, separate aspects of trauma center
18
1
performance. They conclude by noting that outcomes measures should be carefully chosen using high-
2
quality research approaches to ensure that valid quantification of hospital performance can occur.
3
Another article from the same group of investigators evaluates severity adjustment models for
4
determining trauma center quality. The article, by Glance and coauthors,18 in the Journal of Trauma,
5
2005, is entitled, “Evaluating trauma center quality: does the choice of the severity-adjustment model
6
make a difference?” The authors analyzed data from the National Trauma Data Bank and used two older
7
severity adjustment models (TRISS and ASCOT) to identify high and low-quality hospitals using the ob-
8
served/expected mortality ratio. This approach is similar to that used in national hospital quality as-
9
sessment initiatives such as the National Surgical Quality Improvement Program (NSQIP).
10
The hypothesis of this study was that the two trauma severity models would largely agree, and
11
there would be consistent identification of high and low-quality outlier hospitals. More than 91,000 pa-
12
tients were included in this study. The authors found that ASCOT and TRISS failed to agree on more than
13
half of the hospitals analyzed, and that both models consistently over-identified hospitals as high-quality
14
outliers. Over-identification of high-quality outliers probably occurred, according to the investigators,
15
because both of the models consistently overestimated the probability of mortality. Overestimation of
16
mortality risk resulted because both of these predictive models are more than 15 years old. Because
17
trauma outcomes have improved over time, mortality risk estimation has changed. The authors recom-
18
mend development of new mortality risk prediction models that would accurately identify only a few
19
high-quality outlier hospitals. This identification would improve the potential for identifying best prac-
20
tices in high-quality hospitals that could be exported to other institutions for quality improvement pur-
21
poses.
22
The success of the National Surgical Quality Improvement Project (NSQIP) in achieving improved
23
mortality rates within surgical services of the Veteran’s Administration Health System has stimulated
24
efforts to use similar risk-adjusted mortality predictions and comparisons of expected to observed mor-
25
talities as a measure of trauma center quality. This issue is addressed in an article by Shafi and coau-
26
thors19 in the Journal of Trauma in 2008. In this report, the authors queried the National Trauma Data-
27
bank and identified more than 264,000 adult patients treated at Level 1 trauma centers. They utilized
28
multivariate logistical regression analysis and adjusted risk of death using several variables, including
29
age, gender, race, injury mechanism, transfer status, and injury severity. Injury severity was assessed
30
using the injury severity score, Glasgow coma score, and initial systolic blood pressure. Patients were
31
further analyzed to identify injuries to head, chest and/or abdomen.
19
1
After risk adjustment, expected mortality was calculated and compared to observed mortality in
2
each trauma center. The ratio of observed to expected mortality with 95% confidence limits was calcu-
3
lated for each of 58 trauma centers. Each included center had annual patient volumes of more than
4
1000 admissions. Most of the trauma centers were public teaching hospitals representing diverse geo-
5
graphic regions. Observed/expected ratios of 1.0 were considered average performing centers and cen-
6
ters were included in this group if the 95% confidence limits overlapped 1.0. Centers with ratios less
7
than 1.0 were considered high-quality outliers and ratios of greater than 1.0 identified low-quality outli-
8
ers.
9
Fourteen of the centers were considered high-quality outliers and eleven were low-quality out-
10
liers. Institutional quality is determined by two components; one is determined by case mix and the oth-
11
er by quality of patient care. The risk-adjustment method used in this study is designed to illuminate the
12
patient care quality component of trauma center performance. The authors concluded that their data
13
indicate that risk-adjusted outcomes were worthy of inclusion in the trauma center designa-
14
tion/verification process. They note that the traditional approach to designation/verification focused on
15
features of structure and process. Outcomes were evaluated only with the identification of rates of pre-
16
ventable death. These authors recommend that assessment of risk-adjusted mortality and morbidity
17
should be included in the trauma center evaluation process.
18
As mentioned above, outcomes assessments within trauma centers have focused on preventa-
19
ble deaths. Two articles discussed now indicate that preventable death continues to be a problem in
20
trauma centers, including those with superior overall mortality statistics. The first article by Teixeira and
21
coauthors20 in the Journal of Trauma, 2007, is entitled “Preventable or potentially preventable mortality
22
at a mature trauma center.” The authors retrospectively reviewed experiences in a single trauma center
23
over an 8-year interval. They identified 2081 deaths among 35,311 admissions for an overall mortality
24
rate of 5.9%. Fifty-one deaths were classified as preventable or potentially preventable after multidisci-
25
plinary, multi-level review. The preventable or potentially preventable mortality rate was 0.1%. These
26
deaths comprised 2.5% of the patients who died.
27
The authors identified the most common causes of death and these included bleeding, multiple
28
organ failure, and airway compromise. Delay in treatment, clinical judgment errors, missed diagnosis,
29
and technical error accounted for the majority of correctable deficiencies in management. More than
30
half the deaths occurred during the first 24 hours of hospitalization but nearly ⅓ occurred more than 7
31
days after admission; 55% of the deaths occurred in the intensive care unit and 26% occurred in the op-
20
1
erating room. The authors identified one pervasive system error that contributed to several of the
2
deaths and this was a faulty mechanism for trauma team activation. They stress, however, that most of
3
the deaths were from human error.
4
The second article by Ivatury and coauthors21 appeared in the Journal of Trauma, 2008. The arti-
5
cle is entitled “Patient safety in trauma: maximal impact management errors at a level 1 trauma center.”
6
These authors conducted a retrospective analysis of potentially preventable deaths in their trauma cen-
7
ter using The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) taxonomy for root
8
cause analysis. They found that 9.9% of 764 deaths had contributory management errors. Although the
9
overall death rate at their center remained below 5% for the entire 5-year interval of this study, pre-
10
ventable death rate frequency remained stable at 10-15 deaths annually. Human error predominated in
11
preventable deaths and the deaths occurred, for the most part, as a result of errors of diagnosis, delays
12
in diagnosis, and suboptimal decisions about resuscitation.
13
These two reports highlight a current trend in quality research, which is to identify “failure to
14
rescue” as a quality indicator that may differentiate high-quality from low-quality institutions. Failure to
15
rescue represents, in general, a constellation of human errors characterized by failure to recognize and
16
failure to act on signs of developing complications of disease or treatment. Some institutions have re-
17
acted to this problem by forming “emergency response teams” that are in-hospital groups of profes-
18
sionals especially trained to detect and manage emerging complications. Trauma services, by virtue of a
19
tradition of rapid response to life-threatening conditions, should be well suited to provide effective
20
emergency response to critically injured patients. The traditions, within trauma centers, which stress
21
active surveillance, education, and development of cultural characteristics which facilitate active discus-
22
sion of clinical outcomes and rapid response to negative trends should create an environment wherein
23
“failure to rescue” events can be minimized.
24
Most quality research dealing with preventable death has occurred within Level 1 trauma cen-
25
ters and the authors of both of these reports admit that they have no information about the potential
26
frequency or severity of preventable complications and deaths in Level 2 and Level 3 centers. Because
27
most preventable death research has been done in Level 1 centers, and because most Level 1 trauma
28
centers are teaching hospitals, there is inevitable turnover in trauma team personnel because most
29
trauma team members are residents in training. This may offer a partial explanation for the lack of pro-
30
gressive reduction in the frequency of preventable death over time.
21
1
Successful quality improvement requires valid and accurate data on which to base performance
2
improvement measures. Often, trauma centers use their own trauma registries as well as national trau-
3
ma registries and administrative databases to identify risk-adjusted populations to use as standards for
4
performance improvement. There has been consistent skepticism regarding use of administrative data
5
for performance improvement because of inconsistencies in data entry and because motivation for
6
gathering administrative data is most often to maximize reimbursement and not for identifying trends
7
on mortality and morbidity. An article illustrating this problem is presented by Steinberg and coauthors22
8
and appeared in Surgery in 2008. The article is entitled “Comparison of risk adjustment methodologies
9
in surgical quality improvement.” A full text reprint of this article is included with the mailed version of
10
11
this issue of Selected Readings.
The authors report data from their hospital (which, participates in the quality improvement pro-
12
gram of the University Hospitals Consortium as well as NSQIP of the American College of Surgeons).
13
They matched 120 consecutive patient records submitted to the consortium and, also, evaluated by the
14
trained nurse record abstractors of the NSQIP program. Comorbid conditions such as diabetes, hyper-
15
tension, cardiac disease, and pulmonary disease were reported significantly more often in the consorti-
16
um data compared with NSQIP data. The NSQIP review identified more than twice as many complica-
17
tions than did the consortium data. With regard to the specific complication of surgical site infection,
18
NSQIP identified these in 13% of the patients; the consortium data identified a surgical site infection in
19
only 1% of patients. The authors stress that the increased frequency of complication identification in the
20
NSQIP data probably results from the program using standardized definitions for complications and
21
trained nurse chart reviewers. Because improvements in outcomes have been documented in hospitals
22
participating in NSQIP, these authors recommend that the NSQIP approach be used to assess risk-
23
adjusted outcomes of surgical practice.
24
Although there is reason to recommend the use of the NSQIP approach in elective surgical prac-
25
tice and in trauma centers, this approach is limited because a minority of hospitals participate in NSQIP
26
(perhaps because of the cost of participation in this program) and a standardized approach to risk-
27
adjusted outcomes reporting has not been developed for trauma centers. A challenge remains, there-
28
fore, to develop a way to analyze administrative databases and detect important complications of care
29
in these databases. This topic is dealt with in the final article reviewed; the article authored by Fry and
30
coauthors23 in the American Journal of Surgery, 2009. A full text reprint of this report is included in the
31
mailed version of this issue of Selected Readings., 2009. The authors begin by noting that there is a need
22
1
to move beyond the focus on mortality to be able to analyze surgical outcomes in more detail. They fur-
2
ther note that accurately identifying surgical complications has been challenging because of inconsisten-
3
cies in the definitions of complications and because a definitive diagnosis of a complication often is not
4
available until after a patient leaves the hospital. Levels of surveillance for complications vary from hos-
5
pital to hospital.
6
The authors note that efforts such as the NSQIP program are producing risk-adjusted outcomes
7
data but at a significant cost. Some of the complication data reported in NSQIP may, also, have limited
8
clinical relevance. For these reasons, the authors sought to determine if an alternative means of identi-
9
fying complications could be developed to permit use of administrative databases. The authors hypoth-
10
esized that prolonged risk-adjusted postoperative length of stay could be an accurate indicator of post-
11
operative complications. They further hypothesized that coded postoperative complications that did not
12
result in prolonged risk-adjusted length of stay had limited impact on hospital cost and had, therefore,
13
limited clinical and resource consumption impact.
14
They used administrative data to calculate the minimum postoperative length of stay for pa-
15
tients who were free of complications and then analyzed the records of patients with longer than ex-
16
pected lengths of stay to determine whether complications were identified and coded. The data pre-
17
sented indicate that prolonged postoperative risk-adjusted length of stay is a sensitive indicator of in-
18
creased resource consumption and may be a more relevant means of identifying outliers in terms of
19
postoperative complications from administrative data. This method holds out the possibility of being
20
able to identify complications without on-site, nurse-directed chart review. More research is needed to
21
confirm these observations and to identify whether a similar phenomenon is identifiable in trauma cen-
22
ters.
23
Trauma surgeons typically rely on local, regional, and national trauma registries to provide the
24
data that drives quality improvement. Because of this, accuracy and validity of the data are critical. In a
25
previous discussion we noted that accuracy and validity of the data in a trauma center’s registry is a di-
26
rect indicator of institutional commitment to the trauma center. Provision of resources for valid data
27
entry and analysis is a critical component leading to successful quality improvement. The next three arti-
28
cles reviewed deal with the important topic of data accuracy and validity within trauma databases. The
29
first article by Hemmila and coauthors24 in Surgery, 2007, is entitled “Detecting the blind spot: complica-
30
tions in the trauma registry and trauma quality improvement.” This article is supplied as a full-text re-
31
print in this issue of SRGS.
23
1
These authors used data from their Level 1 trauma center gathered using the NSQIP chart re-
2
view method with similar data gathered from general surgery patients in their institution. They then
3
compared the mortality rates and rates of various complications discovered in their patients with com-
4
plications recorded in the National Trauma Data Bank for adult patients treated in Level 1 trauma cen-
5
ters. Overall mortality rates for adult injured patients were higher based on their local data than for data
6
in the National Trauma Data Bank. When their patients were risk-adjusted, however, the observed mor-
7
tality rate was lower than that noted in the national database. Of most concern, from these data, were
8
the observations that the complications identified in their patients using NSQIP data-gathering tech-
9
niques were far more frequent than the complications reported in the national database.
10
From their analysis, they concluded that there is a distinct possibility that morbidity is grossly
11
underreported in the National Trauma Data Bank. Given the fact, as mentioned previously, that accurate
12
reporting of complications requires significant resources, it would not be surprising to learn that compli-
13
cations are underreported in the national databank. This fact should stimulate additional efforts to find
14
ways to accurately detect complications in administrative datasets as suggested by Fry and coauthors23
15
in the article discussed above.
16
Establishing the frequency of data entry errors in trauma registries is a key element necessary to
17
establish means to correct data and improve potential for quality improvement. This topic is dealt with
18
in an article by Hlaing and coauthors25 in the Journal of Trauma, 2006. These authors used cross-
19
validation techniques to detect and characterize data entry errors in their institutional trauma registry.
20
They found that easily obtainable and verifiable variables such as demographics, scene time, transport
21
characteristics, and hospital discharge were associated with error rates of 3%. Detection of specific inju-
22
ry types (aortic injury) were more often subject to errors and the rate approached 10%. Documentation
23
of Glasgow Coma Score was associated with an error rate that exceeded 50%. These authors note the
24
importance of reliable data as a means of accurately determining violations of certain audit filters, for
25
example, discrepancies in scene time for evacuations using ground and air transport. Air transport scene
26
times were longer. When these data were validated, it became obvious that lack of a satisfactory land-
27
ing site was the most common cause of prolonged scene times and not shortcomings in scene care pro-
28
tocols. The authors conclude that the reliance on trauma registry data for trauma care research increas-
29
es the importance of data validation.
30
31
The final article discussed deals with the problem of accurate case ascertainment in trauma registries. The article by Gomez and coauthors26 appeared in the Journal of Trauma, 2009, entitled “The
24
1
missing dead: the problem of case ascertainment in the assessment of trauma center performance.”
2
These authors examined the question of whether failure to apply a uniform definition of “dead on arri-
3
val” changed the ascertainment of trauma deaths and led to lower risk-adjusted mortality rates for cen-
4
ters; this might be unrelated to the quality of patient care. They identified centers with lower than ex-
5
pected early death rates and identified that nearly 47% of actual deaths were not identified because of a
6
non-uniform definition of “dead on arrival.” They then hypothesized that the ratio of early to late deaths
7
could provide a statistic that would reflect, more reliably, the trauma-care-related mortality rates and
8
provide an index of mortality risk independent of case ascertainment. Their data indicate that early
9
death case ascertainment deficiencies do not result in falsely low risk-adjusted mortality rates so long as
10
11
the ratio of early to late deaths is consistent compared with other centers with similar case mixes.
From the perspective of the editor, there will be a continuing need to document the level of per-
12
formance of trauma centers nationwide. It is unlikely that the National Trauma Data Bank, in its current
13
form, can be relied on to determine trauma-related complication rates. Reliable means of determining
14
complications using administrative datasets is an important goal that should be addressed in future re-
15
search efforts.
16
Injury prevention and control
17
As mentioned previously in this overview, the care of patients brought to trauma centers after
18
injury is, inevitably, linked to the process of secondary prevention (minimization of the mortality and
19
morbidity of the acute injury) and tertiary prevention (maximizing the extent of recovery and re-entry
20
into society as a contributing member). Primary prevention efforts are actively ongoing and have ac-
21
complished much in reducing the frequency and pre-hospital fatality rates of injury events. Primary pre-
22
vention uses education, engineering controls (highway and intersection design; stronger steel cages for
23
automobiles) and legislation (mandatory seat belt use and motorcycle helmet use laws) to reduce the
24
frequency and severity of injury events. It is in the conduct of injury prevention research that data are
25
generated that can be used in the political arena to produce health policy change. The use of injury pre-
26
vention data such as motor vehicle crash performance statistics have led automobile manufacturers to
27
market their products on the basis of crash safety profiles (safety sells). The conduct of high-quality inju-
28
ry prevention research is challenging because experimental design requires interaction among public
29
health investigators, engineers, law enforcement personnel, sociologists, and economists, to name a few
30
examples.
25
1
Is knowledge of injury prevention research valuable for general surgeons? There is reason to be-
2
lieve that this question can be answered in the affirmative. General surgeons are frequently in positions
3
of community leadership and are consulted on questions relative to public health and hazard reduction.
4
In their capacity as healthcare providers, general surgeons will have opportunities to counsel injured
5
patients and their families about the potential for preventive interventions to reduce the risk of future
6
injury. Surgeons may be able to influence patients and families to become active in community injury
7
prevention programs. Furthermore, surgeons may be able to offer advice about design and execution of
8
efforts to quantify the effectiveness of injury prevention programs. In this section of the overview, we
9
discuss several articles dealing with research efforts in support of primary injury prevention. These arti-
10
cles provide an overview of public health research efforts into injury prevention and will, we hope, serve
11
to inform surgeons of the challenges and potential benefits of these initiatives.
