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Volume 16(1); June 2003
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Original Articles
Radiologic Indicators on Neurology Injury in Burst Fractures of the Thoracolumbar Spine
Young Do Koh, M.D., and Young-Jin Cheon, M.D.*
J Korean Soc Traumatol. 2003;16(1):1-5.
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Background
In burst fractures of the thoracolumbar spine, neurologic injury often develops due to retropulsion of a bony fragment into the spinal canal. The purpose of this study was to determine the radiologic findings frequently accompaning neurologic injury. Methods: Thirty-two (32) patients with burst fractures of the thoracolumbar spine were divided into 2 groups, 10 with neurologic injury in group 1 and 22 without neurologic injury in group 2, and the relationship between neurologic injury and radiologic factors was retrospectively analyzed. Results: The results were as follows: Denis type A and the extent of the burst component were significantly related to neurologic injury. Canal encroachment by a bony fragment was larger in group 1 than in group 2. Neither the anterior and the posterior vertebral heights, the sagittal index, rotation of the bony fragment, nor a laminar fracture were related with neurologic injury. Conclusion: In summary, factors that influenced the presence of neurologic injury were fracture type, comminution of the vertebral body, and canal encroachment.
Summary
Experimental Study of a Perfluorocarbon Emulsion Blood Substitute in the Hemorrhagic Rat Model
Sung Jun Park, M.D., Dong Phil Kim, M.D.*, Myung Chun Kim, M.D., and Young Gwan Ko, M.D.
J Korean Soc Traumatol. 2003;16(1):6-11.
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Purpose
In recent years, perfluorochemicals (abbreviated as PFCS) have been further refined and have been suggested as artificial blood substitutes. Perftoran, an available PFC in Russia, is a mixture of perfluorodecalin and perfluor-n-metylcyclohexyl-piperidine. This study was designed to determine the effectiveness of perftoran in vivo. Methods: This study was based on an unanesthetized hemorrhagic rat model (30% blood volume loss). The 5 groups studied were as follows: 1. control - no resuscitation fluid in room air 2. normal saline solution - 2.5 times shed blood volume in room air, 3. normal saline solution - 2.5 times shed blood volume in an oxygen supplement, 4. perftoran (PFC: artificial blood substitute) - 1 times shed blood volume in room air, 5. perftoran (PFC: artificial blood substitute) - 1 times shed blood volume in an oxygen supplement. Arterial blood gas, electrolyte, complete blood count were measured parameters. The data were analyzed statistically for differences between the groups (kruskall-wallis analysis). Results: After the infusion of 40% perftoran, the volume of PaO2 measured 10~30 mmHg higher than that of either the control or the saline resuscitation groups. The PaCO2, pH and lactate showed no significant changes after the infusion of 40% perftoran. Conclusion: Perftoran is available for transfusion in the experimental hemorrhagic shock rat model. Further studies are encouraged to investigate its usefulness as an artificial blood substitutesfor the future.
Summary
Suggestions for improvement of ICD-10 based Injury Severity Score (ICISS) based on case-analysis study
Hye Young Jang, M.D., Dong Hoon Lee, M.D., Eun Kyung Eo, M.D., Young Jin Cheon, M.D., and Koo Young Jung, M.D.
J Korean Soc Traumatol. 2003;16(1):12-24.
