- Email: [email protected]
A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission
Letters to the Editor / Injury, Int. J. Care Injured 44 (2013) 1654–1672
values within each comparison group, are closely matched. Very much like the Taiwanese researchers, we found no difference in the outcomes (mortality) between those stabilized and those not stabilized, before transfer to the trauma centre. This equivocal finding of mortality raises important concerns. One explanation could be that, the resuscitation done prior to reaching the Trauma Centre was inadequate. In this case, we need to augment our Emergency Medical Services, to achieve consistently better stabilization of patients. However, while sounding counter-intuitive, field triage and stabilizing patients prior to transfer may not be, actually improving outcomes. Only further research on outcomes, in countries lacking robust EMS systems, can address this concern. Reference 1. Hsiao KY, Lin LC, Chou MH, Chen CC, Lee HC, Foo NP, et al. Outcomes of trauma patients: direct transport versus transfer after stabilisation at another hospital. Injury 2012. http://dx.doi.org/10.1016/j.injury.2012.01.004. [Epub ahead of print].
Vineet Kumar Pritam Suryawanshi Satish B. Dharap Dept of General and Trauma Surgery, LTM General Hospital, Sion, Mumbai 400022, India Nobhojit Roy* Jamsetji Tata Centre for Disaster Management, Tata Institute of Social Sciences, Malti and Jal A D Naoroji Campus, Deonar Farm Road, Mumbai 400 088, India *Corresponding author. Tel.: +91 9821291225 E-mail address: [email protected] (N. Roy)
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point of view. In this situation, we will arrange examination under anaesthesia (EUA) for them. EUA can help pelvic surgeon to identify some occult instability of pelvic ring injury. Claude Sagi et al.2 reported 68 patients performing an examination under anaesthesia with dynamic stress fluoroscopy and revealed occult pelvic ring instability in 50% of presumed APC-1 injuries, 39% of APC-2 injuries, and 37% of LC-1 injuries. The percentage is close to this study, that is, 30% patients need to receive operation. Second, this study performed posterior iliosacral fixation for patients with prolonged pain for improving mobilization. Is this procedure enough? In my opinion, anterior fixation with ramus screw is also important for some types of lateral compression. As figures adapted from Claude Sagi et al.2 They propose a modification to the Young-Burgess Classification system to reflect the dynamic component of pelvic ring instability disclosed on EUA as follows: APC-2a for those injuries requiring anterior only fixation, APC-2b for those injuries that may require treatment with anterior and posterior fixation, LC-1a for those injuries that are stable and do not require internal fixation, and LC-1b for those lateral compression injuries that may require treatment with internal fixation. Dynamic concept seems to be useful in this orthopaedic condition like other ligamentous injuries. Conflict of interest statement The author declares that there are no conflicts of interest. References 1. Scheyerer MJ, Osterhoff G, Wehrle S, Wanner GA, Simmen H-P, Werner CML. Detection of posterior pelvic injuries in fractures of the pubic rami injury. International Journal of the Care of the Injured 2012;43:1326–9. 2. Claude Sagi H, Franco M, Coniglione DO, Stanford JH. Examination under anesthetic for occult pelvic ring instability. Journal of Orthopaedic Trauma 2011;25: 529–37.