12
As we begin the discussion of primary prevention research, we deal with the challenge of pro-
13
ducing data that accurately portray the demographics and risks of injury to specific populations. Provi-
14
sion of such data is the essential first step in building the foundation for research to identify effective
15
injury prevention programs. The first article reviewed is by Ankarath and coauthors27 in Injury, 2002,
16
entitled “Injury patterns associated with mortality following motorcycle crashes.” The authors reviewed
17
data on all patients admitted to hospitals in the Yorkshire region of England during a six-year interval.
18
The investigators used logistic regression analysis to identify injury patterns associated with in-
19
hospital mortality. As would be expected, injuries associated with large force transfer were most associ-
20
ated with mortality. These included head and spinal cord injury, chest injury, abdominal injury, and the
21
combination of pelvic fracture with long bone fracture. Of interest was the observation that the pel-
22
vis/long bone injury pattern was not associated with clear mortality risk alone but was a marker for the
23
presence of other life-threatening injuries.
24
The influence of head injury as a mortality risk factor was reduced in their study, possibly as a
25
consequence of a high frequency of motorcycle helmet use in the patient group they reviewed. Ele-
26
ments of trauma system function were also contributors to motorcycle crash fatalities in that delay in
27
diagnosis and treatment of some chest and abdominal injuries was associated with increased mortality
28
risk. The authors concluded that their data provide suggestive evidence in support of continuation of
29
mandatory motorcycle helmet laws and that their data provide insight into the need for improvement in
30
trauma medical response. The authors acknowledge that their data is limited in that scene deaths were
31
not assessed.
26
1
The next article reviewed analyzes the relationship of patient age to injury severity in motor ve-
2
hicle pedestrian collisions. As the population of the United States ages, this type of analysis becomes
3
more relevant to the fields of intersection design and regulation of crosswalk areas. The article, by De-
4
metriades and coauthors,28 appeared in the Journal of the American College of Surgeons, 2004, and is
5
entitled “Pedestrians injured by automobiles: relationship of age to injury type and severity.” The au-
6
thors reviewed slightly more than 10 years of data from an urban Level 1 trauma center. They assessed
7
injury-related mortality and injury severity related to the age of the patients. The anatomic distribution
8
of the most severe injuries was assessed by tabulating the body regions with the highest abbreviated
9
injury scores for each patient.
10
The data disclose that mortality risk increased with increasing age. In patients aged more than
11
65 years, overall injury mortality was 25.1% compared with an overall mortality risk of 3.2% in children
12
injured in auto-pedestrian collisions. Injury severity, as reflected by the proportion of patients in each
13
age group with injury severity scores > 15 also reflected an increasing severity with age. In the oldest age
14
group, 37% of the patients had injury severity scores > 15.
15
When the distribution of injury severity scores of 30 or more was examined, the oldest age
16
group had the highest proportion of critical injury severity scores. The oldest patient group (65 years of
17
age and older) had a higher incidence of brain and chest trauma compared with the younger age groups.
18
These authors concluded that their data indicate a rising mortality and injury severity risk for older pa-
19
tients and that additional effort to reduce auto-pedestrian collisions in older patients is justified.
20
While severe injuries might tend to disproportionately involve older patients, falls producing
21
single fractures are an extremely common injury mechanism in older patients. This topic is discussed in
22
an article by Boufous and coauthors29 entitled “Hospital admissions following presentations to emer-
23
gency departments for a fracture in older people.” This article appeared in Injury Prevention in 2006.
24
The authors reviewed hospital admission data from an Australian administrative dataset to determine
25
the fracture types that led to hospital admission. They found that the leading fracture type associated
26
with hospital admission was hip fracture. They suggest that this finding is the result of the necessity for
27
open reduction and internal fixation of these fractures. Pelvic fracture was the second most common
28
fracture associated with hospital admission. Few of these fractures required operative intervention but
29
most required inpatient efforts to control pain and re-establish ambulation.
27
1
The third fracture type they analyzed was wrist fracture and these injuries had the lowest hospi-
2
tal admission rate. There was no difference in hospitalization rates in women and men. These authors
3
conclude hip fracture is the most common reason for hospitalization of elderly patients after bony inju-
4
ry. The investigators acknowledge that hospitalization data may underestimate fracture incidence. They
5
recommend that prevention efforts focus on hip fracture in the elderly.
6
Prevention of hip fracture in the elderly is the topic of the next article reviewed. The article by
7
Feldman and Robinovitch30 appeared in the Journal of Biomechanics, 2007, and is entitled “Reducing hip
8
fracture risk during sideways falls: evidence in young adults of the protective effects of impact to the
9
hands and stepping.” The data reviewed comes from experiments performed on 44 young adults. The
10
purpose of the study was to ascertain whether young people deal with falls that have potential impact
11
to the hip in different ways than do older adults.
12
The authors produced a sudden sideways change in the platform on which the subject was
13
standing and used videotape analysis to determine points of impact and timing of impact. They discov-
14
ered that young adults use hand extension and stepping maneuvers to delay impact on the hip. While
15
the hip was impacted in all of the observed falls, the use of the hands for protection and the use of
16
stepping maneuvers delayed and significantly reduced the force of the hip impact. The authors specu-
17
late that re-training of older adults in defensive maneuvers such as these might reduce the health bur-
18
den of hip fracture among the elderly. They recommend that future analyses develop data on fall pro-
19
tective maneuvers related to age.
20
Most injury control experts agree that automobile restraint use is a key factor in reducing mor-
21
tality and injury severity. Most research in this area has shown that primary seat belt laws (authorities
22
are empowered to issue citations if the driver or passengers in the motor vehicle are not using restraint
23
devices) are more effective than secondary laws (citations for non-use of restraint devices can only be
24
issued if the vehicle is being cited for another violation).
25
The next article reviewed is an analysis of data on seat belt use in all 50 states and in the District
26
of Columbia. The article is by Beck and coauthors31 in the American Journal of Public Health, 2009. A full
27
text reprint of this article is included with the mailed version of this issue of Selected Readings. Large
28
administrative databases were queried and overall seat belt use was determined. Social and demo-
29
graphic data were analyzed to determine the societal groups most likely to increase seat belt use in
30
states with primary seat belt laws. The authors confirmed the findings of other investigators that seat
28
1
belt use is higher in states with primary enforcement statutes. Eighty-five percent of motor vehicle oc-
2
cupants were, on average, restrained in states with primary laws compared with an average of 74% in
3
states with secondary laws.
4
Analysis of the social/demographic data disclosed that the groups most likely to increase seat
5
belt use after passage of a primary seat belt law are individuals in lower income groups, non-whites, and
6
young males. These groups are, interestingly, over-represented in the trauma patient population. It
7
would appear, therefore, that primary seat belt laws preferentially affect the groups at highest risk for
8
injury-related mortality and disability. These data suggest that primary seat belt laws are effective.
9
Injury prevention programs are expected to not only reduce the risk and severity of injury but
10
also to be cost effective. The next article reviewed presents an analysis of cost effectiveness of distribu-
11
tion of child restraint devices and child restraint device use education within the context of the Medi-
12
caid-funded child vaccination program. The authors analyzed vehicle crash rates, child injury, and death
13
rates from vehicle crashes and child restraint use in a population eligible for participation in Medicaid-
14
sponsored programs. From their analysis they determined that improved child restraint use could pre-
15
vent 22 deaths, 12 serious injuries, and 51 minor injuries/100,000 low income children annually. Their
16
predictions indicate that distribution of child restraint devices and conduct of child restraint use educa-
17
tion among this vulnerable population would be cost effective in terms of lives saved and future produc-
18
tivity loss recovery. They recommend that child restraints be distributed along with child restraint use
19
education under the auspices of the Medicaid childhood vaccination program.
20
The final three articles reviewed in this section of the overview deal with violence prevention.
21
The first article is entitled “Examining multi-level relationships between bars, hostility, and aggression:
22
social selection and social influence.” The article by Treno and coauthors32 in Addiction, 2007, analyzed
23
demographic data from 36 zip code areas in California and calculated population densities and incidenc-
24
es of hostile behavior. These data were then adjusted for the number of alcohol sales establishments
25
within each zip code. Telephone interviews were conducted to determine drinking habits in terms of
26
frequency and amount consumed. The investigators also assessed locations where drinking occurred
27
and attitudes regarding hostile and aggressive behavior.
28
From their data, the investigators concluded that alcohol consumption contributes to hostile
29
and aggressive behavior. They further noted that social and community influences such as population
30
density and economic factors were also contributors to the lowering of thresholds for aggressive behav-
29
1
ior. While the density of alcohol sales facilities was increased in the areas where aggressive and hostile
2
behaviors occur, the authors could not establish a causal link between the number of bars and aggres-
3
sive behavior.
4
Another report dealing with social and economic factors associated with elevated rates of inter-
5
personal violence is by Fabio and coauthors33 in the American Journal of Public Health, 2009. These au-
6
thors examined possible associations of population density, household characteristics, and racial segre-
7
gation with the observed rates of interpersonal violence. They performed logistic regression analysis to
8
identify factors strongly associated with the occurrence of interpersonal violence events and interper-
9
sonal violence-related death. The data disclose that population density, racial segregation, and the per-
10
centage of households headed by women were all associated with an increased risk of interpersonal
11
violence events and death from violence. The risk of death by interpersonal violence increased for both
12
whites and non-whites in counties with a combination of high population density and high degrees of
13
racial segregation. The authors conclude that the societal damage from segregation is severe and far
14
reaching.
15
Firearm deaths from homicide and suicide are major public health concerns for the United
16
States. Firearm death because of homicide is a challenge to public health officials and society in general,
17
particularly in urban areas. Although reductions in firearm-related death were observed in many urban
18
areas in the first 2-3 years of the 21st century, those rates are now rising again in several large urban
19
communities. Whether firearm deaths are an equivalent problem in rural communities is the topic ad-
20
dressed in an article by Branas and coauthors34 in the American Journal of Public Health, 2004. A full text
21
reprint of this article is included with the mailed version of this issue of Selected Readings.
22
Nationwide, county level data was analyzed to determine the risk of firearm-related death in
23
urban and rural environments. The data disclose a significantly increased risk of firearm death because
24
of homicide in the most urban compared with the most rural counties. Firearm death risk from suicide
25
was remarkably increased in the most rural counties compared to the most urban counties. The in-
26
creased risk of firearm suicide was particularly noticeable in males. The authors postulate that the fre-
27
quent success of firearm suicide attracts males who prefer a quick and efficient method of suicide. The
28
authors concluded that firearm death is an important and pervasive public health problem in the United
29
States. Efforts to curb firearm homicide will address only part of the problem. The authors recommend
30
that research be conducted to identify and ameliorate factors that increase the risk of firearm death.
30
1
The final article reviewed deals with the important problem of firearm violence. The article by
2
Weiner and coauthors35 in Injury Prevention, 2007, is entitled “Reducing firearm violence: a research
3
agenda.” Approximately 200,000 people die, worldwide, from noncombat firearm injuries each year. In
4
the United States 30,000 people die annually from gunshot wounds and 65,000 serious injuries are sus-
5
tained. A defined link between the availability of a firearm and the occurrence of a homicide or suicide
6
has been a difficult link to establish from the point of view of causation. They describe a research docu-
7
ment published by the National Academy of Sciences in 2004 describing the status of research relating
8
to establishing a causal link between firearm availability and firearm violence. The document also sought
9
to establish the relative value of firearm violence prevention programs. The purpose of Weiner and co-
10
authors’ article was to evaluate the opinions expressed in the National Academy of Sciences document
11
and to develop research proposals to strengthen the knowledge base in this important area of public
12
health research.
13
The authors agree with the findings of the 2004 document that a major barrier to research in
14
the area of firearm violence is access to available data, much of it protected by confidentiality statutes.
15
This working group recommends that data be made anonymous by readily available means so that pri-
16
vacy is protected and access to data is improved. The group next considered the links between firearms
17
and suicide, concluding that the weight of the evidence supports a linkage between firearm availability
18
and firearm suicide. They cite evidence in support of the association between firearm availability and
19
firearm suicide attempts. The further cite data that support a linkage between firearm availability and
20
success of firearm suicide attempts.
21
The group next considered the research data that is available in support of and against the value
22
of gun ownership for personal protection. There is not sufficient data to conclude that restricted gun
23
ownership would be successful reducing firearm violence. They recommend that multi-level studies be
24
conducted to examine this issue. As far as programs to restrict access to firearms for “high-risk” users
25
such as felons, the working group was not confident that cost effective programs were feasible to stop
26
the flow of guns to this group. They note that extensive studies to evaluate the potential for obstructing
27
the flow of illegal weapons are sorely needed. In consideration of the value of firearm violence reduc-
28
tion programs, several encouraging local programs deserved further evaluation and dissemination to
29
other locations for additional evaluation.
30
31
From the perspective of the editor, I hope that presentation of these few articles describing various aspects of injury prevention and control will help surgeons recognize the importance of public
31
1
health approaches to injury prevention and encourage surgeons to participate in and support these ef-
2
forts.
3
Interventions to identify and prevent alcohol and drug related injuries
4
Alcohol and drug testing of injured patients has disclosed that frequencies of drug and alcohol
5
use are increased in injured patients. Several data sources suggest that 7.9% of the population of the
6
United States aged 12 years and older use illicit drugs and nearly a quarter of this group consumes alco-
7
hol. Whether more extensive testing would increase the rates of detection of drug and alcohol use and
8
improve efforts to reduce the effects of drug and alcohol use on the risk of injury are important research
9
questions.
10
This topic is discussed in an article by London and Batistella36 in Archives of Surgery, 2007, enti-
11
tled “Testing for substance use in trauma patients: are we doing enough?” The authors queried the Na-
12
tional Trauma Data Bank for information on the rates of testing for drugs and alcohol and frequencies of
13
positive tests. The data examined disclose that approximately half the patients admitted with injury to a
14
hospital are tested for alcohol and half of these have positive results. Thirty-six percent of patients are
15
tested for drug use and nearly half of these patients show positive test results. The authors note that
16
the frequency with which patients are tested for alcohol and drugs has not changed since 1998. More
17
disturbing is their observation that testing for illicit drugs has actually decreased in frequency even
18
though a trend toward increasing rates of positive tests has been identified.
19
A major disincentive to drug and alcohol testing is the provision in the rules of many healthcare
20
insurers allowing withholding payment for care given to injured patients who are found to have used
21
drugs or alcohol. Drug and alcohol use data obtained in the normal course of evaluating and caring for a
22
patient with injuries is not protected from release to third parties and therefore the information is avail-
23
able to health insurers. The authors note that there is a significant amount of data in support of the use-
24
fulness of brief interventions as a means of reducing the risks of injury related to drug and alcohol
25
abuse. They cite several studies that suggest these brief interventions reduce alcohol consumption, inju-
26
ries, and injury events. They cite additional data showing that alcohol abuse is the most common chronic
27
medical condition encountered in hospitalized injured patients. They conclude by suggesting that efforts
28
be launched to encourage legislators to limit the availability of drug and alcohol use data to health in-
29
surers. They further recommend that increased rates of testing be achieved to improve the detection
30
and treatment of these patients.
32
1
It is known that sustaining an injury related to alcohol and/or drug abuse is a potent motivator
2
for behavioral change. This is probably one reason that brief interventions designed to alter alcohol use
3
behaviors have been shown to be effective in reducing consumption and the rate of alcohol-related inju-
4
ry. Most studies have focused on patients who are not “problem drinkers,” (e.g. patients who are chron-
5
ic alcohol abusers and those who are subject to recurrent crashes and injuries to themselves and oth-
6
ers). This important patient group is analyzed in an article by Schermer and coauthors37 in the Journal of
7
Trauma, 2006.
8
9
These authors conducted a prospective randomized trial comparing standard care (provision of
contact information for alcohol treatment services) with a brief intervention designed to alter alcohol
10
use (30-minute protocol-based interview by a social worker or a trauma surgeon). All patients had had a
11
prior driving under the influence citation and had been admitted to a trauma center for treatment of
12
injuries. Only 1 or 2 episodes of driving under the influence of more than 800 episodes result in a driving
13
under the influence citation. This fact should stimulate more active attempts at managing the patients
14
most likely to be responsible for multiple episodes of injury related to alcohol consumption. The authors
15
obtained 3-year followup data on their patients. Overall 16.7% of patients had a DUI arrest within 3
16
years of hospital discharge. Twenty-two percent of patients receiving standard care had a subsequent
17
arrest while only 11% of brief intervention patients had a subsequent arrest. On multivariate analysis,
18
having a brief intervention was the most important determinant of absence of subsequent driving under
19
the influence arrest.
20
The authors describe the brief intervention interview; it consists of empathetic, patient-
21
centered, non-confrontational conversation designed to encourage the patient to talk about the per-
22
sonal effects of alcohol consumption and set the stage for development of attitudes conducive to behav-
23
ioral change. The authors conclude that their data suggest that brief interventions are effective in reduc-
24
ing subsequent arrest for driving under the influence in this group of patients at significantly increased
25
risk for recidivism. They further suggest that more uniform use of alcohol and drug testing could identify
26
more patients at risk and potentially lower rates of alcohol-related arrests and injuries.
