トラウマと治療のジャーナル

Introduction: Trauma patients with a positive blood alcohol concentration (BAC) are often believed to be at high risk for the alcohol withdrawal syndrome (AWS). Therefore some centers prophylaxis all BAC positive patients. This study prospectively measures the incidence of AWS among trauma patients admitted to the hospital who have consumed alcohol and determines their risk factors for AWS.

Methods: A cohort of trauma patients admitted to a non-ICU hospital setting was prospectively monitored for the development of AWS during the first 10 days of hospitalization. The 10-item Alcohol Use Disorders Identification Test (AUDIT) and questions about alcohol withdrawal history were administered on the first day and the revised Clinical Institute for Withdrawal of Alcohol Scale (CIWA-Ar) was administered daily.

Results: 113 patients were followed through discharge or for the first 10 days of hospitalization. 74.3% (n = 84) reported drinking alcohol. Of the 89 patients with a measured BAC, 25 (28%) were positive. Mean BAC for positive patients was 187.7 mg/dl. No person who denied drinking had a measurable BAC or developed AWS. Among the 84 drinkers, 3 were diagnosed with AWS by CIWA-Ar (3.6% risk), giving an incidence rate of 1.4 episodes per 100 patient days. All patients developing AWS admitted to a previous history of AWS symptoms upon stopping drinking. All AWS patients drank at least 2-3 times per week compared to only 37% of drinkers who did not develop AWS (p = .05). Positive response to dependence items from the AUDIT were highly associated with AWS risk (67% AWS vs 16% non-AWS, p = .005). Implementation of a prophylaxis protocol for all positive BAC would have resulted in 88% (22/25) of BAC positive patients receiving unwarranted medication.

Conclusion: AWS has a low incidence rate among intoxicated trauma patients admitted to a non-ICU setting. It is associated with frequent drinking and is found in patients who report dependence symptoms. Patients can reliably tell physicians whether they are at risk for AWS. Routine prophylaxis for positive BAC patients will likely result in substantial excess medication use.

Objective: To investigate the injury pattern, management and outcome of road traffic injuries in the elderly patients (60 years and above) involved in motor vehicle accidents and to compare factors associated with trauma and differences in trauma mortality between elderly and younger adult patients.

Methods: This is a retrospective descriptive study conducted at a teaching hospital during Jun 2002 to Jan 2010, studying the differing pattern, and management of road traffic injuries in patients aged 60 years and above, designated as Group-A, and those below 60 years of age, designated as Group –B, regardless of gender of the patients.

All the patients were referred through casualty and were assessed clinically followed by relevant investigations. Patients who sustained minor injuries were discharged after necessary treatment while those with serious injuries requiring intervention were admitted and managed accordingly. Patients having purely orthopaedic problems like isolated fractures or spine injuries were also excluded from the study. Treatment was instituted according to the severity of the trauma ranging from conservative treatment to laparotomy and chest intubation. The variables studied included demographics of both groups of patients, pattern of injuries sustained in both groups, trauma indices ISS and GCS, mechanism of injury, major injuries sustained, treatment instituted, mean number of hospital days, and morbidity and mortality.

Details of individual patients were recorded on a proforma and data analyzed statistically on SPSS version 17.

Results: A total 300 patients (Group-A n=149[49.66%] versus Group-B n=151[50.33%]) admitted and intervened were included in the study. Male patients predominated both the groups (Group-A. [Mean age 66.91, Std 6.859, Males n=115, Females n= 34] vs Group-B [Mean age 35.52, Std 13.814, Males n= 140, Females n= 11]). The group-A patients had significantly higher proportion of co-morbidities (p<0.001) compared to group-B patients (64.42% versus 18.66%). The mortality rises progressively with age and is almost twice as high as in younger population at all levels of severity of trauma. Incidence of chest injuries with rib fractures was more common in elderly victims (P<0.001) compared to the younger patients (40.26%) versus (12.58%). The overall in hospital mortality in Group-A patients was 14.76% compared to (4.63) in group-B for an almost comparable severity of injuries sustained.

