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Volume 15(2); December 2002
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Original Articles
Trauma Registry with ICD-10-based ICISS
Koo Young Jung, M.D., Hye Young Jang, M.D., and Joo Hyun Suh, M.D.
J Korean Soc Traumatol. 2002;15(2):71-81.
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Backgound: The trauma registry is essential for improving the quality of trauma care. Reappraisal of trauma care adequacy can be performed based on the trauma registry. A trauma
care quality assessment tool should be made so that it will be able to stratify the trauma centers and to estimate the effectiveness of the trauma care system. No data collection system for a trauma registry exists in Korea. Moreover, objective assessment of trauma care has not been tried until now. Existing trauma registries, which are used mainly in developed countries, include all admitted patients, and data collections for those registries is made using extra systems, so the cost of maintenance is high. we were preferentially concerned with severely injured patients, so we began with a small trauma registry focusing only high-risk patients. We also used Internation Classificotion of Direase based Injury Severely Score(ICISS) loth Eddtion(ICD-10) which is routinely made at hospital records offices, instead of the Trauma and Injury Severely Score(TRISS) which is gold standard for registries but needs a special registrar and extra education. Methods : Inclusion criteria for registration were as follows; abnormal RTS (Revised Trauma Score) on admission, injury mechanisms of falls from 5 m or higher and penetrating injuries on the head/neck/trunk, mortality within 48 hours after ED arrival, ICU admission, and emergency operation within 24 hours. Two audit filters, mortality and delayed operation, were applied, and the medical records were rated for trauma care adequacy. The review committee was composed of an emergency physician, a general surgeon, a neurosurgeon, an anethesiologist, and a coordinator. Results : We conducted the registry system during the month of May 2001 at our University hospital. During that period, a total of 4676 patients visited our ED, 1051 (22.5%) patients were injured, and of these, 120 (11.4%) patients were hospitalized. Thirty two patients were included into the trauma registry (3.04% of the total injured and 26.7% of the those hospitalized). The committee reviewed 11 cases (9 patients, 28.1% of the registry patients), 6 mortalities, and 5 delayed operations. The mean ICISS of all registry patients was 0.7930, and the actual mortality rate was 18.8%. Two mortalities were analyzed as preventable deaths based on the ICISS and were judged as the same by the review committee. Conclusion : A curtailed trauma registry could reduce the patient volume to one fourth and might reduce the cost markedly. The trauma committee could manag problems effectively and may make significant improvements in trauma care.
Summary
Mortality Predictive Abilities of the Injury Severity Score and the New Injury Severity Score for Blunt Abdominal Trauma
Tae Young Yu, M.D.*, Young Ho Jin, M.D.*, Tai O Jeong, M.D.*, and Jae Baek Lee, M.D.*
J Korean Soc Traumatol. 2002;15(2):82-87.
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Background
The New Injury Severity Score (NISS) was introduced to improve outcome prediction based on anatomical severity scoring in trauma victims. This study was conducted to evaluate whether the NISS can give a better mortality prediction than the Injury Severity Score (ISS) in blunt abdominal trauma patients. Methods: Individuals who visited Chonbuk University Hospital from January of 1996 to October of 2000 were included in this study if a laparotomy was done due to blunt abdominal trauma. The data on the patients were retrospectively collected to identify the injuries and the outcomes of treatment. Both the NISS and the ISS were calculated. The abbreviated injury scale (AIS-90) protocol was used for the severity calculation. The power of the two scoring systems to predict mortality was gauged through a comparison of the misclassification rates, receiver operating characteristic (ROC)curves, and Hosmer-Lemeshow goodness-of-fit statistics. Results: The mean ISS and the NISS of the nonsurvivors were 25.9±7.7 and 29.2±7 . 8 , respectively. The misclassification rates for the ISS and the NISS were not significantly different. Although there was a significant (p<0.05) difference between the area under the curve (AUC) of the ISS (0.813; 95%CI=0.756~0.869) and the AUC of the NISS (0.830; 95%CI=0.778~0.882), they only had fair a predictive abilities. The Hosmer-Lemeshow statistics showed a slightly better fit for the NISS (x2=10.33, p=0.171) than for the ISS (x2= 1 5 . 1 6 , p<0.05). However, these statistics for the ISS and the NISS indicate a poor predictive performance. Conclusions : Both the ISS and the NISS performed poorly in predicting outcome when the data were limited to patients with blunt abdominal trauma.