27
Additional data supporting the effect of injury, hospitalization, and brief interventions on drink-
28
ing behavior is supplied in an article by Sommers and coauthors38 from Journal of Trauma, 2006. A full
29
text reprint of this article is included with the mailed version of this issue of Selected Readings. This arti-
30
cle also describes a prospective randomized trial in which two groups of patients were chosen to partici-
31
pate in a detailed evaluation of alcohol use. Subsequently, the frequency of alcohol-related injury or ar-
33
1
rest was monitored along with drinking behavior. The experimental group received the evaluation and,
2
in addition, a brief intervention interview. These authors observed decreases in alcohol-related arrests,
3
injuries, and improvements in drinking behavior in both groups. This observation led them to suggest
4
that perhaps the injury event itself is a sufficient motivator for change. The work of other investigators
5
has shown there is a decrease in alcohol consumption over the first month after an injury but then this
6
returns to baseline. This was not observed in Sommers and coauthors’ patients perhaps because the
7
patients knew their drinking behavior was being monitored. The authors also suggest that the detailed
8
alcohol use evaluation given to the patients in the control group may have served the same purpose as
9
the brief intervention as a stimulator for behavioral change.
10
Alcohol and drug screening, combined with interventions to reduce alcohol- and drug-related in-
11
juries, is deemed an important trauma center function and, in fact, a requirement for inclusion of this
12
capability has been promulgated in the trauma center verification program of the American College of
13
Surgeons, Committee on Trauma. An assessment of the effectiveness of this requirement is the subject
14
of Terrell and coauthors39 in the Journal of the American College of Surgeons, 2008. These authors re-
15
port the results of a national survey of 204 Level 1 trauma centers. Seventy-three percent of the centers
16
returned the complete survey instrument.
17
The authors report that more than ⅔ of the trauma centers surveyed routinely obtained screen-
18
ing laboratory studies to detect drugs and/or alcohol. Thirty-nine percent of the surveyed centers con-
19
ducted additional screening assessments with interviews or questionnaires. Only 25% of reporting cen-
20
ters conducted a structured brief intervention designed to reduce the risk of recurrent alcohol-related
21
injury. These authors conclude that, at the time of implementation of the trauma verification program
22
requirement, there is highly variable behavior among the Level 1 trauma centers that responded to the
23
survey. Trauma centers that did not regularly conduct brief interventions cited lack of personnel and
24
financial support to conduct this activity. These authors conclude that additional research will be neces-
25
sary to document whether the requirement for alcohol screening and intervention currently included in
26
the verification requirements will actually be effective.
27
From the perspective of the editor, it seems clear that efforts to reduce the risk of alcohol-
28
related injury have the potential for effectiveness. In their current form, the resources required are sig-
29
nificant and the data reviewed indicate that trauma centers across the United States are not receiving
30
consistent support for this effort. The resourcefulness and forcefulness of trauma center medical direc-
31
tors will be necessary for the resolution of this problem.
34
1
Post-injury psychologic dysfunction
2
Trauma-related psychologic dysfunction has been noted, particularly in combat veterans in each
3
of the recent wars in which Americans participated. The increasing emphasis on the depression symp-
4
toms and anxiety observed in Vietnam veterans has reemerged as a consequence of the conflicts in Iraq
5
and Afghanistan. In this section the importance and the diagnosis and management of trauma-related
6
psychologic disorders are discussed. We review six articles that focus upon detection and management
7
of post-traumatic symptoms of stress (nightmares, flashbacks), anxiety, and depression commonly
8
termed post-traumatic stress disorder. Evidence is presented that this disorder represents an important
9
cause of reduced quality of life in more than one quarter of injured patients. Data which suggests that
10
PTSD exists along a continuum which begins with symptoms of acute stress disorder that surface within
11
days of the injury event will be reviewed. It would appear that ⅓ to ½ of patients who develop acute
12
stress disorder symptoms will go on to display characteristic symptoms of post traumatic stress disorder.
13
Particularly severe symptoms are observed in patients who have survived critical care unit stays after
14
injury, and emerging evidence suggests that similar findings are observed in survivors of nontraumatic
15
critical care illness.
16
The first article by Zatzick and coauthors40 is from Journal of Trauma, 2004. The authors re-
17
viewed the records of 269 patients randomly selected from the trauma registries of two Level1 trauma
18
centers. The patients were administered symptom screens during the index hospital admission to assess
19
the prevalence of acute stress disorder (as opposed to post-traumatic stress disorder that must be diag-
20
nosed 30 days or more after the traumatic event). The investigators documented the presence of acute
21
stress disorder symptoms in 58% of patients analyzed. They noted an increased rate of prior traumatic
22
events compared with the general population (45% of the patients had at least one prior traumatic
23
event compared with less than 10% of the general population). The data disclose that alcohol abuse and
24
depression are common in patients who develop acute stress disorder symptoms after injury. These au-
25
thors recommend screening for acute distress disorder to identify patients at increased risk for long-
26
term psychiatric symptoms of anxiety and depression and increased risks of alcohol and drug abuse.
27
This same team of investigators assessed a national sample of injured patients to determine the
28
long-term impact of post-traumatic stress disorder symptoms on quality of life. A group of more than
29
2000 injured patients cared for in 69 hospitals was analyzed. Symptoms of post-traumatic stress disor-
30
der were noted in 20% of the patients at 1 year. Patients with symptoms had significantly reduced
31
health-related quality of life and a markedly increased risk of not returning to employment. The authors
35
1
discovered a dose-response relationship; an increasing number of discovered psychologic symptoms
2
were related to increased risk for decreased quality of life and increased risk of non-return to active em-
3
ployment. The investigators note that there are small studies reporting significant symptom improve-
4
ment with directed psychiatric care of patients with post-traumatic stress disorder symptoms. They sug-
5
gest that the frequency of this disorder should stimulate additional trials of therapeutic interventions.
6
Additional data documenting the importance of post-traumatic stress disorder in specific patient
7
groups is from an article by Holbrook and coauthors41 in the Journal of Trauma, 2005. A full text reprint
8
of this article is supplied with the mailed version of this issue of Selected Readings. These authors re-
9
viewed data from 401 injured adolescents aged 12-19. Followup was obtained over two years subse-
10
quent to the injury event. The frequency of post-traumatic stress disorder and the risk factors leading to
11
the diagnosis were sought. These authors found evidence of post-traumatic stress disorder symptoms in
12
27% of surviving patients and the symptoms persisted over the two years of followup. Risk factors for
13
the development of symptoms included female gender, older age, perceived threat to life, violence re-
14
lated injury, and inability to control the event. There was a significantly increased risk of prior psycholog-
15
ic problems and alcohol abuse in the patients with symptoms. This work confirms the significant long-
16
term impact of this constellation of symptoms in young patients and identifies risk factors that might be
17
targeted with treatment efforts.
18
An effort to determine the relationship of acute stress disorder symptoms in injured patients to
19
the later development of post-traumatic stress disorder is reported by this same group of investigators
20
in an article that also appeared in the Journal of Trauma, 2005.42 These authors assessed patients for the
21
presence of acute stress disorder and determined whether the presence of acute stress disorder symp-
22
toms was predictive of long-term post-traumatic stress disorder and reduced quality of life. The data
23
presented confirmed the significantly increased frequency of acute stress disorder in these injured pa-
24
tients and there was a significant relationship of acute stress disorder to the development of long-term
25
post-traumatic stress disorder. These authors appropriately raise the question of the potential value of
26
early psychologic intervention in these vulnerable patients. Further research is indicated to document
27
the potential value of directed interventions.
28
The next article reviewed presents data to support the relationship of critical injury to the de-
29
velopment of post-traumatic stress disorder and depression. The article by Ringdal and coauthors43 ap-
30
peared in the Journal of Trauma in 2009. A full text reprint of this article is included with the mailed ver-
31
sion of this issue of Selected Readings. These authors reviewed data from 239 patients who had the fre-
36
1
quency of delusional memories and long-term depression assessed with standard questionnaires. The
2
authors found that 1 patient in 4 experienced delusional memories and had decreased quality of life and
3
increased depressive symptoms 1 year after the critical illness related to their injuries. Increased injury
4
severity, longer ICU stay, and longer intervals on ventilator support were predictive of delusional memo-
5
ries and depression. The authors were able to determine that there was a reduction in symptom severity
6
and improved overall quality of life in patients able to discuss their memories during the acute hospitali-
7
zation. The article confirms the consistent 25-30% risk of post-traumatic stress disorder and depression
8
in injured patients. Whether there is some feature of critical illness that produces the tendency to de-
9
velop these symptoms in survivors of critical injury will require further research.
10
The final article deals with the risk of post-traumatic stress disorder symptoms and depression
11
in critically ill surgery patients who were not injured. This article, by Dowdy and coauthors,44 appeared in
12
Critical Care Medicine in 2009. The authors assessed depression and post-traumatic stress disorder
13
symptoms with a standard questionnaire, finding symptoms present in 28% of patients. Symptom-
14
development risk increased with increasing illness severity. The single intensive care unit characteristic
15
related to symptoms development was the use of benzodiazepines in excess of 75mg/day of midazolam
16
equivalent. There was a history of prior depression or psychologic disorder in most of the patients who
17
developed post-traumatic stress disorder symptoms and/or depression 6 months after their intensive
18
care unit stay. This observation raises the possibility that prior history of depression could be an im-
19
portant piece of information to derive in critically ill and injured patients to assist identifying patients
20
who might benefit from interventions designed to prevent or reduce post-traumatic stress disorder
21
symptoms.
22
From the perspective of the editor, it seems clear that post-traumatic stress disorder is diagnos-
23
able in more than one quarter of injured and critically ill patients. Measures are needed to identify these
24
patients early so that structured interventions can be used. The fact that discussion of the memories
25
and symptoms seems to reduce symptom severity is an intriguing observation that requires further
26
study. It is worth emphasizing, at this point, that effective trauma center response that will ensure ade-
27
quate evaluation and management of post injury psychologic dysfunction is another element of trauma
28
center function that requires resources to accomplish. Without investment in infrastructure and per-
29
sonnel, an effective response will probably not occur.
37
1
Traumatic brain injury
2
Traumatic brain injury is a major contributor to death and disability after injury. Estimates dis-
3
close that 52,000 patients are expected to die annually of brain injury and additional 70,000–90,000 pa-
4
tients will sustain significant long-term disability. Some degree of traumatic brain injury exists in the ma-
5
jority of severely injured, multiple trauma patients admitted to trauma centers. In the face of this, the
6
availability of neurosurgery coverage is a continuing problem for trauma centers. Changes in the pattern
7
of clinical practice for neurosurgeons have decreased the number of these specialists who are willing to
8
undertake cranial procedures. Furthermore, the nature of trauma care, with its concentration in off
9
hours and intrusions on elective practice, has further increased the reluctance of neurosurgeons to pro-
10
vide specialty coverage in the trauma center. From a purely statistical point of view, patients sustaining
11
traumatic brain injury do not often require intracranial operations. This may change somewhat because
12
of the emergence of clinical series supporting the use of decompressing craniectomy in patients with
13
refractory intracranial hypertension.
14
What is clear, at this point, is that optimal outcomes for severely brain-injured patients can be
15
assured only with coordinated, team-oriented care designed to use appropriate interventions such as
16
intracranial pressure monitoring, hyperosmolar therapy, hypothermia, and decompressive craniectomy.
17
Participation by trauma surgeons and neurosurgeons working in collegial groups is necessary to ensure
18
that the appropriately chosen and timed interventions are offered to the patients most likely to benefit
19
from these.
20
In this section of the overview, we briefly review the practice guidelines available for manage-
21
ment of patients with significant traumatic brain injury. In subsequent sections of the overview we will
22
review analyses of the effectiveness of team approaches to brain-injured patients. The contributions of
23
ageing, and the use of drugs that alter coagulation mechanisms to outcomes of brain injury, will be dis-
24
cussed. Evidence about medium- and long-term outcomes of brain injury and factors important in the
25
management of patients with clinically minor brain injury are reviewed in the final sections of this part
26
of the overview.
27
Practice guidelines for the management of traumatic brain injury are produced on a regular ba-
28
sis by the Brain Trauma Foundation. The most recent version of these was published in 2007.45 The
29
guidelines make recommendations about the care of patients with significant brain injury defined as a
30
post-resuscitation Glasgow Coma Score of 8-10. The salient points of the guidelines include, first, recog-
31
nition that there is a significant risk of pre-hospital hypotension and hypoxemia and this risk continues
38
1
into the early phases of in-hospital resuscitation. The guidelines emphasize that outcomes from brain
2
injury are related to the assurance of adequate cerebral perfusion pressure and adequate oxygen deliv-
3
ery; guidelines suggest that systolic blood pressure < 90 be avoided and that arterial oxygen tension be
4
maintained at a level of 60 mmHg or above. Arterial oxygen saturation should not fall below 90%.
5
The guidelines state that emergency treatment of suspected intracranial hypertension with
6
mannitol in doses of 0.25 gm/kg is an effective intervention to buy time for additional diagnostic proce-
7
dures or for preparation for evacuation of intracranial mass lesions. The guidelines state that there is no
8
evidence to support repeated or continuous mannitol therapy. There have been a number of reports of
9
the use of hypertonic saline in patients with documented intracranial hypertension and overall, the evi-
10
dence supports a favorable effect of hypertonic saline on elevated intracranial pressure. The authors
11
note that hypertonic saline has potential benefit for the brain-injured patient above and beyond its os-
12
molar effects. Hypertonic saline increases arterial pressure, reduces the volume of red blood cells, and
13
decreases blood viscosity. These changes brought about by hypertonic saline suggest that use of this
14
therapy might increase cerebral blood flow and oxygen delivery.
15
A corollary question regarding cerebral oxygen delivery relates to the question of transfusion to
16
avoid anemia and the effects of this practice on cerebral oxygenation. This topic is discussed in two re-
17
cent articles.46, 47 Outcomes were assessed and intracranial brain tissue oxygen tensions were assessed
18
respectively. Brain tissue oxygenation improved with transfusion of two units of packed red cells in one
19
study, but there was no effect on brain metabolism. Of interest is that many of the patients who showed
20
improvement did not have abnormally low brain oxygen tension before transfusion. In the other study,
21
assessing outcomes, aggressive transfusion did not result in a positive effect on outcomes in brain-
22
injured patients. On the basis of these studies, it appears that preservation of hemoglobin levels at nor-
23
mal or increased levels is not beneficial for brain-injured patients.
24
Evidence suggests that hypertonic saline reduces brain size by mobilizing water from non-
25
injured brain tissue. The authors point out that a rebound re-elevation of intracranial pressure is not
26
commonly observed after administration of hypertonic saline. They emphasize that there have been
27
trials of continuous administration of hypertonic saline to patients with brain injury and some encourag-
28
ing results have been reported. A potential downside of continuous administration is the risk of pontine
29
myelolysis if hypertonic saline is administered to patients who are hyponatremic. If therapy with hyper-
30
tonic saline is planned, documentation of increased intracranial pressure by intracranial pressure moni-
39
1
toring is essential. Coordinated neurotrauma critical care teams are worthwhile to provide evidence-
2
based care.
3
The issue of the effectiveness of teams practicing evidence-based brain injury care protocols is
4
discussed in an article by Fakhry and coauthors48 in the Journal of Trauma, 2004. A full text reprint of
5
this report is included in the mailed version of this issue of Selected Readings. These authors compared
6
resource consumption for patients treated before and after a protocol based on Brain Trauma Founda-
7
tion practice guidelines was established. There was significant reduction in intensive care unit length of
8
stay as well as hospital length of stay after establishment of the protocol. A nonsignificant trend sug-
9
gests improved discharge Glasgow Outcome Scores in the group treated according to the protocol. In an
10
editorial accompanying the article, Dr. Alex Vladka notes the extreme difficulty in establishing “evi-
11
dence-based protocols” because there is so little class 1 evidence in support of the practices trauma
12
surgeons and neurosurgeons routinely follow. This shortcoming is abundantly true for the Brain Trauma
13
Foundation practice guidelines. And it is not ethically acceptable to conduct randomized prospective
14
trials in which brain-injured patients are treated with and without adherence to Brain Trauma Founda-
15
tion guidelines. It is intuitively attractive to agree that implementing an evidence-based protocol leads
16
to improved outcomes; iron-clad evidence in support of this position is simply not available.
17
The practice guidelines of the Brain Trauma Foundation next consider the use of hypothermia
18
for the treatment of brain injury. The guidelines suggest that mild hypothermia is associated with im-
19
proved discharge Glasgow Outcome Score in patients with severe brain injury. The data further suggest
20
that hypothermia applied for more than 48 hours is superior to shorter intervals. Some studies have
21
suggested that the benefit of hypothermia is offset by an increased risk of pneumonia. The guidelines
22
issued a cautious level III recommendation for the use of hypothermia in adults with severe brain injury
23
defined as a Glasgow Coma Score less than 8
24
In a more recent meta-analysis of data supporting the use of hypothermia, Peterson and coau-
25
thors49 reported that benefits of more than 48 hours of hypothermia were observed in terms of overall
26
mortality, and higher Glasgow Outcome Scores at discharge. The issue of the risk of pneumonia in the
27
patients who were treated with hypothermia remains unsettled. The authors suggest that the Brain
28
Trauma Foundation Guidelines be updated to recommend, with significant level 3 evidence, the use of
29
hypothermia for more than 48 hours in adults with severe brain injury.
40
1
The guidelines indicate that patients with severe brain injury and abnormal CT scans should be
2
followed with intracranial pressure monitoring. Patients who are over 40 years of age, especially with a
3
history of hypotension or hypoxemia and a Glasgow Coma Score of 3-8, are also good candidates for
4
intracranial pressure monitoring even if the CT scan is normal. The guidelines recommend that peripro-
5
cedural prophylactic antibiotics be used according to accepted guidelines. There is not, according to the
6
guidelines document, sufficient evidence to support regular changes in intracranial pressure monitoring
7
catheters or the administration of antibiotics for the purpose of preventing infection in patients with
8
indwelling ventricular catheters
9
The guidelines discuss other important issues such as intracranial pressure monitoring technolo-
10
gy, the use of brain oxygen monitoring, nutritional support, and anti-seizure prophylaxis. Interested
11
readers are encouraged to review the guidelines document.