http://dx.doi.org/10.1016/j.injury.2012.03.036
Letter to the Editor Detection of posterior pelvic injuries in fractures of the pubic rami but only posterior fixation is not always enough Dear Editor,
Kai-Cheng Lin MD* Shan-Wei Yang MD,PhD Yih-Wen Tarng MD,PhD Department of Orthopedic Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan *Corresponding author E-mail address: [email protected] (K.-C. Lin) http://dx.doi.org/10.1016/j.injury.2012.10.026
We read with great interest the recent article by Scheyerer et al.1 They have reported an interesting retrospective study on ‘‘Detection of posterior pelvic injuries in fractures of the pubic rami’’. They had a large series of 233 patients with pubic rami fracture. In these patients, 177 patients had a CT scan for survey, and an injury of the posterior pelvic ring was found on CT scans in 96.8% of the patients. Most lesions represented transforaminal sacral fractures, avulsion fractures of ligaments or compression fractures of the lateral mass. All patients with dorsal injuries could initially be treated conservatively, nevertheless 30% of them needed operative treatment in the course. We had some opinions to the editors. First, do you routinely arrange CT scan for patients with pelvic fracture, especially they had ‘‘only’’ rami fractures? In this patient, they concluded that nearly all cases with fractures of the pubic rami do have a lesion elsewhere within the pelvic ring. In patients with prolonged pain and immobility following ‘pubic rami fractures’ one should be aware that they probably represent an undiagnosed pelvic ring injury and further diagnostic work-up – sometimes even surgery – is warranted. We highly agree with this
Letter to the Editor A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission Daniel et al.1 raised important issues on the clinical decision rule to predict adult patients with traumatic intracranial haemorrhage (ICH) who do not require intensive care unit (ICU) admission. They evaluated 432 cases and found the following three factors to predict adult patients with traumatic ICH who do not require ICU admission: Glasgow Coma Score = 15, isolated head injury, and age < 65. We read this article with interest and would like to add our concerns. Traumatic ICH is one of the important positive findings in most studies of high-risk mild TBI patients.2,3 There are some studies
1656
Letters to the Editor / Injury, Int. J. Care Injured 44 (2013) 1654–1672
aimed to predict positive findings in the brain CT scan of minor head injury patients2,4–7 and they have proposed some signs and symptoms for this purpose. However, Daniel et al. have not included such signs and symptoms as independent variables in their model. It seems logical to consider risk factors for neurosurgical intervention as risk factors of need to ICU admission.6 Therefore, the model may improve by including nausea,5 vomiting,4,5,7 severe headache,2,4,5 raccoon sign,2 amnesia or short term memory deficits,4,6–8 seizure,4 the kind of trauma such as above clavicles4 and open or depressed skull fracture,6,7 as independent variables. We also concern about claiming to rule out ‘‘patients who do NOT require ICU admission’’. This study can well detect which group of patients needs ICU admission according to the data. However, in order to declare which groups of patients do NOT require ICU admission, a study needs a very large sample size to reflect a wide variety of patients and every combination of independent variables included in the model. Therefore, we believe this manuscript would be better to titled as ‘‘A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who require intensive care unit admission.’’
Soheil Saadat Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran Vafa Rahimi-Movaghara,b,* Sina Trauma and Surgery Research Center, Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran b Research Centre for Neural Repair, University of Tehran, Tehran, Iran a
*Corresponding author at: Sina Trauma and Surgery Research Center, Sina Hospital, Hassan-Abad Square, Imam Khomeini Avenue, Tehran University of Medical Sciences, Tehran 11365-3876, Iran. Tel.: +98 915 342 2682/216 675 7010; fax: +98 216 675 7009 E-mail addresses: [email protected] [email protected] (V. Rahimi-Movaghar) http://dx.doi.org/10.1016/j.injury.2012.11.019
Conflict of interest All authors disclose there have been no financial and personal relationships with other people or organizations that could inappropriately influence our work. Examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding. Acknowledgement The authors would like to appreciate Mrs. Pourmand (Sina Hospital, Research Development Centre) for her careful edit of the manuscript. References 1. Nishijima DK, Shahlaie K, Echeverri A, Holmes JF. A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission. Injury 2012;43:1827–32. 2. Saadat S, Ghodsi SM, Naieni KH, Firouznia K, Hosseini M, Kadkhodaie HR, et al. Prediction of intracranial computed tomography findings in patients with minor head injury by using logistic regression. J Neurosurg 2009;111: 688–94. 3. Wong GK, Yeung JH, Graham CA, Zhu XL, Rainer TH, Poon WS. Neurological outcome in patients with traumatic brain injury and its relationship with computed tomography patterns of traumatic subarachnoid hemorrhage. J Neurosurg 2011;114:1510–5. 4. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000;343:100–5. 5. Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. J Emerg Med 1997;15: 453–7. 6. Smits M, Dippel DW, Steyerberg EW, de Haan GG, Dekker HM, Vos PE, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Int Med 2007;146:397–405. 7. Stiell IG, Lesiuk H, Wells GA, Coyle D, McKnight RD, Brison R, et al. Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and economic analysis). Ann Emerg Med 2001;38: 317–22. 8. Sharif-Alhoseini M, Khodadadi H, Chardoli M, Rahimi-Movaghar V. Indications for brain computed tomography scan after minor head injury. J Emerg Trauma Shock 2011;4:472–6.