Summary
Isolated Intraperitoneal Fluid on Abdominal CT in Patient with Blunt Trauma
Kwan Min Ku, M.D, Chae Kyung Lee, M.D., and Hyeon Kyeong Lee, M.D.
J Korean Soc Traumatol. 2002;15(2):88-92.
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Background
The purpose of our study was to determine the clinical significance of isolated intraperitoneal fluid on abdominal CT in blunt trauma patients. Materials and Methods : We retrospectively reviewed the CT scans of 27 patients with blunt abdominal trauma who had scans showing normal findings except for the presence of intraperitoneal fluid. The collections of peritoneal fluid were characterized as small, moderate, or large. The location of the fluid was determined as Morison’s pouch, the perihepatic space, the perisplenic space, the paracolic gutter, the interloopal space, or the pelvic cavity. The amount and the location of fluid were compared between patients who required surgical treatment and those who were managed conservatively. Results : In most patients, the amount of intraperitoneal fluid was small and moderate (66%) as opposed to large (33%). Intraperitoneal fluid tended to accumulate in Morison’s pouch (66%). Eighteen patients had fluid in two or fewer locations, and 9 patients had fluid in three or more locations. Laparotomies were required in two patients (11%) are with a small amount of fluid and one with a moderate amount compared with 4 patients (44%) with large amounts. Mesenteric and small bowel injuries were noted in all six patients at laparotomy. Of the 8 patients with fluid in the interloopal space, 5 (62%) required a laparotomy, which revealed small bowel and mesenteric injuries. Conclusion: Patients with blunt abdominal trauma who have small and moderate amounts of isolated intraperitoneal fluid shown by CT may generally be treated conservatively. However, even a small quantity of intraperitoneal fluid in the interloop location, it should raise suspicion of bowel or mesenteric injury.
Summary
Blunt Splenic Trauma: Value of a Follow-up CT
Chae Kyung Lee, M.D., Kwan Min Ku, M.D., Yeon Hee Oh, M.D., and Hyeon Kyeong Lee, M.D.
J Korean Soc Traumatol. 2002;15(2):93-97.
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Background
s: Nonsurgical management is becoming the preferred treatment method for adult patients who are hemodynamically stable and have blunt splenic injuries. The issue of follow-up computed tomography (CT) for blunt splenic injury in the era of nonsurgical management has been a source of controversy throughout the literature. The purpose of this study was to evaluate the value of follow-up CT in clinically stable patients with blunt splenic trauma treated conservatively. Materials and Methods : The CT scans of 78 patients with blunt splenic injuries were analyzed retrospectively. Patients were divided into three groups: stable patients with no follow-up CT (group I, n=23), stable patients with follow-up CT (group II, n=36), and symptomatic patients with follow-up CT (group III, n=19). The serial hemoglobin values and the clinical findings at the follow-up CT were reviewed. Results: All patients in groups I and II remained clinically stable with good outcomes. In group III, follow-up CT scans demonstrated a worsening condition in 11 patients, of which 8 patients had poor outcomes. Conclusions : Follow-up CT was not useful in patients with clinically stable splenic trauma.
Summary
Clinical Study of Spinal Cord Injuries in Unfra ctured Cervical Spine Injuries : Subluxation and SCIWORA (Spinal Cord Injury Without Radiographic Abnormality)
Sang Kuk Han, M.D., Dong Hyuk Shin, M.D., Sang O Park, M.D., Pil Cho Choi, M.D., Woon Yong Kwon, M.D., Hyoung Gon Song, M.D., Keun Jeong Song, M.D., Yeon Kwon Jeong, M.D., and Bo Seung Kang, M.D.*
J Korean Soc Traumatol. 2002;15(2):98-105.