12
Although the guidelines mention craniotomy for the evacuation of mass lesions such as epidural
13
or subdural hematomas, there is no detailed discussion of decompressive craniectomy for refractory
14
intracranial hypertension. This approach has been described in several reports and has recently been
15
the topic of presentations of data drawn from the care of combat-injured patients from the conflicts in
16
Iraq and Afghanistan. A Cochrane Database Systematic Review authored by Sahuquillo and Arikan ap-
17
peared in 2006.50 A full text reprint of this article is included with the mailed version of this issue of Se-
18
lected Readings. Based on their systematic review, the authors note that there are no randomized trials
19
of sufficiently high quality to recommend the routine use of decompressive craniectomy for refractory
20
intracranial hypertensions after traumatic brain injury.
21
Observational studies using historical controls have observed improved mortality risk and im-
22
proved outcome scores at discharge in patients below age 18 where decompressive craniectomy was
23
used when all other means of controlling intracranial hypertension had failed. Although similar data in
24
adults are not available, these authors recommend use of decompressive craniectomy in adult patients
25
with refractory intracranial hypertension if the patient can be expected to survive other associated inju-
26
ries or if the patient has isolated traumatic brain injury. A single center experience with 23 patients was
27
reported by Jagannathan and coauthors51 in the Journal of Neurosurgery, 2007.
28
All the patients in this series had traumatic brain injury with a mean Glasgow Coma Score of 5
29
on admission. Patient mean age was 12, and the age range was 3-19. Eighteen of the patients survived
30
(70%) and at 2 years of followup, 13 of these patients were in school full time. It seems, therefore, that
41
1
decompressive craniectomy is most useful for young patients. The authors of these reports note that
2
there are ongoing randomized trials of this intervention and the results of these trials will be of interest
3
to surgeons caring for patients with brain injury.
4
The objective of comprehensive care for brain-injured patients is to achieve optimum short and
5
long term optimal outcomes. This topic is discussed in the next several articles reviewed. The first of
6
these is by Udekwu and coauthors52 in the Journal of Trauma, 2004, entitled “Glasgow Coma Scale
7
score, mortality, and functional outcome in head-injured patients.” The authors queried a statewide
8
trauma registry to document mortality and outcomes of brain injury care as assessed by the Functional
9
Independence Measure. These authors documented a non-linear relationship between Glasgow Coma
10
Score and mortality. Mortality fell in a linear fashion for post-resuscitation Glasgow Coma Scores of 3-7,
11
with a more shallow improvement curve for scores higher than 7. The authors suggest that Glasgow
12
Coma Score is not a dependable means of predicting mortality or functional outcomes in individual pa-
13
tients.
14
Additional data analyzing another patient variable, age, provides insight into outcomes of vari-
15
ous patient groups segregated according to age. This article is by Livingston and coauthors53 and ap-
16
peared in the Journal of Trauma in 2005. The authors conducted a multi-institutional trial, under the
17
auspices of the Western Trauma Association, to document 1-year outcomes for patients treated for iso-
18
lated brain injury. Patients included were those with head abbreviated injury scale of ≥3 (severe injury)
19
with no other anatomic area having an abbreviated injury scale of > 1. The Functional Independence
20
Measure was used to assess functional outcome. These authors confirmed other data that suggests that
21
Glasgow Outcome Scores of less than 4 at discharge are associated with poorer 1-year outcomes. What
22
was evident from the data in this article was that age was a strong predictor of 1-year outcomes and the
23
effects of age began at age 45. Patients over 60 were at greatly increased risk of poor functional out-
24
comes at 1 year. The authors noted that few patients received formal rehabilitation and this deficiency
25
may augment the effect of age on functional outcomes. Two additional articles confirm that older adults
26
with brain injury are more likely to die, have longer inpatient lengths of stay, are more likely to be dis-
27
charged to long-term care facilities, and have poorer levels of function in cognitive domains than do
28
younger patients with brain injury.54, 55 The two articles also emphasize the importance of pre-injury
29
function levels as determinants of post-brain-injury recovery. The articles note that falls are a major
30
cause of traumatic brain injury in older adults and this should stimulate research leading to adequate
31
preventive approaches.
42
1
An important question frequently posed in discussions of optimal diagnosis and management of
2
brain-injured patients concerns the effect of alcohol and drugs on the assessment of traumatic brain
3
injury. There are data to suggest that diagnostic uncertainty by treating surgeons over the degree of al-
4
teration in clinical examination results in intoxicated patients could lead to delays in diagnostic and
5
therapeutic interventions.56 An article analyzing the need for delayed neurological examination in intoxi-
6
cated patients by Sperry and coauthors57 appeared in the Journal of Trauma. 2006, entitled “Waiting for
7
the patient to sober up: effect of alcohol intoxication on Glasgow Coma Scale score of brain-injured pa-
8
tients.”
9
The authors note that 35%-%-50% of brain-injured patients present to hospital after ingesting
10
alcohol or drugs. The authors report a 10-year retrospective study of patients with traumatic brain injury
11
who had blood alcohol concentrations assessed on admission. The patients were divided into patients
12
who were “intoxicated” and patients who were “not intoxicated.” The data disclose that blood alcohol
13
level had no demonstrable effect on accurate scoring using the Glasgow Coma Scale. These authors rec-
14
ommend that there should be no delay in calculating Glasgow Coma Scale because of an elevated blood
15
alcohol level. They further caution that an abnormal Glasgow Coma Scale should prompt an immediate
16
and thorough search for a cause of the abnormal score; the abnormality should not be ascribed to an
17
elevated blood alcohol level.
18
Elderly patients are known to be at risk for traumatic brain injury and the effect of age on out-
19
comes has been discussed previously. Elderly patients are also likely to be using drugs that alter coagula-
20
tion mechanisms such as aspirin, warfarin, and clopidogrel. The effects of these drugs on the outcomes
21
of brain injury are the topic of three articles reviewed. A final article discussed deals with the timing of
22
institution of heparin for prevention of venous thromboembolism in patients with brain injury. The first
23
article discussed is by Fortuna and coauthors58 from Surgery, in 2008. These authors reviewed, retro-
24
spectively, data from 416 patients with hemorrhagic traumatic brain injury.
25
Patients were included if they were older than 50 years of age. The authors found, as have oth-
26
ers, that mortality was related to increasing age. They could not identify any mortality differences in pa-
27
tients taking coagulation altering drugs. They postulate that anticoagulant drugs to not have an additive
28
effect on mortality when patients are stratified by age. In the discussion of this paper, the causes of
29
death for the patients who died are not reported and it is therefore not possible to determine if the pa-
30
tients taking anticoagulant drugs died of their brain injury or an associated injury. It is also not possible
31
to discern whether excess bleeding contributed to any of the deaths.
43
1
The second article discussed is by Ivascu and coauthors59 from the Journal of Trauma in 2008.
2
The authors reviewed the records of 109 elderly patients with traumatic brain injury and assessed asso-
3
ciations of mortality with CT scan grade, age, and the use of clopidogrel and/or aspirin. They discovered
4
an association of mortality with the use of these drugs independent of patient age, but not the score of
5
the admission CT scan. These data suggest that the anticoagulant drugs may have increased risk of se-
6
vere intracranial hemorrhage in these patients. The effect of warfarin anticoagulation on mortality from
7
blunt brain injury in elderly patients is examined in an article by Franko and coauthors60 in the Journal of
8
Trauma, 2006. They retrospectively reviewed data from 159 patients who sustained brain injury and
9
who were taking warfarin before the injury. This analysis disclosed that risk of mortality was associated
10
with warfarin use and age. Increasing international normalized ratio was associated with increasing risk
11
of death.
12
The timing of venous thromboembolism prophylaxis in patients with brain injury or patients at
13
increased risk for bleeding is important. This issue is discussed in an article by Norwood and coauthors61
14
in the Journal of Trauma, 2008. The authors reviewed data on 525 patients who had enoxaparin prophy-
15
laxis administered at a mean time after admission of 42 hours. They noted CT scan evidence of progres-
16
sion of brain injury in 3.4% of these patients, but only 1.1% required a change in therapy or craniotomy.
17
The authors concluded that enoxaparin therapy is associated with a low risk of clinically important pro-
18
gression of brain injury and should be used, especially in patients with other high-risk clinical conditions
19
such as lower extremity fracture, pelvic fracture, or spine injury. Their neurosurgeon consultants de-
20
clined to approve admission into the study of a large number of eligible patients so the study could have
21
been biased toward analyzing only low-risk patients.
22
From the perspective of the editor, the problem of patients who sustain brain injury while on
23
anticoagulant drugs is important. The management of these patients will need to be decided based on
24
an understanding of the reason the patient is taking anticoagulant drugs and the risk faced by the pa-
25
tient if the drugs are stopped or reversed. Finding a dependable way to reverse the effects of
26
clopidogrel and aspirin on platelet function has been problematic. There is dependable data to indicate
27
that the use of clopidogrel and aspirin increase blood and blood product use in elective cardiac surgical
28
procedures.62 There is also evidence that aprotinin administered before and during cardiac surgical pro-
29
cedures performed on patients taking clopidogrel and/or aspirin will reduce the volume of bleeding as
30
well as blood product usage.63 There is no high quality data supporting the use of aprotinin in the setting
31
of trauma and emergency management of traumatic brain injury. Platelet transfusion has been used to
44
1
increase the population of normally functioning platelets. Vilahur and coauthors64 published a clinical
2
research study in the Journal of Thrombosis and Haemostasis in 2007 which focussed on the topic of
3
restoration of platelet function and normalization of coagulation following two dosage levels of
4
clopidogrel. These authors used platelets from healthy volunteers and administered these to healthy
5
patients who had taken clopidogrel. Transfusion of 10-12 units of platelets restored coagulation func-
6
tion. The fact that this study used healthy subjects and the fact that the platelets were freshly harvested
7
prior to infusion limits our ability to extrapolate these findings to the care of patients with traumatic
8
brain injury. Banked platelets are known to have attenuated function for the first 12-24 hours after infu-
9
sion. This attenuation of function limits the use of platelet transfusion for the acute management of pa-
10
tients with traumatic brain injury. Similarly, there is no good data supporting the use of other agents
11
such as recombinant factor VIIa as a means of limiting bleeding in patients with traumatic brain injury. It
12
is known that there is no dependable way to reverse the effects of clopidogrel. The identifiable and
13
quantifiable risk of aspirin therapy in the patient with brain injury is difficult to ascertain. Patients who
14
are taking warfarin and are over-anticoagulated (INR>3.0) comprise one group where reversal of antico-
15
agulation will be beneficial. The decision to implement venous thromboembolism prophylaxis will re-
16
quire risk assessment as well. For patients at very high risk, surveillance with ultrasound and/or CT ve-
17
nography may be worth considering if the risk of intracranial hemorrhage is thought to be high. Diagno-
18
sis of venous thrombosis can then prompt therapy with heparin or inferior vena cava filter placement.
19
Readers will recall that a detailed discussion of post injury venous thromboembolic complications ap-
20
peared in Volume 35, Number 4 of Selected Readings in General Surgery.
21
The final three articles discussed deal with the problem of choosing the effective means of mon-
22
itoring the progress of CT findings in patients with clinically mild brain injury. Repeat CT scanning expos-
23
es the patient to additional expense and radiation exposure. If repeat CT scans could be matched with
24
the patients who need them, improved, more cost-effective care would result. The first article discussed
25
is by Sifri and coauthors65 and appeared in the American Journal of Surgery, in 2004. The article is enti-
26
tled “Value of repeat cranial computed axial tomography scanning in patients with minimal head injury.”
27
The authors reviewed records on 151 patients with clinically mild head injury who had persistently nor-
28
mal neurologic examinations. The authors noted that 15% of the patients with persistently normal or
29
improving clinical examination had worse CT scans on repeat scanning but none of these patients re-
30
quired intervention or a change in therapy. Thirty-six percent of patients with worsening neurologic ex-
31
aminations had a worse CT scan on repeat scanning and 33% of these patients required intervention.
45
1
From these data the authors conclude that a persistently normal or improving neurological examination
2
is sufficient for the decision to forego a repeat CT scan.
3
The relationship of neurologic examination change to the need for intervention is examined in
4
an article authored by Brown and coauthors66 in the Journal of Trauma, 2007. The authors reviewed da-
5
ta on 274 patients who were admitted with brain injury and who had an abnormal admission CT scan.
6
When repeat CT scans were done for a changing neurologic examination, intervention was required in
7
38%. When CT scanning was done in 45 patients with normal or improving neurologic examination, in-
8
tervention was required in only 2 patients. These interventions, however, were prompted by the find-
9
ings on the CT scan. The authors note that the 2 patients who had unchanged neurologic examination
10
and required intervention on the basis of CT findings both met criteria for severe brain injury (Glasgow
11
coma score of 8-10).
12
A recent report examining the potential value of routine CT scanning 24 hours or more after
13
admission in patients with clinically mild brain injury is authored by Bee and coauthors67 from the Jour-
14
nal of Trauma in 2009. A full text reprint of this article is included with the mailed version of this issue of
15
Selected Readings. The authors reviewed data from 207 patients admitted with Glasgow Coma Scores of
16
14-15. All patients had abnormal CT scans on admission and 18 of 58 patients who had worsening find-
17
ings on CT scan underwent intervention based on these findings only. The routine followup CT scan is
18
beneficial, these authors conclude, and leads to escalation of neurologic critical care or surgical inter-
19
vention in a significant number of patients.
20
From the perspective of the editor, these seemingly conflicting conclusions about patients with
21
potentially mild brain injury are troubling. What is not known are details of the original determination of
22
the Glasgow Coma Scale? Nor do we know about the potential variance in approaches by the neurosur-
23
gical consultants in the three different institutions. What is worth considering is the cost the patient
24
pays for a misguided effort to reduce resource consumption and radiation exposure. The price for delay
25
in management for a progressing brain injury is high. There are probably other areas in which economies
26
can be realized without placing brain-injured patients at risk.
27
Spine and spinal cord injury
28
Trauma surgeons are frequently confronted with spine injuries that occur in the context of mul-
29
tiple injury from blunt mechanisms. Spinal fractures are challenging injuries, frequently necessitating
30
changes in approach to total injury management because of the need to prevent additional fracture dis-
46
1
placement and possible injury to the spinal cord or spinal nerves. In addition, spine fractures are mark-
2
ers of heavy force transfer and, at least in the case of a thoracolumbar fracture (Chance fracture) predic-
3
tive of intra-abdominal visceral injury. In this section of the overview, we review the diagnosis and man-
4
agement of spine fracture occurring in the setting of multiple injuries. In addition, we will review current
5
management approaches and recent advances in the treatment of spinal cord injury.
6
An article that provides a comprehensive review of spine fracture appeared recently in a 2009
7
issue of The American Surgeon, by Harbrecht and Djurasovic68 entitled “Thoracolumbar spine trauma:
8
diagnostic and therapeutic considerations for the general surgeon.” A full -text reprint of this review is
9
included in this issue of SRGS. The authors open by presenting statistics that offer a perspective on the
10
clinical importance of thoracolumbar spine injury. Approximately 15,000 patients sustain these injuries
11
annually and ⅓ of the spine fractures are associated with significant neurologic disability. Sixteen per-
12
cent of thoracolumbar spine fractures occur between T1 and T10. Fifty-two percent of the fractures oc-
13
cur between T11 and L1. In this area of the thoracolumbar junction, fractures are associated with a sig-
14
nificant risk of paraplegia. Approximately ⅓ of the fractures occur below L1.
15
They next review specific aspects of thoracolumbar spine anatomy and how these features in-
16
fluence the risk of injury. They note that the thoracic portion of the spine is tethered to the rib cage and
17
the sternum and is kyphotic relative to the rest of the spine. These features make this segment of the
18
spine rigid relative to the more distal lumbar spine. The facets of the thoracic spine are oriented coro-
19
nally and this feature provides resistance to flexion-extension forces. Beginning at the thoracolumbar
20
junction, the spine becomes more flexible. The orientation of the facets becomes more sagittal, which
21
provides resistance against rotation but makes this segment of the spine vulnerable to flexion-extension
22
forces. At the thoracolumbar junction, the spinal canal is occupied by the spinal cord and the spinal ca-
23
nal is relatively narrow. This means that small to moderate amounts of bony displacement result in sig-
24
nificant intrusion into the spinal canal and paraplegia risk is greatly increased. Below L1, the spinal canal
25
is wider and is occupied by the cauda equina. This means that neurologic deficits require larger degrees
26
of bony intrusion into the spinal canal and the resulting neurologic deficits are more likely to be nerve
27
root deficits.
28
Harbrecht and Djuravosic note that the diagnosis of spinal injury by physical examination is fre-
29
quently limited because the ability of the patient to cooperate in the physical examination may be im-
30
paired in the multiple injury setting. The presence of spinal deformity, spinal tenderness, and/or neuro-
31
logic deficit is highly suggestive of thoracolumbar fracture. Currently, imaging of the spine is obtained
47
1
with helical CT scanning. Improved multi-slice CT scanning machines allow reconstruction of the central
2
and lateral spine columns, particularly the “middle column” of the spine (that segment including the
3
dorsal third of the vertebral body), the main supporting structure of the spine. The authors acknowledge
4
that the majority of spine fractures discovered with CT scanning are minor and do not require specific
5
treatment.
