Journal of Trauma and Injury

Volume 26(4); December 2013

Original Articles

A Simple and Easy Method to Prevent Intravenous Fluid Heat Loss in Hypothermia: Sun Hwa Lee, Yoon Hee Choi, Dong Hoon Lee; J Trauma Inj. 2013;26(4):255-260.

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Abstract PDF: PURPOSE
For the treat hypothermia patients, active warming might be needed. In most emergency departments, IV warm saline infusion is used for treatments. However, during IV warm saline infusion, heat loss from the warm saline may occur and aggravate hypothermia. Thus, in this study, we conducted an experiment on conserving heat loss from warm saline by using a simple method.
METHODS
Four insulation methods were used for this study. 1) wrapping the set tube for the administration of the IV fluid with a cotton bandage, 2) wrapping the set tube for the administration of the IV fluid with a cotton bandage with aluminum foil, 3) wrapping the warm saline bag and tube with a cotton bandage, and 4) wrapping the warm saline bag and tube with a cotton bandage with aluminum foil. Intravenous fluid was preheated to a temperature between 38-40degrees C. The temperatures of the saline bag temperature and the distal end of the IV administration set were measured every ten minutes for an hour. The infusion rate was 1000 cc/hr, and to obtain an accurate infusion rate, we used an infusion pump.
RESULTS
The mean initial temperature of the saline bag was 39.11degrees C. An hour later, the fluid temperature at the distal end of the fluid temperature ranged from 29.63degrees C to 34.3degrees C. Without any insulation, the initial temperature of the pre-heated warm saline, 39degreeshad decreased to 34.8degrees C after having been run through the 170-cm-long IV administration tube, and after 1-hour, the temperature was 29.63degrees C. As we expected, heat loss was prevented most by wrapping both the saline bag and the IV administration set with a cotton bandage and aluminum foil.
CONCLUSION
Wrapping both the saline bag and the IV administration set with a cotton bandage and aluminum foil can prevent heat loss during IV infusion in Emergency departments.; Summary

Transfer Patterns of Multiple Trauma Patients in University Hospital after Acute Phase Management: Jong Min Lee, Ji Young Jang, Seung Hwan Lee, Jae Gil Lee; J Trauma Inj. 2013;26(4):261-265.

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Abstract PDF: PURPOSE
The aim of this study is to evaluate the transfer pattern of multiple trauma patients after acute phase management and to determine whether the time between the surgeon's decision and the actual transfer correlates with the patient's insurance type.
METHODS
Three hundred ninety-two(392) multiple trauma patients visited the emergency room from January 2011 to April 2013. Among the 143 patients who were admitted by a trauma surgeon, 47 were transferred to another hospital after acute phase management. The age, gender, trauma mechanism, Revised trauma score (RTS), Injury severity score (ISS), insurance type, length of ICU stay and hospital stay were analyzed through a retrospective chart review.
RESULTS
The mean age was 47.7 years, and traffic accident was the most common mechanism(26, 55.3%). The mean RTS and ISS were 6.93 and 22.7, respectively. Twenty-five patients(53%) were covered by National health insurance, and 20 patients(42.6%) were covered by automobile insurance. Patients were transferred to primary (4.3%), secondary(80.9%), tertiary(4.3%) and care(10.6%) hospitals. The mean time from transfer decision to actual transfer was significantly longer for patients who were covered by automobile insurance than it was for patients who were covered by national health insurance (p=0.038).
CONCLUSION
An appropriate transfer system at the end of acute phase care is essential for managing trauma centers with limited staffing and facilities. In addition, the mean time from transfer decision to actual transfer seemed to be definitely related to the type of insurance covering the patient.; Summary

Experiences with Pancreaticoduodenal Injuries at a Single Institute: Jin Beom Cho, Jun Hyun Lee, Do Sang Lee; J Trauma Inj. 2013;26(4):266-272.

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Abstract PDF: PURPOSE
Although the duodenum and the pancreas are protected by surrounding organs and have a low probability of injury during trauma, the mortality and the morbidity due to complications is high. This report includes the pancreaticoduodenal injuries we observed that were treated at a single institute.
METHODS
The medical records of patients admitted to our institute between 2001 and 2012 for pancreaticoduodenal injury were retrospectively reviewed.
RESULTS
In our hospital, between 2001 and 2012, 15 patients were admitted for a pancreaticoduodenal injury. All patients experienced blunt trauma, 6 of whom were involved in traffic accidents and 9 of whom received injuries from physical assault. Most of the patients were men(13 of 15 patients, 86%) with a mean age of 23 years (range, 5-39 years). All patients were admitted to the emergency center and managed by the surgeons on duty. The mean value of the injury severity score was 22. The mortality rate was 6%(1 of 15 patients). Seven of the fourteen surviving patients(50%) had duodenal injury, 6 patients(42%) had a pancreatic injury, and 1 patient(7%) had a combined pancreaticoduodenal injury. The surgical procedures were targeted at damage control.
CONCLUSION
In conclusion, we believe that damage control surgery is the optimal management for a pancreaticoduodenal injury.; Summary

CT Based Hemoperitoneum Scoring for Clinicians: Objectifying the Severity of Splenic Injury and Recovery: Hong Kyung Shin, Ra Yeong Song, Ho Seong Han, Yoo Seok Yoon, Jai Young Cho, Dae Wook Hwang, Kyuwhan Jung, Young Ki Kim, Woo Hyung Lee; J Trauma Inj. 2013;26(4):273-278.