Conclusion: The incidence of road traffic accidents is on the rise in the elderly. The elderly patients have a different pattern of road traffic injuries and they respond poorly to the sustained injuries despite low ISS compared to the younger patients.

Objective: Determine whether preoperative AP pelvis radiographies under manual traction influence surgeon choice for implants in intertrochanteric fractures compared with standard radiographies.

Methods: Fifty-eight patients with intertrochanteric fractures were prospectively enrolled from four tertiary teaching hospitals. All patients had standard AP pelvis radiographies taken as well as radiographies under manual traction of affected limb, 116 images total. Three fellowship trained trauma surgeons and three hip surgeons blindly reviewed the images and indicated their implant choice for each case: extra or intramedullary fixation. The observers received randomly assigned images and were unaware of the radiography technique, patient number, and repetition of patients within the set of images. Statistical analyses were performed using Cohen Kappa method and McNemar, Q Cochran, and Wilcoxon tests.

Results: Manual traction radiographies changed surgeon-implant choice in 35.06% (range: 27.6% to 43.1%). However, traction radiographies provided no improvement in weak inter-observer reliability for treatment indication (k=0.264, p<0.001) compared to standard radiographies (k=0.220, p<0.001), when using Mann-Whitney test (p=0.359). Traction views did not increase predilection for either method. Hip surgeons agreed more than trauma surgeons concerning implant choice.

Conclusions: Manual traction radiographies modified surgeon choice in up to one third of intertrochanteric fracture cases.

We report the occurrence of a radial head fracture (Mason Johnston type 4), combined with a Monteggia type II equivalent fracture and Galeazzi fracture pattern in the same forearm of a 19-year-old man involved in a road traffic accident.

Fractures of the radius and ulna bones were openly reduced and fixed; the radial head fracture was managed conservatively. The case was complicated by elbow dislocation and radioulnar instability, which was treated conservatively with a satisfactory outcome.

Introduction: Urethral injuries associated with pelvic fractures are regarded as rare in women and thus discussed infrequently. We reviewed our series of girls/women who presented with urethral injuries.

Materials and Methods: Eleven patients (age range 8-49 years) presenting with urethral injuries and admitted to urological services were reviewed. All had associated injuries, generally more severe than seen in males with urethral injuries.

Results: All the eleven patients had severe injuries. Three of them underwent immediate repair of the urethra, whereas the remaining eight underwent repair 7-15 days later. In the follow-up period three developed stricture, one needing a Mitrofanoff’s procedure to self catheterize and the remaining two needing regular dilatation. One patient developed urinary incontinence.

Conclusions: Pelvic fractures are associated with urethral injuries, though less common among the females. A more severe injury is needed to damage the female urethra than is necessary in males.

Introduction: Protocols for caring for elderly hip fracture patients vary among hospitals. The purpose of this study was to examine two different approaches of care for this patient population at our institution.

Methods: Retrospective review of 389 consecutive patients 65 years and older with the diagnosis of a low- energy, hip fracture between January 2006 and May 2010. 227 consecutive patients for which a nonstandard method of admission (OP) to either medicine (133 patients) or orthopedic service (94 patients) were compared to a new plan of care (NP) that included 162 consecutive patients in which all patients were admitted to medicine. We evaluated perioperative complications rates, time to surgery (TTS), and length of hospital stay (LOS).

Results: There were no significant differences in LOS, TTS, 30 day re-admission, rapid response codes, perioperative complications or death between either model of care. The NP did demonstrate a significant increase in patients being transfused (51.85% vs. 36.56%) and number of patients being diagnosed with Vitamin D deficiency (42.12% vs. 20.70%).

Conclusion: While our change in protocol did not alter the rate of perioperative complications, nor did it provide quicker care or shorter hospital stays, it did provide more comprehensive osteoporosis care to our patients