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Background
Due to several limitations of the Trauma and Injury Severity Score (TRISS), the ICD-9CM-based Injury Severity Score (ICISS) has recently been proposed as an alternative method. Few limitations are known about the ICISS because of it’s recent application. The purpose of this study was to examine the limitations of the ICD-10-based ICISS and the ICISS full model by using a case analysis. Objects & Method: Seven years of data on 595 patients who suffered from serious injury were collected prospectively. We compared the final outcomes of the patients with the probabilities of survival (Ps) from the ICISS full model. The cutoff value of Ps from the ICISS full model that we decided for patient’s survival was 0.5. Expired patients with high values of the Ps were defined as“ unexpected deaths”; conversely, patient with low values of the Ps that survived were defined as “unexpected survivals”. We only reviewed the medical records in “unexpected” cases, searching for the causes of the mismatch. The known limitations of the ICISS (and the full model) were categorized and then assigned to each case. Throughout the process, we were able to identify limitations of the ICISS (and the full model) not known till now. Results: Among the 595 patients, 212 patients (35.6%) expired. The average score of the ICISS full model was 0.622. Limitations of the ICISS (and the full model) are as follows: First, various levels of severity could not be distinguished with the ICISS because they are represented as a single code. Secondly, some diagnoses couldn’t be represented in current ICD-10 code. Thirdly, the ICD code couldn’t distinguish a unilateral injury from a bilateral injury, distorting the injury severity. Fourthly, the survival risk ratio (SRR) database may be unreliable in cases of low-incidence injuries and in cases of patients who died before a definite diagnosis. Because the structure of the ICISS full model resembles the TRISS, the limitations are similar, and those are a dichomotous age portion and consideration of only the ‘initial’revised trauma score (RTS). Though it is said that the ICISS has the potential to reflect non-trauma illnesses, preexisting medical conditions and post-injury medical complications cannot be included in the ICISS model. Conclusion: We suggest the followings for improving the ICISS (and the full model). First, limitations shared with the TRISS should be corrected. Second, so that pre-existing conditions can be considered, some pre-existing conditions should be included in the ICISS as constituents. Third, a SRR database for non-trauma illnesses should be established so that post-injury medical complications can be considered. Some ICD-10 codes not established until now should be newly made. The exsiting ICD-10 code should be modified to include various severities and lateralities. Fourth, several SRR databases, corresponding to the levels of the trauma care of the medical institution, should be established, and multicenter trials on SRR databases should be conducted in the future. Fifth, autopsies should be routine in cases where definite diagnoses were not made.
Summary
Preservation of Renal Function after Conservative Treatment for Trauma: Short_term followup results with 99m technetium dime rcapto-succinic acid
Un Chang Choi, M.D., Ho Hun Jeong, M.D., Jong Bouk Lee, M.D., and Jung Chul Yun, M.D.
J Korean Soc Traumatol. 2003;16(1):25-30.
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AbstractAbstract PDF
Background
Whether adequate renal function is preserved or not is an important factor in conservative management of patients with renal trauma. A99 mtechnetium dimercapto-succinic acid (99mTc-DMSA) scan is useful for radionuclide scintigraphy to evaluate the renal function quartitatively. Methods : Forty-five (45) patients with renal injury who had undergone conservative treatment had their relative renal functions estimated by using a 99mTc-DMSA renal scan 2 months following successful management. Results: Preservation of renal function was considered adequate if more than a third of the injured kidney had been preserved. Associated organ injury was present in 13 (29%) patients, and the mean injury severity score (ISS) was 13. On the injury side, the mean relative renal function according to the degree of renal injury was 90.2% in grade 1, 84.3% in grade 2, 73.7% in grade 3, and 52.1% in grade 4. In 16 (100%) of the 16 patients with minor renal injury and 25 (86%) of the 29 patients with major renal injury, adequate renal function had been preserved. Conclusions: This study shows that conservative management of renal trauma, including grade-3 and 4 major injury, is effective and that a high correlation is present between the degree of renal injury and the relative renal function. A longer follow up is needed to confirm these results.
Summary
Role of the Pulse Oximetry as a Triage Tool in Chest Trauma Patients
Jae-Chol Yoon, M.D., Kyoung-Soo Lim, M.D., Ryuk-Ahn, M.D., Shin-Ahn, M.D., Dong-Woo Seo, M.D., Won Kim, M.D., Youn-Back, Choi, M.D.*
J Korean Soc Traumatol. 2003;16(1):31-36.