Vahid Eslami Sina Trauma and Surgery Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
Letter to the Editor A supplementary study from China: The use of pain medications after operative treatment of an ankle fracture The results in the article titled ‘Satisfaction with pain relief after operative treatment of an ankle fracture’ very much attracted the attention of the authors.1 In its discussion, the authors called for multicentre studies to improve the external validity. Here, we want to share the use of pain medications after operative treatment of an ankle fracture in China. According to the exclusion criteria in that article, we searched the patients’ data bank in the Second Affiliated Hospital, Medical School of Xi’an Jiaotong University, Xi’an, China, over the period from June 2010 up to August 2012. Finally, 15 male and 18 female patients were enrolled. The age range was 9–80 years, with a mean age of 45 years. In the 33 ankle fractures, 22 cases belonged to Weber B, 10 cases to Weber C and only one to Weber A. The average number of days from injury to surgery was 6 days, ranging from 6 h to 21 days. Above all, the sex, mean age, types of fractures and average number of days from injury to surgery had no significant difference compared with those of the USA and the Netherlands. As for operative anaesthesia, 22 patients were given epidural block, five general anaesthesia, four combined spinal–epidural anaesthesia and two were given spinal anaesthesia. Obviously, the kinds of anaesthesia were different from those used in the above-referred two countries. We put forth two possible reasons that would help explain it. One was that epidural block was much cheaper than general anaesthesia in China. The other one might be that their psychological tolerance was stronger in the rich cultural background. In the operating room, patients could at all times converse with the analgesists and the surgeons. The implants we used in China were also different from those used in the USA and the Netherlands. In 24 ankle fractures, the surgeons used one titanium plate for the fracture of lateral malleolus or distal fibula and a few screws for internal malleolus fracture, which were meant to be absorbable screws. In a few special cases, Kirschner wires were chosen to fix the fragments. The use of pain medication on the first postoperative day in China was shown in the following Table.
values within each comparison group, are closely matched. Very much like the Taiwanese researchers, we found no difference in the outcomes (mortality) between those stabilized and those not stabilized, before transfer to the trauma centre. This equivocal finding of mortality raises important concerns. One explanation could be that, the resuscitation done prior to reaching the Trauma Centre was inadequate. In this case, we need to augment our Emergency Medical Services, to achieve consistently better stabilization of patients. However, while sounding counter-intuitive, field triage and stabilizing patients prior to transfer may not be, actually improving outcomes. Only further research on outcomes, in countries lacking robust EMS systems, can address this concern. Reference 1. Hsiao KY, Lin LC, Chou MH, Chen CC, Lee HC, Foo NP, et al. Outcomes of trauma patients: direct transport versus transfer after stabilisation at another hospital. Injury 2012. http://dx.doi.org/10.1016/j.injury.2012.01.004. [Epub ahead of print].
Vineet Kumar Pritam Suryawanshi Satish B. Dharap Dept of General and Trauma Surgery, LTM General Hospital, Sion, Mumbai 400022, India Nobhojit Roy* Jamsetji Tata Centre for Disaster Management, Tata Institute of Social Sciences, Malti and Jal A D Naoroji Campus, Deonar Farm Road, Mumbai 400 088, India *Corresponding author. Tel.: +91 9821291225 E-mail address: [email protected] (N. Roy)
1655
point of view. In this situation, we will arrange examination under anaesthesia (EUA) for them. EUA can help pelvic surgeon to identify some occult instability of pelvic ring injury. Claude Sagi et al.2 reported 68 patients performing an examination under anaesthesia with dynamic stress fluoroscopy and revealed occult pelvic ring instability in 50% of presumed APC-1 injuries, 39% of APC-2 injuries, and 37% of LC-1 injuries. The percentage is close to this study, that is, 30% patients need to receive operation. Second, this study performed posterior iliosacral fixation for patients with prolonged pain for improving mobilization. Is this procedure enough? In my opinion, anterior fixation with ramus screw is also important for some types of lateral compression. As figures adapted from Claude Sagi et al.2 They propose a modification to the Young-Burgess Classification system to reflect the dynamic component of pelvic ring instability disclosed on EUA as follows: APC-2a for those injuries requiring anterior only fixation, APC-2b for those injuries that may require treatment with anterior and posterior fixation, LC-1a for those injuries that are stable and do not require internal fixation, and LC-1b for those lateral compression injuries that may require treatment with internal fixation. Dynamic concept seems to be useful in this orthopaedic condition like other ligamentous injuries. Conflict of interest statement The author declares that there are no conflicts of interest. References 1. Scheyerer MJ, Osterhoff G, Wehrle S, Wanner GA, Simmen H-P, Werner CML. Detection of posterior pelvic injuries in fractures of the pubic rami injury. International Journal of the Care of the Injured 2012;43:1326–9. 2. Claude Sagi H, Franco M, Coniglione DO, Stanford JH. Examination under anesthetic for occult pelvic ring instability. Journal of Orthopaedic Trauma 2011;25: 529–37.