6
On the other hand, CT imaging is obtained frequently for the evaluation of thoracic and ab-
7
dominal injury and spine images can be reconstructed using specialized computer software. The time
8
spent in imaging the torso structures is therefore reduced. Despite these particular advantages, sur-
9
geons need to be aware of the risk of radiation exposure and limit unnecessary imaging where possible.
10
Recently, there has been interest in developing protocols for imaging of the cervical spine with the ob-
11
jective of eliminating imaging where unnecessary. This topic will be discussed in a subsequent issue of
12
SRGS.
13
In addition to the middle column of the spine (mentioned above) the supporting spinal struc-
14
tures are also grouped into an anterior column consisting of the anterior spinal ligament, the anterior
15
half of the annulus fibrosus, and the anterior half of the vertebral body. The posterior column consists of
16
the posterior bony arch and the supporting structures, including the facets and associated ligamentous
17
complexes. Spinal fractures are divided into three groups, including compression fractures, fracture dis-
18
locations, seat-belt fractures (Chance), and burst fractures. In all fracture mechanisms, evaluation with
19
imaging studies of the posterior ligamentous structures is important because of the critical role these
20
structures play in assuring spinal stability. The authors note that there is a thoracolumbar fracture sever-
21
ity score that includes features of the fracture type, assessment of the posterior ligamentous complex,
22
and evaluation of neurologic deficit. They provide a clear description of the mechanisms of the various
23
fracture types and the forces that produce them. The reader is referred to the text of the article for this
24
information.
25
Treatment of spine fracture depends upon an evaluation of the presence and extent of any as-
26
sociated neurologic deficit, and an assessment of the stability of the spine. Intrusion into the spinal canal
27
with ongoing neurologic deficit progression from spinal cord compression mandates operation to de-
28
compress the spinal cord. MR imaging is used to ascertain the status of the posterior ligamentous com-
29
plex. A stable fracture pattern with intact posterior ligamentous complex indicates that stabilization of
30
the fracture with an orthotic device will be successful. If the fracture is unstable because of damage to
31
the posterior ligamentous complex, operation with instrumentation and spinal fusion is required.
48
1
Spinal cord injury with paraplegia or quadriplegia is a devastating injury that subjects the patient
2
to a reduced life expectancy in addition to the severe disability. In addition, the cost of caring for spinal
3
cord injury patients is enormous. Younger patients who survive for more than 2 years will, in all likeli-
4
hood survive for 20-30 years. Older patients (more than 55 years of age) have a very high, 2-year mortal-
5
ity rate. A limiting factor in the care of high cervical spinal cord injuries is the ability of the patient to be
6
weaned from the ventilator. Electrical stimulation of the diaphragm offers promise as a means of facili-
7
tating the weaning process in ventilator-dependent patients. Previous efforts to establish electrical
8
stimulation of the phrenic nerves within the thoracic cavity were limited by fibrosis induced by the stim-
9
ulator. Currently, efforts at diaphragmatic stimulation have focused upon stimulation of the distal
10
phrenic nerves using electrical stimulators placed on the abdominal surface of the diaphragm via a lapa-
11
roscopic approach. An article describing the current status of this intervention by DiMarco and coau-
12
thors69 appeared in Chest in 2005. These authors provide data on 5 patients who had stimulating elec-
13
trodes placed laparoscopically. Immediate increases in spontaneous tidal volume were observed in 4 of
14
the 5 patients and this increase in tidal volume continued during a conditioning period lasting up to 25
15
weeks. Two patients were able to discontinue ventilator support and 2 were able to be off the ventilator
16
for most of each day. One patient showed no response, possibly because of phrenic nerve fibrosis.
17
Overall, this approach shows promise as a means of removing one of the most important obstacles to
18
rehabilitation of quadriplegic patients.
19
There are no dependable acute treatments for recovery of complete spinal cord injuries result-
20
ing in paralysis. The use of spinal cord cooling through an indwelling epidural catheter, for protection of
21
the spinal cord during operations on the thoracic aorta, has stimulated interest is using this approach for
22
acute spinal cord injury with neurologic deficit. Recent news articles describing the apparently successful
23
treatment of an injured professional athlete have rekindled hope that local hypothermia of the spinal
24
cord might result in recovery of spinal cord function. Two articles are reviewed here describing the ex-
25
perimental basis and the current clinical status of hypothermia for the treatment of acute spinal cord
26
injury.
27
The first article, by Ha and Kim70 in Spine, 2008, described the use of moderate epidural hypo-
28
thermia (30° C for 48 hours) in a rodent model of spinal cord contusion. They observed significant de-
29
creases in neural cell apoptosis and glial activation. In addition, there was improvement in neurologic
30
function in the rats where hypothermia was used. A clinical review of the use of hypothermia in acute
31
spinal cord injury was published in Spine Journal in 2008. This article is authored by Kwon and coau-
49
1
thors71 who note that there are several theoretic examples of the neuroprotective effects of hypother-
2
mia, including the reduction of cellular enzymatic activity and reduction of cellular energy requirements
3
that might prevent ischemic cell death. The authors reviewed the world’s literature on use of systemic
4
and/or local hypothermia for acute spinal cord injury and concluded that there is no valid clinical evi-
5
dence supporting this intervention as an acceptable therapy for acute spinal cord injury.
6
The pathophysiology of spinal cord injury includes local hemorrhage and deposition of coagula-
7
tion proteins into the area of acute injury. The hypertonicity of blood and proteinaceous material elabo-
8
rated at the site of the injury produces edema and increased interstitial pressure. Normal egress of this
9
fluid is functionally blocked from overload of escape pathways for the fluid because there are no lym-
10
phatic channels in the spinal cord. Cell death from compression occurs, but additional cell death occurs
11
because of the elaboration of excitotoxic substances such as glutamate into the area of injury. Cavitation
12
and scarring occur, preventing the transmission of neural signals from the proximal to the distal spinal
13
cord.
14
Two articles reviewing different approaches to the treatment of acute spinal cord injury are ref-
15
erenced at this point. The first, by Coutts and Keirstead,72 reviews the potential and the challenges asso-
16
ciated with stem cell treatment for acute spinal cord injury. The authors note the encouraging animal
17
data that has shown functional recovery of spinal function, albeit partial, after stem cell therapy. Differ-
18
entiation of the stem cells after implantation and transformation of the cells into actively growing cells
19
producing sensory nerves resulted in pain in areas served by the segment of the spinal cord proximal to
20
the injury and this limited the success of the experiment. The authors review a number of technical and
21
ethical issues that have to be addressed before instituting human studies. Despite the challenges, it
22
seems likely that stem cell trials for selected patients with acute spinal cord injury are feasible within the
23
next decade.
24
A novel approach to resolution of the acute aspects of spinal cord injury and the delivery of un-
25
differentiated stem cells to the area of injury is reviewed in an article by Goldsmith73 from the Journal of
26
the American College of Surgeons, 2008. The author reviews the experimental studies that have shown
27
revascularization of the injured spinal cord by omental tissue application to the surface of the spinal
28
cord at the site of injury. Edema resolution has been documented and animal studies have documented
29
some partial return of function. There are, however, no long-term studies of this technique and there
30
are several obstacles to the acute use of this intervention. But, the evidence is provocative and offers
31
additional avenues of treatment that might, at least theoretically, be applied in combination to help re-
50
1
store function in this group of patients for whom there is no effective therapy other than aggressive re-
2
habilitation.
3
Pelvic fracture
4
The pelvis consists of three bones bound together by strong ligamentous complexes. Disruption
5
of the pelvic ring will generally require fracture of bony elements combined with damage to the liga-
6
mentous structures. Pelvic fractures are common in patients injured by blunt mechanism. Most frac-
7
tures of the pelvis are minor, non-displaced fractures of the pubic rami. These fractures do not require
8
treatment aside from pain control and physical therapy for assistance in gaining pain free ambulation.
9
More severe fractures of the pelvic ring, with multiple areas of displacement, are markers of major force
10
transfer and occur in patients injured in high-speed motor vehicle crashes, auto-pedestrian collisions,
11
and in falls from heights. In this section of the overview, we discuss several features of the epidemiolo-
12
gy, diagnosis, and management of patients with severe pelvic fracture.
13
Pelvic fractures are classified according to the direction of the force producing the fracture and
14
the degree of bony displacement. The available classification schemes are discussed by Sagi in Chapter
15
49 of a recently published trauma text.74 Readers are encouraged to review the classification schemes
16
using that source. The Young-Burgess system is one of the most frequently used classifications. This sys-
17
tem is shown in the accompanying table and is reproduced with permission. The epidemiology of pelvic
18
fracture will be reviewed focussing on several articles that review mechanisms, associated injuries, and
19
vulnerable patient groups
20
The first article reviewed is by Demetirades and coauthors75 and appeared in the Journal of the
21
American College of Surgeons, 2002. They reviewed data on more than 16,000 patients in an institution-
22
al trauma registry. One thousand five hundred forty-five patients sustained pelvic fracture (9.3% of to-
23
tal). The observed mortality was 13.5% overall, but only 0.8% of patients died as a direct result of pelvic
24
fracture. The main injury mechanism was motor vehicle crash although the authors note that other inju-
25
ry mechanisms such as auto-pedestrian collisions, motorcycle crashes, and falls are more likely to pro-
26
duce severe pelvic fracture. The authors confirmed other studies which have shown an association of
27
severe pelvic fracture with thoracic aortic injury. The association of pelvic fracture from high force trans-
28
fer with injuries to other abdominal organs was noteworthy. There was also increased risk of bladder
29
and urethral injury in patients with high force transfer pelvic fracture. The main injury mechanism was
30
motor vehicle crash, although other injury mechanisms such as auto-pedestrian collisions, motorcycle
51
1
crashes, and falls are more likely to produce severe pelvic fracture. The authors confirmed other studies
2
that have shown an association of severe pelvic fracture with thoracic aortic injury.
3
Another study examining the epidemiology of pelvic ring fracture by Rowe and coauthors76 ap-
4
peared in Surgery, 2004. The authors reviewed detailed motor vehicle crash analysis data using the
5
CIREN database. They found that lateral impact crashes where there was vehicle size incompatibility
6
were factors associated with the production of pelvic ring fracture. Female patients were at higher risk
7
for pelvic fracture. The authors emphasize that the data reviewed focused on newer vehicles more likely
8
to have modern restraint devices. Regardless, it was obvious that currently available side impact protec-
9
tive devices did not protect patients, particularly women, from pelvic fracture. Readers may note that
10
this is not a surprising observation given the fact that the current design of side impact protective devic-
11
es is directed toward protection of occupants’ head and neck areas.
12
Examination of the epidemiologic characteristics in different age groups is the topic of the next
13
several articles reviewed. The first of these is by Demetriades and coauthors77 and appeared in the Jour-
14
nal of Trauma, 2003, entitled “Pelvic fractures in pediatric and adult trauma patients: are they different
15
injuries?” The authors reviewed data from a single institution database over an interval of 8 years. Dur-
16
ing that interval, more than 14,000 patients were admitted and pelvic fracture was present in 10% of the
17
patients. The authors found that the risk of pelvic fracture was increased two fold for adult patients in
18
the most common pelvic fracture mechanism groups, including motor vehicle crashes and auto-
19
pedestrian collisions. In patients whose injuries occurred from falls greater than 15 feet, the risk of pel-
20
vic fracture was 7 times greater in adults than in the pediatric age group. The authors found that the risk
21
of severe pelvic fracture was equivalent in both groups. This is likely because the fact that severity of
22
pelvic fracture is related to the degree of force transfer and not to the injury mechanism or the age of
23
the patient. The risk of associated intra-abdominal solid organ and hollow viscus injury was equivalent in
24
both age groups. Of interest is the observation from these data that the risk of life-threatening bleeding
25
from pelvic fracture was low (2.9%) in adults, but no instances of life-threatening hemorrhage were ob-
26
served in the injured children.
27
A limitation of this report is that patients were not grouped according to a standard pelvic frac-
28
ture classification scheme. The frequencies of other severe injuries that may cluster in one or another of
29
the age groups such as brain injury and thoracic injury were not reported. Finally, we have no infor-
30
mation on whether there was a disproportionate frequency of death at the scene in adults and children.
52
1
Despite these limitations, the data are important and contribute to establishment of baseline risk for
2
adults and children who sustain pelvic fracture.
3
Additional consideration of important characteristics of pelvic fractures in children is found in an
4
article authored by Chia and coauthors78 from the Journal of Trauma in 2004, entitled “Pelvic fractures
5
and associated injuries in children.” The authors reviewed admissions to a single center during 17 years.
6
In that time, 120 children with pelvic fractures were seen. The median age of the children was 9 years
7
and motor vehicle pedestrian collision was the most common cause of the pelvic fracture. Five of the
8
patients died of injuries. Associated injuries required operative intervention more often than pelvic frac-
9
tures. The authors were able to provide 3-year followup data for their patients and they noted that dis-
10
abling neurologic dysfunction and/or growth abnormality, with leg length discrepancy, were recorded in
11
nearly 30% of the surviving children. The majority of the long-term complications were related to asso-
12
ciated brain, spinal cord, and/or peripheral nerve injury. Immaturity of the ligamentous structures in the
13
pelvis might contribute to the leg length discrepancies noted. In closing they report that pelvic fracture
14
in children is frequently a marker for major force transfer and associated injuries are common. A limita-
15
tion of this article is that the patient experiences occurred in a prolonged interval and the authors do
16
not provide any information about changes in patient management that could have occurred during the
17
17-year span of their report. Despite this limitation, the report serves to remind clinicians that auto-
18
pedestrian collision resulting in pelvic fracture is a major injury requiring multidisciplinary team effort to
19
assure optimal outcomes.
20
The next three articles reviewed deal with pelvic fractures occurring at the opposite extreme of
21
age. The first of these articles by Henry and coauthors79 appeared in the Journal of Trauma, 2002, enti-
22
tled “Pelvic fracture in geriatric patients: a distinct clinical entity.” The authors classified pelvic fractures
23
using standard classification schemes that emphasize direction of the injuring force and degree of frac-
24
ture displacement. Patients older than 55 years had a greatly increased risk of sustaining lateral com-
25
pression fractures. Examining the data, older patients also were more often injured from auto-
26
pedestrian collisions and fall compared with the younger patients. This may explain, in part at least, the
27
propensity for older patients to have lateral compression fractures. Although the older patients had
28
more lateral compression fractures, the fractures they sustained had lower frequencies of severe dis-
29
placement. Despite this, older patients had a higher risk of bleeding requiring transfusion and/or angi-
30
ography than did the younger patients.
53
1
This observation serves to emphasize the lack of association between fracture classification
2
schemes that equate “severity” with the degree of bony displacement and the risk of significant pelvic
3
fracture hemorrhage. In the discussion section of their paper, these authors cite data emphasizing the
4
dissociation of bleeding risk from fracture pattern. This issue will be discussed in more detail in a later
5
section. In concluding the article, these authors speculate that the higher risk of bleeding from pelvic
6
fracture in older patients might be, in part, because of the increased risk of osteoporosis in this age
7
group. An editorial comment by Dr. Christine Cocanour accompanies this report. She notes that another
8
possible explanation for the increased bleeding risk in older patients may be the use of drugs that alter
9
coagulation. Data on this association were not provided in this article.
10
A more recent report provides additional data confirming the increased risk of mortality from in-
11
jury faced by elderly patients, especially those with pelvic fracture. This article is by Dechert and coau-
12
thors80 in The American Surgeon, 2009. The authors reviewed data from a group of 1223 patients cared
13
for in their institution over the course of a 6- year interval. One hundred fifty-seven of these patients
14
were more than 65 years of age and they were compared with the younger cohort. The elderly injured
15
patients with pelvic fracture were also compared with a group of 1770 patients aged 65 years or older
16
who were injured but did not sustain a pelvic fracture. The authors noted that advanced age increased
17
mortality risk regardless of injury pattern.
18
The authors also noted that elderly patients were more likely to die of multiple systems organ
19
failure; younger patients were more likely to die from blood loss. They confirmed reports of others not-
20
ing increasing rates of comorbidity in elderly injured patients. Whereas this report uses a more conven-
21
tional definition of the elderly patient than did the earlier report, the contribution of pelvic fracture to
22
mortality and complications is less clear. The article clearly shows that advanced age but not the injury
23
pattern itself is more likely to drive higher mortality risk.
24
The next article explores the potential relationship between fracture pattern and the risk of pel-
25
vic visceral injury. The authors reviewed data from 362 patients with pelvic fracture seen at their institu-
26
tion. They found that 32 of these patients had rectal (8 patients) or lower urinary tract injuries (24 pa-
27
tients). The presence of anterior pelvic fracture in association with separation of the sacroiliac joint was
28
more likely to be a marker for these visceral injuries than other fracture patterns. Thus, visceral injury
29
was more likely to occur with anterior compression fracture forces. The presence of an anterior com-
30
pression force injury with fracture of the inferior pubic ramus was strongly associated with lower urinary
31
tract injury. The authors note, as others have, that blood at the urethral meatus was not present in sev-
54
1
eral of their patients who sustained urethral disruption. No data were supplied on the presence or ab-
2
sence of perineal laceration and open pelvic fracture in the patients with rectal injury.