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Abstract PDF: PURPOSE
In patients with splenic trauma, Computed Tomography (CT) scan is helpful in selecting treatment options and evaluating resolution after NOM (Non-Operative Management). The purpose of this study was to suggest a CT based hemoperitoneum (HP) scoring system that can easily be used by clinicians to evaluate the severity of injury and recovery.
METHODS
A retrospective review of patients with splenic trauma admitted to our hospital between May 2003 and January 2013 was conducted. Patients diagnosed with isolated spleen injury who had a CT scan on admission were included. 1 or 2 points were given according to location and amount of hematoma in the CT image. Using the existing ultrasonography (US) based HP scoring system, the same method was applied to obtain our CT based HP scoring (CBHS) system, which ranges from 0 to 8 points. The CBHS system can be easily used by clinicians for a quick assessment of splenic injury.
RESULTS
Of the 39 patients meeting the inclusion criteria, 6 patients were managed operatively and 33 non-operatively. There was a significant difference in CBHS between the OM (operative management) group and the NOM group.(p=0.03) CBHS showed correlation with Hb (hemoglobin), Hct (hematocrit), spleen injury grade(AAST), and Hounsfield unit of ROI (Region of interest). (p=0.17, p=0.18, p<0.000, p=0.02, respectively) After successful NOM with stabilized Hb level, the amount of hemoperitoneum was scored in the follow-up CT. CBHS demonstrated correlation with decreased spleen injury grade, decreased Hounsfield unit of ROI (Region of interest) (p=0.039, p=0.049, respectively), and also objectively reflected patient recovery.
CONCLUSION
CBHS can be used as an objective and intuitive tool for clinicians in grading the severity of splenic injury by scoring the amount of hemoperitoneum, and in assessing recovery.; Summary

The Choice of Management in Patients with Splenic Blunt Trauma: A Single Center Study: Ji Young Jang, Seung Hwan Lee, Jae Gil Lee; J Trauma Inj. 2013;26(4):280-285.

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Abstract PDF: PURPOSE
Nowadays, non-operative management increases in patients with blunt splenic injury due to development of diagnostic and interventional technique. The purpose of this study is to evaluate the management in patients with blunt splenic injury and effect of clinical state such as shock on the choice of management.
METHODS
From April 2007 to July 2013, we retrospectively reviewed the medical charts of fifty patients who had splenic injury after blunt trauma. The demographic characteristics, American Association for the Surgery of Trauma (AAST) grade of splenic injury, management method (emergency operation, angiographic embolization or observation) and clinical outcome were analyzed.
RESULTS
The mean age was 41.5+/-21.4 years and male was 44(88%). Twenty patients(40%) were in shock condition initially and five patients(10%) underwent emergency operation due to hemodynamic instability. Emergency angiographic embolization was performed in 20 patients(40%) and 25 patients were managed conservatively. When patients were divided into shock group (SG) and non-shock group (NSG), Patients in SG had significantly higher serum lactate level and base deficit than NSG (lactate; 4.5+/-3.4 mmol/L, base deficit; 5.8+/-4.4 mmol/L vs 1.9+/-1.4 mmol/L, 2.8+/-2.5 mmol/L, p=0.007, p=0.013). There was no significant difference of AAST grade and contrast blush rate in abdomen CT between two groups. Among 45 patients with non-operative management, four patients(8.9%) got delayed angiographic embolization and 3 patient died from companied organ injury.
CONCLUSION
Non-operative management can be acceptable management option in patients with splenic blunt trauma under intensive hemodynamic monitoring.; Summary

Clinical and Radiological Outcome of Distal Femoral Fracture in Elderly Patient Group: Hee Gon Park, Yeon Jun Kim, Ho Seong Jang; J Trauma Inj. 2013;26(4):286-290.