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AbstractAbstract PDF
Background
The blunt chest injuries are the most important problems in civil practice especially due to the increasing incidence of the traffic accident. But early acute grading of the severity of chest injuries is known to be difficult. Method: A prospective investigation was performed on 57 blunt chest trauma patients admitted to Emergency Department of Asan Medical Center during March 2003. In all patients, the correlations between oxygen saturation (SpO2), respiratory rate, thoracic Abbreviated Injury Scale (AIS), and Injury Severity Scale (ISS) were investigated. Results: The difference of thoracic AIS and ISS between low SpO2 group (SpO2< 95%) group and normal SpO2 group (SpO2≥ 95% group) was statistically significant (P<0.05). The difference of thoracic AIS between abnormal respiratory rate group (< 16 breaths/min. or > 24 breaths/min.) and normal respiratory rate group (16-24 breaths/min.) was statistically significant (P<0.05), but difference of ISS was not statistically significant (P=0.07). Abnormal respiratory rate group had lower oxygen saturation compared with normal respiratory rate group in chest trauma patients (P< 0.05). Conclusion: We conclude that oxygen saturation measured by pulse oximetry and respiratory rate can be used as a triage tool for severity grading of chest injuries at the emergency department. But we recommend oxygen saturation measured by pulse oximetry rather than respiratory rate as a triage tool because of it’s accuracy, simplicity and rapidity in emergency department.
Summary
The Evaluation of the Hospital Transfer Adequacy to the Tertiary
Hospital in Trauma Patients
Jae-Ho Lee, M.D., Kyoung-Soo Lim M.D., Ryuk Ahn, M.D., Dong-Woo Seo, M.D.,
Shin Ahn, M.D., Won Kim, M.D., Youn-Back Choi, M.D.*
J Korean Soc Traumatol. 2003;16(1):37-42.
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AbstractAbstract PDF
Background
Multiple trauma patients should be triaged properly by simple triage method like a triage score(TS) or revised trauma score(RTS) at the primary hospital. Severely injured patients(TS <9 or t-RTS <12) should be transferred to the tertiary hospital as early as possible. This study was designed to evaluate whether major trauma patients were adequately transferred to the tertiary hospital according to trama guidelines. Method: All trauma patients transferred to Asan Medical Center(AMC) were analyzed from March 1, 2003 to May 31, 2003. TS, t-RTS, injury severity score(ISS), transfer time from primary hospital to AMC were checked prospectively. Golden transfer time was defined as arrival time within 1 hour after accident. The presence of transfer note or laboratory(radiologic) results was also checked. ISS above 16, TS below 8, t-RTS below 11, and ICU admission cases were considered as the major trauma. Major trauma patients were compared with other variables to evaluated the adequacy of patient transfer. Result: Overall 324 cases, 38 cases(10.2%) were major trauma. Mean ISS was 6.0±0.6, The cases of ISS above 16 were 32 cases in number and occupied 9.9%, ISS below 15 were 292 cases (90.1%). No major trauma patients were transferred within golden time. Conclusion: All major trauma patients were not transferred within the golden transfer time. Multiple trauma patients were inadequately transferred to tertiary hospital in the aspect of time delay, unnecessary prehospital evaluations such as laboratory and radiologic examination. In primary hospital, major trauma patients should be triaged by TS or t-RTS and be transferred as
soon as primary survey of ATLS was finished.
Summary
Clinical Patterns of Pelvic Fracture at the Emergency Department
Young Jin Cheon, M.D., Sang Jin Lee, M.D. and Young Do Koh, M.D.*
J Korean Soc Traumatol. 2003;16(1):43-49.