3
The authors recommend that a low threshold for performing retrograde urethrography be
4
adopted. And, they recommend rigid proctosigmoidoscopy for patients who have perineal injury or
5
blood discovered on digital rectal examination. Rigid proctoscopy is usually chosen over flexible endos-
6
copy because of the frequent need to transfer the patient for flexible examination. There are no data to
7
suggest that one technique is inferior to the other for detecting rectal injury. Open pelvic fracture with
8
perineal laceration is frequently an indication for proctoscopic examination whether or not there is
9
blood found on rectal examination.
10
11
12
The management of lower urinary tract injuries is discussed in the next section on genitourinary
injuries. Rectal injury is discussed within the issues of SRGS dealing with colon and rectal problems.
The final article discussed in this section deals with the outcomes of pregnant patients who sus-
13
tain pelvic fracture. The article is by Leggon and coauthors81 from the Journal of Trauma in 2002. The
14
authors reviewed the literature searching for reports of pregnant patients who had sustained pelvic
15
fracture. They were able to discover data on 101 patients; maternal and fetal mortality were significant
16
in this patient group. Maternal mortality was 9% and fetal mortality was 35%. They found that motor
17
vehicle crashes were associated with increased risk of fetal mortality and auto-pedestrian collisions
18
were more likely to kill the mother. This is not surprising because anterior compression fracture forces
19
are more likely in motor vehicle crashes and this force transfer mechanism likely delivers force directly
20
to the uterus. Auto-pedestrian collisions are associated with heavy force transfer to the patient struck,
21
with high likelihood of associated injuries leading to maternal mortality.
22
Diagnosis of pelvic fracture is usually accomplished using a synthesis of clinical information that
23
includes knowledge of the injury mechanism, physical examination, and supplementary imaging. Pelvic
24
fracture is suspected when there are symptoms of pelvis or lower back pain and tenderness in a patient
25
who is able to cooperate with the physical examination. Educational activities that guide trauma prac-
26
tice, primarily the Advanced Trauma Life Support Course offered by the Committee on Trauma of the
27
American College of Surgeons, suggest that physical examination of the pelvis has a sufficiently high
28
negative predictive value that supplemental imaging can be eliminated in patients whose physical ex-
29
aminations are completely negative. In actual practice, pelvic imaging, using the anterior-posterior pelvis
30
radiograph is frequently a routine part of the screening imaging studies obtained in the trauma resusci-
55
1
tation area. Data to examine the appropriateness of this practice are supplied as a part of the discussion
2
on diagnosis of pelvic fracture.
3
The first article discussed is by Gonzalez and coauthors82 from the Journal of the American Col-
4
lege of Surgeons, 2002. The authors reviewed data on 2,176 patients admitted to a Level 1 trauma cen-
5
ter during the course of 32 months. Surgical resident staff performed a patient interview and physical
6
examination of the pelvis. The interview assessed the presence of pain in the area of the pelvis and low-
7
er back. The pelvic physical examination consisted of inspection of the pelvic area for contusions, abra-
8
sions, and lacerations over bony prominences and in the perineal area. Lateral anterior-posterior com-
9
pression of the iliac wings and lateral-medial compression were performed. The area of the pubic sym-
10
physis was examined for tenderness and widening. The urethral meatus was examined for blood, and a
11
rectal examination was performed. The examination was recorded on a designated form and all patients
12
then underwent an anterior-posterior pelvic radiograph. Ninety-seven patients were diagnosed with
13
pelvic fracture. In alert patients able to cooperate with the physical examination, there were 7 missed
14
injuries on physical examination (sensitivity 93%). None of the missed fractures required specific treat-
15
ment. The anterior-posterior radiograph had sensitivity for fracture of 87%. In patients with elevated
16
blood alcohol examinations, the sensitivity of the clinical examination in this group was 95%. These au-
17
thors recommend elimination of the radiograph of the pelvis in alert patients with negative clinical ex-
18
amination.
19
The topic of diagnosis of pelvic fracture is further explored in an article authored by Duane and
20
coauthors83 in The American Surgeon, 2001. These authors compared findings of physical examination
21
and anterior-posterior pelvic radiographs in 108 patients with pelvic fracture and 111 patients without
22
pelvic fracture. They found that the combination of a negative lower back and pelvic examination re-
23
sulted in a negative predictive value of 87% for pelvic fracture diagnosed by radiographic imaging. They
24
recommend, on the basis of their data, that the anterior-posterior pelvic radiograph be used selectively.
25
Patients with Glasgow Coma Scores of less than 14, patients with positive physical examinations, and
26
patients who, for any reason, cannot cooperate with a physical examination are referred for radiograph-
27
ic imaging. Patients who can participate in the physical examination and who have a negative examina-
28
tion do not require imaging.
29
The same group of authors conducted a prospective analysis based on the findings of their ret-
30
rospective study. These data are contained in a report that appeared in the Journal of Trauma in 2002.84
31
The article is entitled “Blunt trauma and the role of routine pelvic radiographs: a prospective analysis.” A
56
1
full text reprint of this article is supplied with the mailed version of this issue of Selected Readings. In
2
this report the authors prospectively analyzed 45 patients included in a protocol that dictated that pelvic
3
radiographs would be performed in patients who were not alert or patients who had positive physical
4
examinations. Patients with negative physical examinations would be followed without radiographic ex-
5
aminations. Their data, in this prospective analysis, confirmed the findings of the retrospective analysis.
6
The sensitivity of the physical examination was 100% and the negative predictive value of the physical
7
examination was 100%. This study is limited because all patients who were eligible for evaluation were
8
not included in the prospective protocol. The authors acknowledge that some resident teams were
9
more diligent entering patients into the protocol than others. This fact raises the possibility that the pro-
10
tocol patients underwent more thorough physical assessment. It is possible that the accuracy of the
11
physical examination is subject to variability and fractures might be missed. Given the consistent obser-
12
vation by experienced trauma surgeons that fractures missed in patients with negative physical exami-
13
nations tend to be minor and rarely require any specific treatment, the limitations of this study do not
14
eclipse the basic message that the radiographic examination of the pelvis can be used selectively.
15
Given the increasing use of helical multidetector CT imaging in patients with multiple blunt
16
trauma, a legitimate concern exists whether CT can effectively replace the anterior-posterior pelvic ra-
17
diograph as the screening imaging modality of choice in selected injured patients. This topic is addressed
18
in a report by Vo and coauthors85 in Emergency Radiology, 2004. The authors reviewed findings of CT
19
imaging studies in 60 patients found to have pelvic fractures and compared these findings with the ante-
20
rior-posterior radiograph findings in the same group of patients. CT imaging disclosed 163 fractures in 60
21
patients.
22
From the same group, the anterior-posterior radiograph disclosed 132 fractures in 52 patients.
23
Thus there were 88 falsely negative anterior-posterior radiographs. These authors contend that elimina-
24
tion of the anterior-posterior pelvis radiograph in patients who will undergo CT imaging of the abdomen
25
and pelvis will reduce costs, reduce radiation exposure, and increase efficiency. This study is limited be-
26
cause the clinical impact of the fractures discovered was not assessed and reported. CT imaging is very
27
sensitive for discovery of fractures. The superiority of CT imaging is based, in this report, partially on the
28
fact that CT was better at finding acetabular fractures. It is well known that the anterior-posterior pelvic
29
radiograph is an inferior means for diagnosis acetabular fractures. Despite these limitations, it does
30
seem reasonable to conclude that patients who are going to have CT imaging can forego routine anteri-
31
or-posterior pelvic radiographs.
57
1
In the foregoing discussion, the utility of imaging in adult patients at risk for pelvic fracture was
2
the focus. The next article discussed evaluates imaging in pediatric patients. The article is by Guilla-
3
mondegui and coauthors86 from the Journal of Trauma, 2003, entitled “The utility of the pelvic radio-
4
graph in the assessment of pediatric pelvic fractures.” The authors reviewed data from consecutively
5
admitted patients in a pediatric trauma center. Findings from CT imaging were compared with findings
6
on anterior-posterior radiographs. The authors discovered that the anterior-posterior radiograph missed
7
almost 50% of the fractures discovered by pelvic CT imaging. This observation is not surprising because
8
the CT images discover more fractures than plain radiographs. Missing from these data is an assessment
9
of the clinical impact of fractures missed on plain images. Also, the study is limited in that the radiologist
10
reviewing the CT images was not blinded to the findings on plain images. This fact is brought out in the
11
discussion that accompanies this article. Importantly, the authors do not contend that the CT scan
12
should become a screening tool for detection of pelvic fractures. They do support the position that pa-
13
tients who have findings that place them at risk for pelvic fracture and who are going to undergo CT im-
14
aging, will benefit from CT examination of the pelvis.
15
Pelvic fracture hemorrhage is uncommon but is a life-threatening complication of pelvic frac-
16
ture. The approaches to pelvic fracture hemorrhage recognize that pelvic bleeding can arise from bone
17
edges, venous lacerations, and from arterial injuries. Occasionally, major arterial and venous trunks are
18
injured. In the overwhelming majority of patients, however, bleeding arises from bone edges and from
19
multiple injuries of small and medium sized arteries and veins. Several avenues are available to control
20
pelvic fracture bleeding, including reduction of the volume of the pelvis using external compression or
21
temporary external fixation, angiography with embolization, and packing of the pelvis with gauze
22
sponges. The articles discussed in this section deal with the approaches to diagnosis of pelvic fracture
23
bleeding and definitive control of the bleeding site(s).
24
The first article is by Heetveld and coauthors87 from the World Journal of Surgery in 2004. The
25
authors used a multidisciplinary approach to develop evidence-based guidelines for the evaluation and
26
management of hemodynamically unstable patients with pelvic fractures. They then retrospectively re-
27
viewed their practice to determine the level of compliance with these guidelines. The guidelines stress
28
rapid identification of the presence of pelvic fracture, the presence of ongoing hemorrhage, and the
29
presence or absence of intraperitoneal fluid. The authors used diagnostic peritoneal aspiration (10 mL or
30
more of gross blood on aspiration was considered positive) or ultrasound to evaluate intraperitoneal
31
bleeding. They used compression or external approximation devices to reduce pelvic volume and the
58
1
practice guidelines required that the decision to use angiography and embolization be made within 90
2
minutes of the patient’s arrival at the trauma center.
3
If ultrasound or diagnostic peritoneal aspiration was positive, the patient went to the operating
4
room for exploration. If there were no intraperitoneal injuries and the pelvic hematoma was expanding,
5
the patient had rapid application of an external device for reduction of pelvic volume and preparations
6
were made for angiography if reduction of pelvic volume did not produce hemodynamic stability. Simi-
7
larly, patients who underwent angiography without identification of a bleeding point and who then de-
8
veloped a positive ultrasound or diagnostic peritoneal aspiration were explored.
9
The authors found that their practice, as assessed by retrospective review of records, was not
10
compliant with the evidence-based guidelines. Slightly more than 50% patients had evaluation for intra-
11
abdominal bleeding within the required time frame and only 38% of patients were transferred for angi-
12
ography within 90 minutes. These authors concluded that presence of trauma attendings during the ear-
13
ly stage of resuscitation and evaluation was likely to improve compliance and that education on the
14
guidelines was necessary to achieve the necessary “buy-in” of surgery attendings to ensure compliance
15
with the protocol.
16
The next articles reviewed evaluate clinical predictors of pelvic fracture bleeding. The first article
17
reviewed is by Eastridge and coauthors88 in the Journal of Trauma in 2005. These authors reviewed pa-
18
tients who were hypotensive, with signs of ongoing blood loss. Patients with pelvic fractures were classi-
19
fied according to estimates of pelvic fracture stability using standard pelvic fracture classification scales.
20
Patients with stable fracture patterns had intraperitoneal sources for their bleeding in the majority of
21
cases. Patients with unstable fracture patterns were more likely to have pelvic fracture hemorrhage.
22
When pelvic fracture hemorrhage was likely, patients were treated with pelvic compression and angi-
23
ography initially. Patients bleeding from both sites tended to have lower mortality risk if they underwent
24
angiography first. The close association of fracture pattern with bleeding site may be explained, at least
25
partially, by the fact that no patient was more than 50 years of age. Little data are given about associat-
26
ed injuries that might contribute to ongoing shock such as thoracic injury.
27
Finally, as pointed out in an editorial comment authored by Dr. Thomas Scalea following the ar-
28
ticle, external fixation was not used. It is not clear that external compression is as effective as external
29
fixation for reduction of pelvic volume. Another article evaluating the ability of fracture pattern to pre-
30
dict risk of bleeding is authored by Sarin and coauthors89 from the Journal of Trauma, 2005, entitled
59
1
“Pelvic fracture pattern does not always predict the need for urgent embolization.” The authors re-
2
viewed data from 283 patients with pelvic fractures who arrived in a hypotensive state in the trauma
3
resuscitation area. Of these patients, 37 underwent angiography and embolization for an identified pel-
4
vic bleeding site. The authors grouped fracture patterns according to the presence or absence of “major
5
ligamentous disruption.” Ligamentous disruption was defined according to fracture patterns from ante-
6
rior-posterior compression forces, lateral compression forces, or combined forces with bony displace-
7
ment. The authors found that fracture pattern did not correlate with the need for angiography and em-
8
bolization. They found that the bleeding risk in women increased with age but this association was not
9
observed in men. This observation is likely to be partially explained by the fact that there were no men
10
older than 45, while there were several women aged more than 60 years. The older women patients
11
probably did not completely account for the lack of association of fracture pattern with bleeding. It is
12
more likely that there is a limit to the sensitivity of fracture pattern as a predictor of bleeding. For this
13
reason, fracture pattern is only one index surgeons should use to evaluate patients for the risk of pelvic
14
fracture bleeding.
15
The potential for using an estimate of pelvic hemorrhage volume assessed by measuring the size
16
of the pelvic hematoma is evaluated in an article by Blackmore and coauthors90 in Archives of Surgery,
17
2003. These authors measured the volume of pelvic hematoma as found on CT images and related the
18
size of the pelvic hematoma to the need for interventions to control bleeding. They found an association
19
between the size of the hematoma and the need for angiography. They also found that patients with
20
estimated hematoma volumes greater than 500 mL were more likely to require transfusion and were
21
more likely to have an arterial bleeder found on angiography.
22
The major limitation of this approach, as acknowledged by the authors, is that hematoma vol-
23
ume measurement cannot be accomplished within the time frames when decisions about angiography
24
and embolization have to be made. This limitation stimulated the authors to conduct a detailed assess-
25
ment of predictors of pelvic fracture bleeding and the need for angiography. This followup article ap-
26
peared in the Journal of Trauma, 2006.91 The authors reviewed data from 627 eligible patients retro-
27
spectively and performed logistic regression analysis to identify factors that predicted major pelvic frac-
28
ture bleeding. Major bleeding was defined on the basis of angiographic findings and transfusion re-
29
quirement. The data disclose that an admitting heart rate of 130 beats/min or greater, a hematocrit of
30
30% or less, obturator ring fracture, and wide pubic symphysis diastasis were predictors of major bleed-
31
ing. Patients with none of the predictors had a 0.16% risk for bleeding; patients with 3 or 4 factors had a
60
1
66% chance of major hemorrhage. This article confirms that fracture pattern alone cannot accurately
2
predict the risk of pelvic fracture hemorrhage. A combination of fracture pattern assessment with phys-
3
iologic variables is more likely to identify patients who are at high risk for bleeding.
4
Many patients with pelvic fracture undergo CT imaging to identify injuries within the thorax, ab-
5
domen, and pelvis. Extravasation of contrast material has been identified as evidence of arterial bleed-
6
ing. Whether all patients with contrast extravasation should immediately undergo angiography with
7
embolization is the topic of an article by Diamond and coauthors92 in the Journal of Trauma, 2009. In a
8
group of 70 patients with CT evidence of contrast extravasation, 39 had extravasation in pelvic sites and
9
33 additional patients had extravasation in both abdominal and pelvic sites. Of the 39 patients with pel-
10
vic extravasation, 12 underwent immediate angiography and 3 had no arterial bleeding identified (it is
11
worth noting that this represents a 75% positive rate for angiographic identification of a potential site of
12
bleeding). The authors identified 27 patients who were hemodynamically stable despite having contrast
13
extravasation in a pelvic location. These patients were monitored closely; 4 required subsequent arteri-
14
ography and intervention, and 23 successfully completed nonoperative therapy. The authors conclude
15
that stable patients with pelvic sites of contrast extravasation can be safely managed nonoperatively.
16
The limitation of this study is its small size. It is likely that selected patients can be managed without an-
17
giography if they are stable. The frequent need for intervention for associated injuries in patients with
18
pelvic fracture and suspected pelvic fracture bleeding make nonoperative management challenging for
19
this group of patients. Frequently, angiography, even if negative, will facilitate patient management by
20
helping to eliminate a potential source of bleeding.
21
Treatment of pelvic fracture bleeding is the topic of the next group of articles discussed. The
22
first of these is authored by Simpson and coauthors93 and was a case report in the Journal of Trauma,
23
2002. The authors describe reduction of pelvic volume in 2 patients with pubic symphysis diastasis by
24
applying a bedsheet around the pelvis at a level just caudal to the anterior superior iliac spines. Reduc-
25
tion in pelvic volume as assessed by reduction of pubic symphysis diastasis was 87% in one patient and
26
38% in the other patient. Sufficient hemodynamic stability was achieved to allow evaluation and treat-
27
ment of associated injuries to move forward and for external fixation of the pelvis in the operating room
28
to occur. Readers should note that one of the authors of this article (Dr. Bottlang) subsequently devel-
29
oped the T-Pod® device that can be applied to the pelvis during resuscitation to easily reduce pelvic vol-
30
ume.