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Abstract PDF: PURPOSE
To report the postoperative Clinical and Radiological outcomes following distal femoral fractures in elderly patients compared with young patients.
METHODS
From March, 1996 to March, 2012, 83 patients who received surgical treatment for fractures of the distal femur were enrolled in this retrospective study. Ages more than 65 was named group A. Group A was 49 cases and mean age is 72.5 year(65~91year). Group B was 49 cases and mean age is 45.7 year(16~61 year). Surgical methods are retrograde IM nail, locking compression plate, cannulated screw and postoperative rehabilitation is no difference between two groups. Clinical results were evaluated using Neer scores, radiographic results and the presence of clinical complications.
RESULTS
The mean union period was 18.4(12-40) weeks in group A and 17(10-24) weeks in group B. Neer functional scores are no significant statistical difference between two groups. There are 5 cases metal breakage in group A and 1case in group B. There are 3 cases nonunion in group A and 1 case in group B.
CONCLUSION
In the case of fractures of the distal femur in elderly patients, locking plate using minimally invasive percutaneous periosteal osteosynthesis (MIPPO) technique may be one of the most effective methods and preoperative bone stock evaluation in important.; Summary

Case Reports

Clinical Analysis of Ventilator-associated Pneumonia (VAP) in Blunt-chest-trauma Patients: Joong Hwan Oh, Il Hwan Park, Chun Sung Byun, Geum Suk Bae; J Trauma Inj. 2013;26(4):291-296.

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Abstract PDF: PURPOSE
Prolonged ventilation leads to a higher incidence of ventilator-associated pneumonia (VAP), resulting in weaning failure and increased medical costs. The aim of this study was to analyze clinical results and prognostic factors of VAP in patients with blunt chest trauma.
METHODS
From 2007 to 2011, one hundred patients undergoing mechanical ventilation for more than 48 hours were divided into two groups: a VAP-negative group, (32 patients, mean age; 53 years, M:F=25:7) and a VAP-positive group, (68 patients, mean age; 60 years, M:F=56:12). VAP was diagnosed using clinical symptoms, radiologic findings and microorganisms. The injury severity score (ISS), shock, combined injuries, computerized tomographic pulmonary findings, transfusion, chronic obstructive lung disease (COPD), ventilation time, stay in intensive care unit (ICU) and hospital stays, complications such as sepsis or disseminated intravascular coagulation (DIC) and microorganisms were analyzed. Chi square, t-test, Mann-Whitney U test and logistic regression analysies were used with SPSS 18 software.
RESULTS
Age, sex, ISS, shock and combined injuries showed no differences between the VAP - negative group and - positive group (p>0.05), but ventilation time, ICU and hospital stays, blood transfusion and complications such as sepsis or DIC showed significant differencies (p<0.05). Four patients(13%) showed no clinical symptoms eventhough blood cultures were positive. Regardless of VAP, mortality-related factors were shock (p=0.036), transfusion (p=0.042), COPD (p=0.029), mechanical ventilation time (p=0.011), ICU stay (p=0.032), and sepsis (p=0.000). Microorgnisms were MRSA(43%), pseudomonas(24%), acinetobacter(16%), streptococcus(9%), klebsiela(4%), staphillococus aureus(4%). However there was no difference in mortality between the two groups.
CONCLUSION
VAP itself was not related with mortality. Consideration of mortality-related factors for VAP and its aggressive treatment play important roles in improving patient outcomes.; Summary

Traumatic Asphyxia due to Blunt Chest Trauma with External Auditory Canal Bleeding: Je Ho Lee, Kyu Hyouck Kyoung, Jeong Won Kim, Hui Jun Yang, Eun Seog Hong; J Trauma Inj. 2013;26(4):297-299.

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Abstract PDF: Traumatic asphyxia, also called 'Perthes syndrome', is characterized by subconjunctival hemorrhage, cervicofacialpetechiae and cyanosis resulting from venous hypertension caused by an abrupt, severe, compressive force to the thoracoabdominal region. A 37-year-old male patient who was transferred to the emergency room due to chest trauma by overturning of a forkcrane. His head, neck, and shoulders showed severe ecchymosis, and his upper chest was cyanotic. There was bilateral subconjunctival hemorrhage and bilateral ear bleeding without tympanic rupture. Perthes syndrome is a rare condition and we treated a patient with typical and atypical symptoms; thus we report this case of Perthes syndrome.; Summary

Traumatic Organized Hematoma Mimicking Intra-peritoneal Tumor: A Case Report: Jong Min Park, Seong Yup Kim, Il Yong Chung, Woo Shik Kim, Yong Chul Shin, Yeong Cheol Kim, Sei Hyeog Park; J Trauma Inj. 2013;26(4):300-303.