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Background
s: The object of this retrospective study was to evaluate the clinical pattern of the patients with pelvic fracture due to blunt trauma. We analyzed the correlation between clinical symptoms, pelvic fracture classification, trauma score and ultimate outcome of treatment. In addition the purpose of the study was to establish a guideline for management in emergency departments. Methods: We performed a retrospective analysis of 90 patients with pelvic fractures during a 2 year period from January 2001 to December 2002 who presented in our emergency department. All data were collected from the medical records and were entered in a database for analysis on the basis of: age, sex, mechanism of injury, vital signs at admission, abbreviated injury scores (AIS), injury severity scores (ISS), anatomical grading of the fracture, clinical outcome (including hospital mortality), length of hospital stay, length of intensive-care-unit stay, requirement of crystalloid fluid, and blood product. The data were stratified into patients less than 55years of age (young group) and 55 years of age or older (old group). The data were also stratified according to the fracture grading and the trauma scores. Results: Among 90 patients, the numbers of male and female were similar (42:48). The most frequent fracture pattern was grade 3 (n=30, 33.3%), followed by grade 1. According to stratification by age, mortality in the older age group (n=25, 27.8%) was higher than it was in the younger group (p<0.05). However, there were no significant differences between the two groups as to the length of hospital stay, the admitting systolic blood pressure, the heart rate, and the fluid and blood product requirements. According to stratification based on the fracture grading system, the severe-fracture group (grade 3, n=30) showed higher mortality than the mild-fracture group (grades 1, 2 and 4). Also, systolic blood pressure at admission was significantly lower in the severe-fracture group than in the mild-fracture group. Stratification by using the AIS showed significant differences in the hospital mortality, the length of hospital stay, the admitting systolic blood pressure, and the requirement for fluid and blood products between the severely injured group (n=37, 41.1%; AIS (3 in any of head, thorax, abdomen) and the mild injured group. Conclusion: The severity of pelvic fracture is associated with the AIS and the associated injury. Correlations with age and fracture grade are weaker than the correlation with the AIS.
Summary
Small Bowel Injury after Blunt Abdominal Trauma: An Analysis of Diagnostic Methods
Jae Woon Lee, M.D., Jin Whan Kim, M.D., Jang Ho Kim, M.D.*, Hae Chang Jo, M.D., and Byung Jo Bae, M.D.
J Korean Soc Traumatol. 2003;16(1):50-57.
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AbstractAbstract PDF
Background
Although small bowel rupture has been reported to be the third most common injury in blunt abdominal trauma, but small bowel injury is an infrequent diagnosis, and there is not much agreement on how to make the diagnosis. The purpose of this study was to evaluate methods for making the diagnosis of blunt small bowel injury. Materials and Methods: The charts of 45 patients with small bowel injury by blunt trauma who were admitted to the Department of General Surgery of Daegu Fatima Hospital from January 1998 to December 2002 were reviewed. Each record was reviewed for detailed history, laboratory findings, and diagnostic methods. Results: A total of 45 patients who had small bowel perforations were included in this study. Forty-two had an abnormality on physical examination (93.3%). Thirty-four had CT abnormalities (75.6%). Thirty-two had leukocytosis (71.1%). Of the thirty-four patients with CT abnormalities, twenty had bowel-wall thickening, twenty-six had free air, and eighteen had fluid collection. Delays in the diagnosis of small bowel perforation are directly responsible for one-third of the deaths. Conclusion: Blunt small bowel perforation after trauma is relatively uncommon. When it is present, the results of physical examination, laboratory test (CBC), abdominal CT have to be considered initially.
Summary
Treatment of Occult Pneumothoraces according to Computed Tomog raphic Scan Classification
Jin Seong Cho, M.D., Yong Su Lim, M.D., Gun Lee, M.D., Seung Youl Hyun, M.D.*, Wook Jin, M.D.**, Seong Youn Hwang, M.D.***
J Korean Soc Traumatol. 2003;16(1):58-63.