61
1
The use of pelvic compression devices for control of pelvic fracture bleeding is the topic of a re-
2
port authored by Croce and coauthors94 which appeared in the Journal of the American College of Sur-
3
geons in 2007. A full text reprint of this article is supplied with the mailed version of this issue of Select-
4
ed Readings. The authors report a single institution, retrospective, experience with 186 patients who
5
had significant pelvic fracture bleeding. These patients were a subgroup of 3,359 patients with pelvic
6
fracture seen at the authors’ trauma center over a 10 year interval. For the purposes of this analysis, the
7
authors compared 93 patients who were managed initially with external pelvic fixation to a similar sized
8
group of patients treated with a pelvic orthotic device. The pelvic orthotic device was the T-Pod® device
9
mentioned previously. The authors report that the groups were similar in terms of fracture type, age,
10
and severity of shock. They observed decreases in both 24 hour and 48 hour transfusion volumes in the
11
patients treated with the pelvic orthotic device. Hospital length of stay was also reduced in the orthotic
12
device patients. While there was a trend toward reduced overall mortality in the orthotic device group,
13
this did not reach statistical significance. The data reported in this article were presented at the annual
14
meeting of the Southern Surgical Association in December of 2006. The discussion of the paper that oc-
15
curred at the time of the meeting is included with the article reported in the Journal of the American
16
College of Surgeons. In the discussion, several surgeons pointed out a limitation of the study which is
17
that the orthotic device patients were all treated in a more recent era of the authors’ experience and it
18
is not possible, from the data presented, to determine what other interventions and protocol improve-
19
ments may have occurred concurrently with the introduction of the pelvic orthotic device. Concerns
20
were also raised relevant to the potential for skin breakdown as well as fracture over-correction which
21
may occur with prolonged use of the orthotic device and the application of the device to fractures which
22
have cranial-caudal displacement of the hemipelvis. The senior author, Dr. Croce, acknowledged the lim-
23
itations of the study and reported that the protocol employed in his trauma center provides for imaging
24
documentation of the extent of reduction of bony displacement. He further noted that he agreed with
25
the need to frequently assess the patients who are placed in the pelvic orthotic device for skin pressure
26
changes. Several of the discussants noted that the response to the orthotic device is frequently rapid,
27
occurring within hours, and with stabilization of coagulation and other supportive measures, the orthot-
28
ic device can be discontinued, usually within 1-3 days. Shortening the interval of orthotic device use will
29
be another factor that will probably act to reduce the risk of pressure related damage to the skin. Final-
30
ly, because there was no data presented in this report regarding the impact of use of the orthotic device
31
on the frequency and timing of angiography with embolization, no conclusions can be drawn regarding
62
1
the effect of the orthotic device on significant arterial bleeding. It seems likely that the orthotic device
2
will have its most notable impact on venous and bone edge bleeding.
3
In most trauma centers in the United States, arrest of pelvic hemorrhage is done by a combina-
4
tion of external compression (increasingly using the T-Pod device) or external fixation in the operating
5
room. There are a number of centers that use the external C-clamp. The C-clamp compresses the poste-
6
rior elements of the pelvis. Disadvantages of the C-clamp include the risk of entry site infection and bony
7
penetration by the prongs of the clamp. The external fixator devices are placed anteriorly. The external
8
fixator device and the C-clamp can be placed in the trauma resuscitation area but many trauma ortho-
9
pedists prefer to place these devices in the operating room. Access to the abdomen can be compro-
10
mised by the position of the external fixator device. External fixation and C-clamp application are varia-
11
bly employed by trauma orthopedic surgeons. Data to support one approach over the other are not
12
available.
13
Making the decision for external fixation or immediate angiography is challenging and is based
14
on a synthesis of clinical information. This topic is addressed in an article authored by Miller and coau-
15
thors95 in the Journal of Trauma, 2003, entitled “External fixation or arteriogram in bleeding pelvic frac-
16
ture: initial therapy guided by markers of arterial hemorrhage.” A full text reprint of this article is includ-
17
ed with the mailed version of this issue of Selected Readings. The authors divided patients with pelvic
18
fracture into resuscitation responders (defined as stabilization of blood pressure at a level above 90
19
mmHg for more than 2 hours with 2 units or fewer of blood transfusion) and non-responders. The au-
20
thors found 73% of non-responders had an arterial hemorrhage site identified on angiography. Three
21
patients in the responder category underwent angiography and none had a bleeding site identified. In
22
patients believed amenable to external fixation, non-response was highly predictive of discovery of an
23
arterial bleeding site by angiography. Of patients who underwent CT imaging before angiography, the
24
presence of contrast extravasation had sensitivity of 57% and positive predictive value of 75% for dis-
25
covery of an arterial bleeding site on angiography. These authors recommend that patients at high risk
26
of pelvic fracture bleeding who do not respond to resuscitation should be evaluated immediately with
27
angiography.
28
From the perspective of the editor, the decision to pursue external compression, external fixa-
29
tion, or angiography will need to be made taking into account features of the pelvic fracture. Patients
30
with wide pubic symphysis diastasis will frequently stabilize with reduction of the diastasis with a pelvic
31
compression device; patients with cranial-caudal displacement of the hemipelvis will frequently not re-
63
1
spond to this therapy. Another factor will be availability and preferences of the trauma orthopaedist.
2
External fixation and/or C-clamp application frequently takes time. Patients with clinical evidence of on-
3
going bleeding are probably best served, if the bleeding is most likely coming from the pelvis, with im-
4
mediate angiography and embolization. It is necessary that equipment and personnel equivalent to the
5
trauma operating room be available in the angiography suite. Anesthesia support, monitoring equip-
6
ment and provision for rapid infusion of blood and blood products are essential. Fortunately, with many
7
trauma centers equipping angiography suites for the performance of endovascular procedures, gather-
8
ing the necessary personnel and equipment is becoming a smaller challenge. Any center deciding to at-
9
tempt angiographic embolization of unstable patients will require an honest assessment of the availabil-
10
ity of the necessary personnel and equipment. Encouraging results from one European center and one
11
American report suggested the use of a C-clamp and/or pelvic packing either through an extraperitoneal
12
approach using groin incisions or via laparotomy.96, 97 The initial small European series consisted of 20
13
patients and a 25% mortality rate was reported. The American report analyzed data on 28 patients and
14
these authors reported a reduction in mortality from 40% in a group of historical controls where they
15
relied on angiography and embolization to 25% in the current report using preperitoneal packing.
16
Preperitoneal packing has not been applied in a sufficient number of American centers to produce de-
17
pendable data to recommend its use. A multi-institutional trial would be valuable in correcting this defi-
18
ciency in our knowledge. Packing may be applicable to some patients who have ongoing pelvic hemor-
19
rhage and who also require exploratory laparotomy for abdominal bleeding.
20
Genitourinary injuries
21
The discussion of genitourinary injuries in this section of the overview review, sequentially, im-
22
portant areas of knowledge for the general surgeon who may be called upon to manage, or assist in
23
managing, injuries to the kidney, ureter, bladder, urethra, and external genitalia. Recent changes in
24
management of kidney and bladder injuries with the emergence of successful nonoperative approaches
25
will be emphasized.
26
Injuries to the kidney may occur as a consequence of blunt or penetrating injury mechanisms.
27
The main objectives in management of renal injury are to control bleeding from all injured organs, in-
28
cluding the kidney, and to preserve functioning renal tissue, if preservation of renal function is possible
29
in keeping with the need to deal with other life-threatening injuries. As life expectancy has increased in
30
many areas of the world, chronic renal insufficiency from diseases such as atherosclerotic cardiovascular
31
disease and diabetes has become more frequent. Avoidance of nephrectomy in patients with renal inju-
64
1
ry is an important component of prevention of renal insufficiency. Renal injury severity is scored using
2
the renal injury severity scale developed by the American Association for the Surgery of Trauma. The
3
scale is described in a chapter authored by Thomas and coauthors in a recently published trauma text-
4
book.74 The table is reproduced here with permission.
5
If it is safe to do so, preoperative CT imaging of the kidney is obtained and this allows grading of the re-
6
nal injury. Imaging frequently discloses sites of active bleeding and urine extravasation. Stable renal he-
7
matomas from blunt or penetrating injury not associated with urine extravasation can usually be man-
8
aged nonoperatively. If abdominal exploration is needed urgently and preoperative imaging is not possi-
9
ble, a one-shot, on table, intravenous pyelogram can assist in determining functional status of the unin-
10
jured kidney, the degree of function in the injured kidney, and the presence of urine extravasation. Suc-
11
cessful visualization of contrast excretion in the uninjured kidney occurs more commonly than detailed
12
visualization of the injured kidney. In the unstable or intermittently unstable patient, visualization of
13
either kidney may not be possible. In addition, positioning of radiologic equipment and proper timing of
14
contrast administration are challenging in the setting of acute trauma with injuries to other organs and
15
ongoing blood loss. Overall, results of one-shot pyelography have been variable. It may be necessary for
16
the surgeon and/or urologist to determine the need for renal exploration from inspection of the kidney
17
and overall assessment of the patient.
18
As we begin the discussion of renal injury, we will sequentially consider the decision process
19
leading to renal exploration, the sequential technical steps in renal exploration, repair, or nephrectomy,
20
and the techniques of renal repair. The first article reviewed is by Shariat and coauthors98 in the Journal
21
of Trauma, 2008, entitled “Development of a highly accurate nomogram for prediction of the need for
22
exploration in patients with renal trauma.” These authors reviewed clinical and laboratory information
23
from a total of 419 patients who sustained renal injury. Logistic regression models were developed to
24
evaluate the univariate and multivariate predictors of renal exploration. Eighty-nine patients underwent
25
renal exploration. The authors found that the need for renal exploration was accurately predicted by a
26
nomogram they designed using the following factors: 1) renal injury severity as assessed by the AAST
27
renal injury scale; 2) mechanism of injury; 3) serum creatinine; and 4) blood urea nitrogen.
28
The nomogram predicted the need for exploration with an accuracy of 96.9% and was signifi-
29
cantly more accurate than any of its components although the AAST renal injury scale had a predictive
30
accuracy of 88%. The authors noted that the need for exploration and nephrectomy increased sequen-
31
tially with injury grade. For grade II injuries, for example, 9% of patients were explored with no patient
65
1
requiring nephrectomy; 58%, of grade IV injuries underwent exploration with more than 50% of these
2
patients requiring nephrectomy. All grade V injuries were explored, and 91% of these patients required
3
nephrectomy. The authors note that the majority of renal injuries from blunt trauma can be managed
4
nonoperatively. A significant proportion of patients with penetrating injury can likewise be managed
5
without exploration.
6
The authors also report that many patients who undergo renal exploration can be managed with
7
renal repair. This topic will be addressed in the discussion of a subsequent article. The authors conclude
8
by noting that nomograms such as the one they have developed will have potential utility in the conduct
9
of future clinical trials. From the perspective of the editor, it would seem that gathering sufficient data
10
on each patient to be able to predict the need for renal exploration in real time, during an abdominal
11
exploration for multiple injuries would be challenging. The necessary imaging to accurately determine
12
the grade of injury and the laboratory data may not be available.
13
Additional data about prediction of renal exploration, renal repair, and nephrectomy are dis-
14
cussed in an article authored by Wright and coauthors99 from the Journal of Urology, 2006. These au-
15
thors reviewed data from the National Trauma Data Bank in order to determine the frequency of renal
16
injury and the frequencies of renal exploration, renal repair, and nephrectomy. They found 8,465 pa-
17
tients with renal injury among 742,744 patients analyzed in the database. This represents an overall re-
18
nal injury frequency of 1.1%. Most patients were injured by blunt mechanism and only 19% of patients
19
sustained penetrating injury. The overall mortality for blunt injured patients was 16% and 10% for pa-
20
tients with penetrating injury. Nephrectomy was performed in 4% of patients who sustained blunt injury
21
and 21% of patients with penetrating injury.
22
These authors noted that the main predictors of nephrectomy in this cohort were physiologic
23
indices of injury severity such as shock and renal injury severity as assessed by the AAST injury scale. For
24
patients with blunt injury, most were managed nonoperatively. If renal exploration was needed, nearly
25
90% required nephrectomy. Interestingly, nearly ⅔ of patients with penetrating renal injury were man-
26
aged without renal exploration. If exploration was required, more than half of the patients could be
27
managed with renal repair. The main predictors of nephrectomy were injuries to other abdominal or-
28
gans, hemodynamic instability, and renal injury severity.
29
In an editorial comment that accompanies this article, Dr. Richard Santucci notes the increasing
30
rate of nonoperative management of both blunt and penetrating renal injury. This is likely because of
31
the increasing availability of rapid CT imaging which permits a higher proportion of patients to have ac-
66
1
curate assessment of the grade of renal injury, the presence of normal function in the uninjured kidney,
2
and the presence of urinary extravasation. In the absence of active bleeding and urinary extravasation,
3
most injuries are managed nonoperatively, regardless of injury mechanism. From the data presented in
4
this article, the authors conclude that nephrectomy for renal trauma may occur because of irreparable
5
damage to the kidney and/or the presence of other significant intra-abdominal injuries necessitating a
6
“damage control” approach to multiple injuries with ongoing blood loss. Another possible influence,
7
though, could be unfamiliarity of the operating surgeon with techniques for renal repair. Technical as-
8
pects of the management of renal injury are discussed in the next section of the overview.
9
10
11
Table 2 contains the sequential steps for conducting renal repair from the book chapter authored by Thomas and colleagues, noted previously,74 and is reproduced here, with permission.
An article containing a detailed description of the technique of renal exploration and repair is by
12
Voelzke and McAninch100 in the Journal of Trauma, 2009, entitled “Renal gunshot wounds: clinical man-
13
agement and outcome.” A full text reprint of this article is included with the mailed version of this issue
14
of Selected Readings. The data contained in this article were presented at the annual meeting of the
15
American Association for the Surgery of Trauma in 2008. The authors reviewed experiences from a sin-
16
gle institution using a prospectively maintained renal injury database. They reviewed data on 201 pa-
17
tients and were able to obtain preoperative or intraoperative imaging using CT or one-shot intravenous
18
pyelography in nearly 70% of their patients. A stable frequency of nonoperative management of renal
19
gunshot wounds of 38% existed despite increasing proportions of nonoperative management of renal
20
injuries from blunt mechanism or stab wounds.
21
The authors report a salvage rate for 206 renal injuries of 85%. They describe a technical ap-
22
proach that includes heavy reliance on one-shot intravenous pyelography intraoperatively to assess
23
function of the uninjured kidney and to detect urinary extravasation. They routinely use control of the
24
renal vessels before exploration. These authors assessed the frequency of instances where they deter-
25
mined that renal vascular control contributed significantly to the salvage of the kidney. They determined
26
that renal vascular control contributed significantly to renal salvage in 12% of the instances when it was
27
used. They acknowledge that other authors have interpreted the low frequency of documented value of
28
this maneuver to indicate that its value is limited. The renal pedicles are exposed, using a midline ap-
29
proach to the aorta or, for a left-sided injury, an incision in the retroperitoneum just medial to the infe-
30
rior mesenteric vein. These approaches are illustrated in the two figures reproduced from this article
67
1
with permission. The authors had 2 patients who required late nephrectomy for continued postopera-
2
tive bleeding. The remaining 28 nephrectomies were performed acutely.
3
These authors stress that their success at renal salvage is because of the close working relation-
4
ship they have with their trauma surgeons and the fact that they have developed, over time, a depend-
5
able protocol for obtaining intraoperative imaging using one-shot intravenous pyelography. They
6
acknowledge that their reliance on nonoperative therapy for gunshot wounds of the kidney is lower
7
than reported by others. This issue is mentioned in the discussion that accompanies the article.
8
The authors next discuss the techniques used for renal repair. These are illustrated in the figure,
9
reproduced here, with permission. These steps include the use of hemostatic agents, fibrin sealant, and
10
vascularized omental patch overlay of parenchymal and collecting system repairs. These authors use
11
partial nephrectomy, particularly for isolated lower pole kidney injuries. A dependent drain is placed
12
through a separate incision as illustrated in the figure, included above. In the discussion that accompa-
13
nies the article, mention was made of the decisions that are necessary in the management of patients
14
with multiple intra-abdominal injuries and continuing blood loss. In this setting, the authors restrict ef-
15
forts at renal salvage to 1 hour. If repair is not possible with 1 hour, nephrectomy is chosen as the safest
16
alternative.
17
Injuries to the ureter result primarily from penetrating injuries to the abdomen and retroperito-
18
neum. Ureteral injuries also occur as a consequence of elective or emergent operations for colonic dis-
19
ease and for the management of retroperitoneal neoplasia. Although the principles of management of
20
ureteral injury from external trauma or intraoperative complications are similar, this discussion focuses
21
on the management of ureteral injury sustained because of external penetrating trauma. An article that
22
describes a recent experience with ureteral injury management is by Fraga and coauthors101 in the In-
23
ternational Brazilian Journal of Urology, 2007.
24
The authors review experiences with 20 patients who sustained ureteral injury from penetrating
25
trauma. They note that penetrating injury to the ureter is not common, occurring in 2-5% of patients
26
with abdominal gunshot wounds. Ureteral injury as a complication of abdominal or pelvic surgery occurs
27
most commonly in association with hysterectomy. Colon resection is the second most common associ-
28
ated procedure. In the setting of external trauma, ureteral injury is clinically silent and early symptoms
29
are usually absent. Very few patients have hematuria. The authors classified ureteral injuries according
30
to the American Association for the Surgery of Trauma injury scale which groups ureteral injuries into
68
1
five categories ranging from contusion or hematoma (grade I) to avulsion with > 2 cm of devasculariza-
2
tion (grade V). Grades II and III are partial transections. Grade IV injury is a complete transection with
3
less than 2 cm of devascularization. Two of their 20 patients had hematuria and both had injuries to
4
other parts of the genitourinary system (1 bladder and 1 kidney injury). The diagnosis was made during
5
the course of operation for other injuries in 18 patients.