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Abstract PDF: Blunt abdominal trauma is commonly encountered in the emergency department. The lack of historical data and the presence of distracting injuries or altered mental status, from head injury or intoxication, can make these injuries difficult to diagnose and manage. We experienced a case of traumatic organized hematoma misdiagnosed as intra-peritoneal tumor with intestinal obstruction. A 52-year-old homeless male patient who have chronic alcoholism was admitted via emergency room with infra-umbilical abdominal pain. At admission, he was drunken status and so we could not be aware of blows to the abdomen. He had a unknown large operation scar on mid abdomen. A computed tomography (CT) scan showed the intestinal obstruction of the ileum level with 5.5cm sized mesenteric tumor. We performed adhesiolysis and widely segmental resection of small bowel including tumor with side-to-side anastomosis due to great discrepancy in size. He stated later that he was a victim of the violence before 3 weeks. A final pathologic report revealed well encapsulated, traumatic mesenteric hematoma with organizing thrombi, ischemia and abscess formation with multiple adhesion bands. Finally, the patient was discharged without complications on postoperative day 14.; Summary

A Case of Successful Endoscopic and Conservative Treatment for Intentional Ingestion of Sharp Foreign Bodies in the Alimentary Tract: Jong Min Park, Seong Yup Kim, Il Yong Chung, Woo Shik Kim, Yong Chul Shin, Yeong Cheol Kim, Sei Hyeog Park; J Trauma Inj. 2013;26(4):304-307.

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Abstract PDF: Food bolus impaction is the most common cause of esophageal foreign body obstruction in adults. Other causes include intentional ingestion in psychiatric patients or prison inmates. We experienced successful treatment of a patient with intentional ingestion of multiple sharp foreign bodies(25 cutter and razor fragments). A 47-year-old male patient who was suffering from chronic alcoholism was admitted, via the emergency room, with dysphagia and neck pain. He was suffering from alcoholic liver cirrhosis and psychiatric problems, such as chronic alcoholism, anxiety disorder and insomnia. The patient had intended to leave the hospital after having swallowed the sharp objects. Plain radiographs and computed tomography (CT) scan showed multiple, scattered metal fragments in the esophagus, stomach, and small bowel. We performed emergent endoscopy and successfully removed one impacted blade in the upper esophagus using by a snare with an overtube. The rest of the fragments had already passed through the pylorus, so we could not find them with endoscopy. We checked the patient with simple abdominal radiographs and careful physical examinations every day. All remaining fragments were uneventfully excreted through stool during the patient's 6 day hospital stay. Finally, we were able to confirm the presence of the objects in the stool, and radiographs were negative. The patient was discharged without complications after 14 days hospital stay and then was followed by the Department of Psychiatry.; Summary

The Management of Arteriovenous Malformation Diagnosed after Extremity Trauma: Seong Yup Kim, Sung Chan Jin; J Trauma Inj. 2013;26(4):308-311.

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Abstract PDF: Congenital arteriovenous malformation is rare disease. Endovascular treatment is one of the important modality in the treatment of arteriovenous malformation. We report a successful treatment case of arteriovenous malformation with endovascular treatment.; Summary

The Occurence of Deep Vein Thrombosis in Abdominal Compartment Patient: Seong Yup Kim, Sung Chan Jin; J Trauma Inj. 2013;26(4):312-315.

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Abstract PDF: Abdominal compartment syndrome is one cause of deep vein thrombosis of lower extremity. Although prophylactic dose of anticoagulation agent is safely started after 24~48 hours without the evidence of active bleeding, there may be bleeding complication related to invasive procedure which trauma victims undergo. Inferior vena cava filter should be considered in the treatment plan of this complex situation.; Summary

Rupture of the Cervical Esophagus from Blunt Trauma: Seunghyuk Nam, Sun Kyun Ro, Jin Hwan Cheong, Ki Chul Park, Chul Burm Lee; J Trauma Inj. 2013;26(4):316-318.

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Abstract PDF: Rupture of the esophagus after blunt trauma is a rare event. But any type of esophageal rupture has the high morbidity and mortality rate. In these situations, the sign and symptom of the esophageal rupture is subtle and nonspecific; therefore, the physicians are usually not suspicious. Delaying in diagnosis prevents proper treatment (surgical or non-surgical) before significant complications occurred. We report a case of a cervical esophageal perforation with primary repair and drainage after blunt trauma.; Summary

Traumatic Cervical Spinal Cord Injury Patient with Jejunal Perforation: Seung Je Go, Jeung Seuk Yoon, Jung Ho Yun; J Trauma Inj. 2013;26(4):319-322.

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Abstract PDF: A 66 year-old woman had cervical spinal cord injury by an automobile. We performed emergency operation for partial quadriplegia. She recovered from motor weakness gradually, but complained of abdominal distension and mild dyspnea. A physical examination of her abdomen did not have tenderness and rebound tenderness. She underwent a decubitus view of chest X-ray due to aggravated dyspnea at postoperative 4 days. We detected free air gas of abdomen and immediately identified a cause of pneumoperitoneum by abdominal computed tomography. We performed an emergent laparotomy and confirmed a jejunal perforation. After an operation, she recovered well and is under rehabilitation.; Summary

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