http://dx.doi.org/10.1016/j.injury.2012.03.036
Letter to the Editor Detection of posterior pelvic injuries in fractures of the pubic rami but only posterior fixation is not always enough Dear Editor,
Kai-Cheng Lin MD* Shan-Wei Yang MD,PhD Yih-Wen Tarng MD,PhD Department of Orthopedic Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan *Corresponding author E-mail address: [email protected] (K.-C. Lin) http://dx.doi.org/10.1016/j.injury.2012.10.026
We read with great interest the recent article by Scheyerer et al.1 They have reported an interesting retrospective study on ‘‘Detection of posterior pelvic injuries in fractures of the pubic rami’’. They had a large series of 233 patients with pubic rami fracture. In these patients, 177 patients had a CT scan for survey, and an injury of the posterior pelvic ring was found on CT scans in 96.8% of the patients. Most lesions represented transforaminal sacral fractures, avulsion fractures of ligaments or compression fractures of the lateral mass. All patients with dorsal injuries could initially be treated conservatively, nevertheless 30% of them needed operative treatment in the course. We had some opinions to the editors. First, do you routinely arrange CT scan for patients with pelvic fracture, especially they had ‘‘only’’ rami fractures? In this patient, they concluded that nearly all cases with fractures of the pubic rami do have a lesion elsewhere within the pelvic ring. In patients with prolonged pain and immobility following ‘pubic rami fractures’ one should be aware that they probably represent an undiagnosed pelvic ring injury and further diagnostic work-up – sometimes even surgery – is warranted. We highly agree with this
Letter to the Editor A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission Daniel et al.1 raised important issues on the clinical decision rule to predict adult patients with traumatic intracranial haemorrhage (ICH) who do not require intensive care unit (ICU) admission. They evaluated 432 cases and found the following three factors to predict adult patients with traumatic ICH who do not require ICU admission: Glasgow Coma Score = 15, isolated head injury, and age < 65. We read this article with interest and would like to add our concerns. Traumatic ICH is one of the important positive findings in most studies of high-risk mild TBI patients.2,3 There are some studies
1656
Letters to the Editor / Injury, Int. J. Care Injured 44 (2013) 1654–1672
aimed to predict positive findings in the brain CT scan of minor head injury patients2,4–7 and they have proposed some signs and symptoms for this purpose. However, Daniel et al. have not included such signs and symptoms as independent variables in their model. It seems logical to consider risk factors for neurosurgical intervention as risk factors of need to ICU admission.6 Therefore, the model may improve by including nausea,5 vomiting,4,5,7 severe headache,2,4,5 raccoon sign,2 amnesia or short term memory deficits,4,6–8 seizure,4 the kind of trauma such as above clavicles4 and open or depressed skull fracture,6,7 as independent variables. We also concern about claiming to rule out ‘‘patients who do NOT require ICU admission’’. This study can well detect which group of patients needs ICU admission according to the data. However, in order to declare which groups of patients do NOT require ICU admission, a study needs a very large sample size to reflect a wide variety of patients and every combination of independent variables included in the model. Therefore, we believe this manuscript would be better to titled as ‘‘A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who require intensive care unit admission.’’