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Background
Cervical spine injuries with or without spinal cord injury are the most commonly missed serious injuries, and the missed or delayed diagnosis may cause serious, catastrophic consequences for patients and have medico-legal implications for physicians. The diagnosis of subluxation or spinal cord injuries in the absence of vertebral fractures poses problems for physicians. The purpose of this study was to find the etiology, the clinical features, and imaging findings of unfractured cervical spine injuries, subluxations and spinal cord injuries without radiographic abnormality (SCIWORA). Methods: Between 1997 and 2002, 81 patients of cervical spine blunt trauma without fractures were enrolled. They underwent both simple cervical X-rays and magnetic resonance imaging (MRI) and were divided into three groups based on neurologic and radiologic findings: subluxation, SCIWORA, and normal. Data were obtained from a review of the medical records in the form of the National Emergency X-radiography Utilization Study (NEXUS) criteria. We investigated the causes of trauma, the clinical features, and the patterns of spinal cord injury in each group. Results : Among the 81 patients, subluxation accounted for 29, SCIWORA for 25, and normal for 27. The most common cause of the subluxation and SCIWORA was motor vehicle accidents, followed by falls. All patients had at least one of the NEXUS criteria. Central disc herniation and cord compression were common findings in patients with subluxation and SCIWORA. Conclusion: In our study, none of the patients had cervical spine fractures or serious malalignment. Also, none had severe craniofacial injuries or major multiple trauma, but all had spinal cord injuries. In adults with subluxation or SCIWORA, central disc herniation and spinal
stenosis played an important role.
Summary
Clinical Review of Lower Urinary Tract Injury
Min Hong Choa, M.D., Jun Seok Park, M.D., Dae Kon Sohn, M.D.,
Kwang Hyun Cho, M.D., and Hahn Shick Lee, M.D.
J Korean Soc Traumatol. 2002;15(2):106-112.
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AbstractAbstract PDF
Purpose
: We reviewed the clinical features of lower urinary tract injury patients for the purpose of early diagnosis and proper management. Methods : From January 1996 to December 2000, 45 patients with lower urinary tract injury were treated at our emergency department (ED). Among those patients, 31 patients were included and studied retrospectively based on medical records. Injuries of iatrogenic origins and patients who had been transferred after diagnosis outside the ED were excluded. Results : There were 16 patients with bladder injuries and 15 patients with urethral injuries. Their mean age was 39.7±19.0 (mean±SD), and 28 patients (90.3%) were male. The most common mechanism of bladder injury was motor vehicle accidents (62.6%) and that of urethral injury was falling (66.7%). The initial symptoms of bladder injury were gross hematuria (75.8%), abdominal pain( 50%), and voiding difficulty (12.5%), and those of urethral injury were blood at meatus (46.7%), gross hematuria (40%), and microscopic hematuria (13.3%). Anterior urethral injuries (76.3%) were more common than posterior injuries (26.7%), and incomplete rupture (53.4%) was more common then complete cupture. Six patients of complete rupture and 1 patient of incomplete rupture were treated with suprapubic cystostomy and the remaining patients were treated with foley catheterization. To evaluate the bladder injuries, we perpormed a retrograde cystography and/or an abdominal CT scan. All the patients with intraperitoneal bladder ruptures (11 cases) were treated with an emergency operation. The patients with extraperitoneal bladder ruptures were treated conservatively, except for 1 case of an operation. Conclusion: These findings, couple with clinical suspicion can help to diagnose the patients with lower urinary tract injury at the ED.
Summary
Comparison of Outcomes Between Different Types of Bladder Drainage after Primary Repair of Intraperitoneal Bladder Ruptures
Hyung Il Lee, M.D., Dae Gon Kim, M.D., and Dal Bong Ha, M.D.
J Korean Soc Traumatol. 2002;15(2):113-117.