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AbstractAbstract PDF
Background
Occult pneumothorax defined as a pneumothorax that is detected by computed tomography (CT) scaning, not routine supine screening chest roentgenograms. Optimal treatment for blunt trauma occult pneumothoraces has not been defined. Methods: Chest & abdominal CT scans of all trauma patients about 1-year period were retrospectively reviewed. To help guide management, we used Wolfman et al’s classification, based on size and location: (a) minuscule ( <1 cm in greatest thickness, seen on four or fewer); (b) anterior ( >1cm in greatest thickness, but not extending beyond the midcoronal line); (c) anterolateral (extending beyond the midcoronal line). Results: 43 patients with 48 pneumothoraces were enrolled. 16 of 17 cases with minuscule pneumothorax were observed without complications; one of 17 cases had chest tube placement. 19 of 25 cases with anterior pneumothroax were observed and resolved without complication; six had chest tube placement. Three of six cases with anterolateral pneumothorax were observed and resolved without complication; The others had chest tube placement. 16 cases in each group received positive pressure ventilation or general anesthesia. 14 of 16 cases were no difference in overall complication rate. Conclusions: Our data suggest that it is possible to safely observe patients of minuscule and anterior pneumothorax. But anterolateral pneumothorax must be treated with closed thoracostomy. Occult pneumothroaces can be safely observed in patients with blunt trauma injury regardless of the need for positive pressure ventilation.
Summary
Case Reports
A Case of Small Bowel Perforation with False Negative Findings in Diagnostic Peritoneal Lavage
Kwang Jung Lee, M.D., Soon Young Yun, M.D., Hye Young Jang, M.D., Eun Kyung Eo, M.D., Koo Young Jung, M.D.
J Korean Soc Traumatol. 2003;16(1):64-67.
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AbstractAbstract PDF
Although diagnostic peritoneal lavage (DPL) is a well-established, reliably objective method of diagnosis for intraperitoneal injury, it is too sensitive to be used as an indicator for an emergency celiotomy. Therefore, since the development of ultrasonography and advanced computed tomographic scanners, the role of DPL has been markedly reduced. Despite such remarkable advances, however, radiologic diagnosis of intestinal injury cannot always provide definitive results, and DPL may still be valuable in such instances in which intestinal injury cannot be ruled out. We used a new DPL criterion that had previously been introduced to aid in the diagnosis of intestinal injury. This report presents the case of a patient who was diagnosed with a small bowel injury after operation in spite of a negative DPL; a brief review of the subject is also presented.
Summary
A Case of Traumatic Chylothorax occurred by Falling
Yong Hwan Kim, M.D.
J Korean Soc Traumatol. 2003;16(1):68-72.
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AbstractAbstract PDF
Traumatic chylothorax can be iatrogenic or non-iatrogenic. Traumatic chylothroax is a rare entity, as the thoracic duct has a protected posterior location. In most cases chylothorax is caused by damage to the thoracic duct or one of its branches in association with flexion-extension injury to the thoracic spine. Diagnosis and subsequent management present significant problems for the clinician, prompt diagnosis is essential to achieve an effective therapeutic goal. A 54-year-old woman was transferred for thoracic trauma secondary to penetrating injury with a branch of tree following a fall. During the treatment, traumatic chylothorax was discovered and successfully treated by conservative approach.
Summary
Delayed Upper Airway Obstruction Due to Cervical Hematoma after Blunt Neck Trauma in a Patient with Neurofibromatosis
Sang Jin Lee, M.D., Hye Young Jang, M.D., Eun Kyung Eo, M.D., Cheon Young Jin, M.D., Koo Young Jung, M.D.
J Korean Soc Traumatol. 2003;16(1):73-77.
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AbstractAbstract PDF
In a patient with blunt trauma to the neck, there is potential for airway obstruction. In this situation, clinicians must be alert to protect the airway, and rapid assessment and management are essential for saving the life of the patient. A 56-year-old man with neurofibromatosis suffered from a huge, traumatic cervical hematoma following a fall injury. About 43 hours after the injury, he complained of dyspnea, and respiratory failure developed due to the cervical hematoma enlarging. After an emergency cricothyroidotomy, his ventilation was improved. Neck exploration was done, and the culprit vessel - the external carotid artery - was ligated. A high index of suspicion and a serial evaluation for delayed airway complications in neck trauma patients with neurofibromatosis are required because their blood vessels can be genetically fragile to minor trauma. Therefore, ED physicians should know about the management of difficult airways and should not hesitate performing an emergency cricothyroidotomy as a definitive rescue technique for the failed airway.
Summary
J Trauma Inj : Journal of Trauma and Injury
© The Korean Society of Traumatology.