6
There were 2 late ureteral leaks and both of these occurred in patients with ureteral contusions.
7
This observation emphasizes that significant complications can occur with low grade ureteral injuries.
8
The authors stress the need for complete ureteral exploration whenever the trajectory of the injuring
9
agent is suspected to be near the ureter. They used loop diuretics and/or methylene blue injection to
10
assist in identifying the ureteral injury in selected patients. They stress that these adjuncts do not substi-
11
tute for complete exploration. When an injury is identified, the ureter is débrided and re-anastomosed
12
with a spatulated closure using fine absorbable suture. A drain is placed adjacent, but not in contact,
13
with the repair. Ureteral stents are used in most patients. Ureteral implantation into the bladder was
14
used in 3 of their patients. Bladder flap reconstruction of the ureter was not used in their patients.
15
They emphasize that overall patient safety is paramount. In critically ill patients ureteral ligation
16
with nephrostomy tube drainage is acceptable. Although they did not use preoperative imaging in their
17
patients, they agree that CT and retrograde pyelography are valuable tools for identifying and classifying
18
late onset symptoms of ureteral injury. In the two editorial comments that accompany this report, both
19
noted the potential for preoperative imaging to identify ureteral injury in stable patients. Prolonged ile-
20
us, flank pain, and urine drainage, through wounds or drain sites, were common signs of late onset ure-
21
teral injury. In both of their late onset injuries, endoscopic stenting of the injury led to complete healing.
22
Injuries to the bladder occur as a result of penetrating or blunt injury. Bladder rupture due to
23
blunt injury is frequently associated with fractures of the anterior pelvic ring. Clinical signs and symp-
24
toms are non-specific. Gross hematuria is seen in the vast majority of patients and the association of
25
gross hematuria with lower abdominal and/or pelvic trauma requires radiographic imaging. Retrograde
26
cystography is successful in identifying bladder tears if the bladder is sufficiently distended (at least 300
27
mL/kg of contrast in adults and 20 mL/kg of contrast in children).
28
Anterior-posterior views as well as lateral views of the distended bladder are necessary. Repeat
29
images obtained after drainage of the bladder assists in identifying subtle tears. Currently, bladder imag-
30
ing is obtained during CT imaging of trauma patients. The bladder is distended with contrast and multi-
69
1
ple distended and drained bladder views are obtained. Before the routine use of CT cystography, de-
2
layed diagnosis from inadequate imaging was reported in up to 23% of patients with anterior pelvic frac-
3
ture.102 CT cystography has improved the image quality and fewer missed injuries are now reported.
4
Guidelines for bladder imaging are contained in a report authored by Morey and coauthors103 in
5
the Journal of Trauma, 2001, entitled “Bladder rupture after blunt trauma: guidelines for diagnostic im-
6
aging.” These authors reported clinical experience with 53 blunt injuries resulting in bladder lacerations.
7
All patients presented with gross hematuria and 85% had pelvic fracture. Because a combination of pel-
8
vic fracture and gross hematuria is highly suggestive of bladder rupture, all patients with this constella-
9
tion of findings are referred for bladder imaging. Patients with isolated pelvic fracture or isolated hema-
10
turia can be imaged selectively. Bladder injuries may be intraperitoneal tears or extraperitoneal tears.
11
The former require formal exploration and suture repair in two layers using absorbable suture. Extraper-
12
itoneal bladder tears can usually be managed with catheter drainage of the bladder. In the report by
13
Morey and coauthors, all intraperitoneal bladder ruptures were managed operatively. Nearly ⅔ of ex-
14
traperitoneal bladder tears were managed without formal exploration. The remainder was repaired dur-
15
ing the course of exploratory laparotomy and management of associated injuries.
16
Injury to the urethra in association with pelvic fracture is a source of significant disability in both
17
men and women. Urethral injury should be suspected in patients with anterior pelvic fractures and pel-
18
vic fractures resulting from straddle mechanisms and perineal impact. The diagnosis can be strongly
19
suspected if there is blood at the urethral meatus in males or intravaginal blood and/or urine leakage in
20
females. Especially in men, attention to the injury mechanism is important as a means of raising suspi-
21
cion of injury, because blood at the meatus may be absent in the presence of urethral disruption. A gen-
22
tle attempt to pass a urethral catheter may disclose urethral injury with obstruction. Retrograde ure-
23
thrography is then able to document the injury. As noted previously, during the discussion of pelvic frac-
24
ture, posterior urethra disruption can contribute toto sexual dysfunction as a long-term complication of
25
pelvic fracture.
26
The risk of erectile dysfunction in patients with pelvic fracture and urethral injury is the topic of
27
an article by Shenfeld and coauthors104 from the Journal of Urology, 2003. They report detailed evalua-
28
tion and management data on 20 consecutive cases of urethral injury associated with pelvic fracture and
29
erectile dysfunction. When sexual dysfunction is defined broadly (either as erectile failure or erectile
30
function that is less than pre-injury) this complication may occur in more than 70% of patients with
31
combined pelvic fracture and urethral disruption. The authors note that diagnostic testing can deter-
70
1
mine whether the erectile dysfunction is neurogenic from disruption of nerves at the apex of the pros-
2
tate, or vascular, because of thrombosis or obstruction of nutrient blood vessels. Neurogenic sexual dys-
3
function can be successfully treated pharmacologically while vascular obstruction can be treated with
4
vascular reconstruction procedures.
5
The diagnosis and management of urethral injury also has important implications for recovery of
6
normal urination function and/or the overall orthopaedic management of the pelvic fracture. Prolonged
7
suprapubic drainage of the bladder may prevent satisfactory internal fixation of the pelvic fracture be-
8
cause of an increased risk of post-stabilization infection. Delay of stabilization or failure to stabilize the
9
fractures increases the risk of chronic pain, abnormal ambulation, and failure to return to normal levels
10
of activity. This issue is discussed in an article by Mayher and coauthors105 in Urology in 2001. The au-
11
thors reviewed more than 40 patients with pelvic fracture and associated urethral disruptions that de-
12
layed internal reduction and stabilization of the pelvic fracture because of persistent suprapubic cathe-
13
ter drainage; this resulted in chronic disabling pain in 75% of the patients reviewed.
14
Recently, early endoscopic realignment of the urethral disruption has led to early removal of the
15
suprapubic drainage catheter and successful open reduction and internal stabilization of the fractured
16
pelvis. This topic is discussed in a report by Mouraviev and coauthors106 in the Journal of Urology, 2005.
17
Because this article includes detailed information about the diagnosis of urethral disruption and the
18
techniques that the authors use for successful endoscopy assisted early urethral realignment, it is in-
19
cluded as a full-text reprint in this issue of SRGS. The article is entitled “The treatment of posterior ure-
20
thral disruption associated with pelvic fractures: comparative experience of early realignment versus
21
delayed urethroplasty. “
22
The authors reviewed data on 191 men with urethral disruption. Of the 96 long-term survivors,
23
outcomes in 57 patients who underwent early realignment were compared with data on 39 men who
24
underwent delayed repair. The average followup interval was nearly 9 years. The frequencies of urethral
25
stricture, sexual dysfunction, and incontinence were all lower in the early realignment patients. The
26
overall frequency of urethral stricture was reduced by 50% in the early realignment group compared
27
with the patients managed by delayed repair. The number of procedures necessary to repair a stricture
28
was likewise reduced in the early realignment patients. Although it is possible that patients treated with
29
late repair had more severe total injury patterns and less favorable urethral injuries, the contrast in re-
30
sults is striking.
71
1
Urethral injury is also an important complication of pelvic fracture in females, especially young
2
girls. Urethral injury complicating pelvic fracture in girls can lead to incontinence and urethral stricture.
3
Diagnosis and management of urethral injury in young females is reviewed in two articles.107, 108 The
4
available data indicates that lower urinary injury in children occurs in less than 3% of pelvic fractures.
5
When urethral injury occurs, diagnosis is made by direct vaginal examination and gentle passage of a
6
urethral catheter. Repair of the urethra with autogenous vaginal tissue or buccal mucosa restores conti-
7
nence and normal or near normal urination in most patients.
8
Injury to the external genitalia can occur from gunshot injuries; stab wound and edged instru-
9
ment lacerations, human bites, or blunt injuries. The diagnosis and management of these injuries are
10
reviewed in the next 3 articles. The first is by Phonsombat and coauthors109 in the Journal of Urology,
11
2007, entitled “Penetrating external genital trauma: a 30 year single institution experience.” A full text
12
reprint of the article is included with the mailed version of this issue of Selected Readings. The authors
13
review data on 110 patients. Most patients sustained gunshot injuries or self-emasculation injuries using
14
edged instruments. Seven percent of the patients sustained bite injuries. Operative exploration was per-
15
formed in approximately 75% of all injury groups. Complete penile amputation was treated with replan-
16
tation of the penis in 5 patients with success noted in 4.
17
The authors emphasize the challenges associated with self emasculation injuries because of de-
18
lay in presentation for care and, often, failure of these psychotic patients to bring the severed tissue to
19
the hospital with them. Conservative debridement is recommended to preserve tissue and function.
20
These authors noted a very low incidence of penile curvature after conservative debridement and clo-
21
sure of the corpora cavernosum. Patients with minor injuries that do not violate the Buck’s fascial layer
22
can be managed nonoperatively.
23
An alternative surgical technique for complete repair of corpus cavernosum lacerations is de-
24
scribed in an article by Kunkle and coauthors110 in the Journal of Trauma, 2008, entitled “Evaluation and
25
management of gunshot wounds of the penis: 20 year experience at an urban center.” The authors re-
26
view data on 63 patients they treated after gunshot injury to the penis. Associated significant injury was
27
observed in 84% of patients. Urethral injury was the most common associated urologic injury and was
28
discovered by retrograde urethrography in more than 90% of the cases. Penile exploration was per-
29
formed in 70% of the patients using a coronal incision followed by complete penile degloving to expose
30
the corpora cavernosum.
72
1
Corporal lacerations were sutured after conservative debridement and urethral injuries were
2
managed with direct suture repair in the majority of cases. Early realignment and suture repair of ure-
3
thral injuries was associated with a 13% need for delayed treatment of stricture whereas delayed ure-
4
thral repair was associated with a 75% incidence of urethral stricture requiring repair. Corporal injec-
5
tions were performed to produce tumescence so that penile curvature could be detected. Only 55 pa-
6
tients had erectile dysfunction after repair, and all of these were managed with pharmacotherapy. The
7
authors recommend complete corporal exposure with suture of corporal lacerations and early repair of
8
urethral injuries due to penile gunshot wounds.
73
1
The final injury discussed in this section of the overview is blunt injury to the testicles. The arti-
2
cle discussed is by Buckley and McAninch111 from the Journal of Urology, 2006, entitled “Use of ultraso-
3
nography for the diagnosis of testicular injuries in blunt scrotal trauma.” The authors of this report note
4
that delayed or missed diagnosis of tunica albuginea rupture can lead to serious disability and testicular
5
loss. Physical examination in the acute phase is difficult, and serious injuries can easily be missed. Many
6
urologists recommend early complete testicular exploration to ensure maximum opportunity for testicu-
7
lar salvage. In this report, the sensitivity and specificity of testicular ultrasound to detect injury are eval-
8
uated. All patients with equivocal physical findings underwent ultrasound examination and then surgical
9
exploration. The ultrasound findings of heterogenous echo pattern and loss of contour definition were
10
100% sensitive and had a specificity of 94%. If the patients had been operated on based on the ultra-
11
sound findings alone, no significant injuries would have been missed. Testicular salvage was possible in
12
92% of patients, including 83% of those with testicular rupture. Testicular loss was from delayed presen-
13
tation for treatment in the 44 patients where this occurred. These authors recommend that ultrasound
14
be used to select patients for scrotal exploration.
74
1
2
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Cothren CC, Osborn PM, Moore EE, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007; 62(4):834-9; discussion 839-42.
Shariat SF, Trinh QD, Morey AF, et al. Development of a highly accurate nomogram for prediction of the need for exploration in patients with renal trauma. J Trauma 2008; 64(6):1451-8.
Wright JL, Nathens AB, Rivara FP, Wessells H. Renal and extrarenal predictors of nephrectomy
from the national trauma data bank. J Urol 2006; 175(3 Pt 1):970-5; discussion 975.
Voelzke BB, McAninch JW. Renal gunshot wounds: clinical management and outcome. J Trauma
2009; 66(3):593-600; discussion 600-1.
Fraga GP, Borges GM, Mantovani M, et al. Penetrating ureteral trauma. Int Braz J Urol 2007;
33(2):142-8, discussion 149-50.
Ziran BH, Chamberlin E, Shuler FD, Shah M. Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J Trauma 2005; 58(3):533-7.
Morey AF, Iverson AJ, Swan A, et al. Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma 2001; 51(4):683-6.
Shenfeld OZ, Kiselgorf D, Gofrit ON, et al. The incidence and causes of erectile dysfunction after
pelvic fractures associated with posterior urethral disruption. J Urol 2003; 169(6):2173-6.
79
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
105.
106.
107.
108.
109.
110.
111.
Mayher BE, Guyton JL, Gingrich JR. Impact of urethral injury management on the treatment and
outcome of concurrent pelvic fractures. Urology 2001; 57(3):439-42.
Mouraviev VB, Coburn M, Santucci RA. The treatment of posterior urethral disruption associated
with pelvic fractures: comparative experience of early realignment versus delayed urethroplasty. J Urol 2005; 173(3):873-6.
Tarman GJ, Kaplan GW, Lerman SL, et al. Lower genitourinary injury and pelvic fractures in pediatric patients. Urology 2002; 59(1):123-6; discussion 126.
Dorairajan LN, Gupta H, Kumar S. Pelvic fracture-associated urethral injuries in girls: experience
with primary repair. BJU Int 2004; 94(1):134-6.
Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: a 30-year single
institution experience. J Urol 2008; 180(1):192-5; discussion 195-6.
Kunkle DA, Lebed BD, Mydlo JH, Pontari MA. Evaluation and management of gunshot wounds of
the penis: 20-year experience at an urban trauma center. J Trauma 2008; 64(4):1038-42.
Buckley JC, McAninch JW. Use of ultrasonography for the diagnosis of testicular injuries in blunt
scrotal trauma. J Urol 2006; 175(1):175-8.
18
80
1
2
TABLES
3
81
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Young – Burgess Pelvic Fracture
Classification
Lateral compression (LC) injuries: anterior injury =
rami fractures
LC-1 = sacral fracture on side of impact
LC-2 = crescent fracture on side of impact
LC-3 type one or two injury on side of impact with
contralateral open book injury
Anterior-posterior compression (APC): anterior
injury = symphyseal diastasis/rami fractures
APC-1 = minor opening of symphysis and sacraliliac joint anteriorly
APC-2 = opening of anterior sacral-iliac joint,
posterior ligaments intact
APC-3 = Complete disruption of sacral-iliac joint
Vertical shear fracture
Cranial-caudal displacement of hemipelvis with
symphysis diastasis or rami fractures anteriorly;
iliac wing, sacral fracture or sacral-iliac joint disruption posteriorly
Combination injury
Any combination of the above types
Table 1: Young-Burgess pelvic fracture classification. Modified from Sagi, with permission
82
1
2
3
Renal Injury Scale
4
5
Clinical Description
6
Contusion or non-expanding7
subcapsular hematoma, No
8
laceration
9
Non-expanding peri-renal
10
hematoma
11
12
Cortical laceration < 1 cm deep
with no urinary extravasation
13
14
Cortical laceration > 1 cm deep
15
without urinary extravasation
16
Laceration through corticome17
dullary junction into collecting
system or Vascular segmental
18
renal artery or vein injury with
19
contained hematoma or partial
20
renal vessel laceration or vessel
thrombosis
21
22
Laceration: shattered kidney or
23
renal pedicle vascular injury
24
American Association for the Surgery of Trauma
Injury Grade
Grade I
Grade II
Grade III
Grade IV
Grade V
25
26
27
28
29
83
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
1.
2.
3.
4.
5.
6.
7.
8.
Steps in management of renal injury
Consider preliminary vascular control – occlude vessels with Rummel
tourniquets
Complete renal exposure
Judicious debridement of obviously non-viable tissue
Hemostasis by individual suture ligation of bleeding vessels (4-0 chromic
suture on RB-1 needle)
Watertight closure of collecting system (suture or closure of overlying parenchyma)
Coverage of laceration with omental patch or by approximation of overlying parenchyma
Consider use of hemostatic agent or fibrin sealant over repair
Perirenal drain through separate, dependent incision
Table 1 Steps in operative management of renal injury. Modified from
Thompson, with permission.
84
1
2
FIGURES
85
1
2
3
4
5
6
7
8
9
10
Figure 1 Approach to renal vessels anterior to aorta. Modified from Voelzke with permission.
11
12
13
14
15
16
17
86
1
2
3
4
5
6
7
8
9
10
11
Figure 2 Approach to renal vessels medial to
inferior mesenteric vein. Modified from
Voelzke, with permission
12
13
87
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Figure 3: Techniques of renal repair. Reproduced from Voelzke, with permission
16
17
18
19
20
21
22
88