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AbstractAbstract PDF
Background
: Primary bladder repair with a suprapubic catheter is considered to be effective for managing intraperitoneal bladder ruptures. We compared the outcomes obtained by using an indwelling suprapubic and urethral catheter together with those obtained by using an indwelling urethral catheter only for injuries. Methods : We reviewed the medical records of 45 intraperitoneal bladder rupture patients who had been treated during the period from May 1995 to April 2000. The patient characteristics, the mechanism of injury, the associated injuries, the duration of catheter indwelling, and the complications were reviewed. Results : The mean age of the patients was 41.2 years old, and the most common cause of bladder rupture was traffic accidents (28 cases, 62%). There were 42 (93%) intraperitoneal bladder ruptures, and 3 (7%) were combined with extraperitoneal bladder rupture. After primary bladder repair, the bladder was drained with a suprapubic and a urethral catheter together in 20 cases (44%) and with only a urethral catheter in 25 cases (66%). There were no significant differences between these 2 groups with respect to mechanism of injury, patient’s age, associated injury, or the bladder repair technique. The location of the injury was the bladder dome in all cases and the mean length of the bladder tear were 6.0 cm in the suprapubic and urethral catheter group while it was 6.2 cm in the urethral catheter only group (p=0.695). Also, the mean duration of drainage was 14.1 days in the suprapubic and urethral catheter group and 15.6 days in the urethral catheter only group (p=0.365). A urethral stricture occurred in 1 (2%) of the 45 patient in the suprapubic and urethral catheter together group. Conclusion : We conclude that intraperitoneal bladder ruptures can be successfully managed with primary repair of the injury and use of an indwelling urethral catheter alone.
Summary
Clinical Significance of a Visual Internal Urethrotomy
in Urethral Stricture
Kyung Seop Lee, M.D.
J Korean Soc Traumatol. 2002;15(2):118-122.
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AbstractAbstract PDF
Background
: A visual internal urethrotomy is a reasonable initial procedure in partial and complete urethral strictures. We reviewed our experiences with 62 partial and complete urethral strictures. Methods : The outcomes of treatment of 62 patients who were managed by visual internal urethrotomy were analyed based on the length and site of strictures, and on whether the strictures was partial and complete. Results : The procedure was completed successfully in 10 of the 21 men with a complete urethral stricture (47.6%) and 30 of the 41 men with a partial urethral stricture (73.1%). Also, success rate for strictures with lengths less than 1 cm and more than 1 cm were 66.7% and 45%, respectively. The morbidity rate was 8.1% in the visual internal urethrotomy, and those cases were successfully treated conservatively. Conclusion : A visual internal urethrotomy is repetitive, safe, and effective as a primary treatment in urethral stricture, especially in partially obstructed strictures and in strictures shorter than 1 cm.
Summary
Case Report
Isolated Small Bowel Injury Caused by Blunt Abdominal Trauma - A Case Report -
Mi Ran Kim, M.D., Seok Yong Ryu, M.D., and Hong Yong Kim, M.D.
J Korean Soc Traumatol. 2002;15(2):123-126.
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AbstractAbstract PDF
Blunt small bowel injury (SBI) is infrequent although it is reported to be the third most common injury in Korea. Furthermore, significant variations exist in the diagnostic approach to patients with suspected blunt SBI so that diagnosis and management present a significant challenge for trauma surgeons and emergency physicians. Delays in diagnosis and management are responsible for increased mortality and morbidity, so it is very important to select an appropriative diagnostic modality rapidly in a given situation. With the increasing popularity of computed tomographic (CT) scans as the preferred diagnostic modality in blunt abdominal trauma, intestinal injuries may be potentially missed, so many authors recommend the use of diagnostic peritoneal lavage (DPL) to evaluate blunt abdominal trauma in which no remarkable findings expected of small bowel injury exist. This report presents the case of a patient who was diagnosed with an isolated small bowel injury after a significant delay and a brief review of the subject.
Summary
J Trauma Inj : Journal of Trauma and Injury
© The Korean Society of Traumatology.