Soheil Saadat Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran Vafa Rahimi-Movaghara,b,* Sina Trauma and Surgery Research Center, Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran b Research Centre for Neural Repair, University of Tehran, Tehran, Iran a
*Corresponding author at: Sina Trauma and Surgery Research Center, Sina Hospital, Hassan-Abad Square, Imam Khomeini Avenue, Tehran University of Medical Sciences, Tehran 11365-3876, Iran. Tel.: +98 915 342 2682/216 675 7010; fax: +98 216 675 7009 E-mail addresses: [email protected] [email protected] (V. Rahimi-Movaghar) http://dx.doi.org/10.1016/j.injury.2012.11.019
Conflict of interest All authors disclose there have been no financial and personal relationships with other people or organizations that could inappropriately influence our work. Examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding. Acknowledgement The authors would like to appreciate Mrs. Pourmand (Sina Hospital, Research Development Centre) for her careful edit of the manuscript. References 1. Nishijima DK, Shahlaie K, Echeverri A, Holmes JF. A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission. Injury 2012;43:1827–32. 2. Saadat S, Ghodsi SM, Naieni KH, Firouznia K, Hosseini M, Kadkhodaie HR, et al. Prediction of intracranial computed tomography findings in patients with minor head injury by using logistic regression. J Neurosurg 2009;111: 688–94. 3. Wong GK, Yeung JH, Graham CA, Zhu XL, Rainer TH, Poon WS. Neurological outcome in patients with traumatic brain injury and its relationship with computed tomography patterns of traumatic subarachnoid hemorrhage. J Neurosurg 2011;114:1510–5. 4. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000;343:100–5. 5. Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. J Emerg Med 1997;15: 453–7. 6. Smits M, Dippel DW, Steyerberg EW, de Haan GG, Dekker HM, Vos PE, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Int Med 2007;146:397–405. 7. Stiell IG, Lesiuk H, Wells GA, Coyle D, McKnight RD, Brison R, et al. Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and economic analysis). Ann Emerg Med 2001;38: 317–22. 8. Sharif-Alhoseini M, Khodadadi H, Chardoli M, Rahimi-Movaghar V. Indications for brain computed tomography scan after minor head injury. J Emerg Trauma Shock 2011;4:472–6.
Vahid Eslami Sina Trauma and Surgery Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
Letter to the Editor A supplementary study from China: The use of pain medications after operative treatment of an ankle fracture The results in the article titled ‘Satisfaction with pain relief after operative treatment of an ankle fracture’ very much attracted the attention of the authors.1 In its discussion, the authors called for multicentre studies to improve the external validity. Here, we want to share the use of pain medications after operative treatment of an ankle fracture in China. According to the exclusion criteria in that article, we searched the patients’ data bank in the Second Affiliated Hospital, Medical School of Xi’an Jiaotong University, Xi’an, China, over the period from June 2010 up to August 2012. Finally, 15 male and 18 female patients were enrolled. The age range was 9–80 years, with a mean age of 45 years. In the 33 ankle fractures, 22 cases belonged to Weber B, 10 cases to Weber C and only one to Weber A. The average number of days from injury to surgery was 6 days, ranging from 6 h to 21 days. Above all, the sex, mean age, types of fractures and average number of days from injury to surgery had no significant difference compared with those of the USA and the Netherlands. As for operative anaesthesia, 22 patients were given epidural block, five general anaesthesia, four combined spinal–epidural anaesthesia and two were given spinal anaesthesia. Obviously, the kinds of anaesthesia were different from those used in the above-referred two countries. We put forth two possible reasons that would help explain it. One was that epidural block was much cheaper than general anaesthesia in China. The other one might be that their psychological tolerance was stronger in the rich cultural background. In the operating room, patients could at all times converse with the analgesists and the surgeons. The implants we used in China were also different from those used in the USA and the Netherlands. In 24 ankle fractures, the surgeons used one titanium plate for the fracture of lateral malleolus or distal fibula and a few screws for internal malleolus fracture, which were meant to be absorbable screws. In a few special cases, Kirschner wires were chosen to fix the fragments. The use of pain medication on the first postoperative day in China was shown in the following Table.