- Email: [email protected]
Correlation of the Serum Antithrombin III to Injury Severity in Patients with Severe Trauma
Research Forum Abstracts
233
Use of the Tongue-Blade Test to Identify Patients with Mandible & Maxillary Sinus Fractures
Haydel MJ, Meyers R, Mills L, Louisiana State University Health Science Center at New Orleans, New Orleans, LA; Louisiana State University Health Science Center at New Orleans, New Orleans, LA
Background: The tongue-blade test has been used to identify patients with mandible fractures. The patient with a suspected mandible fracture is asked to bite down on a wooden tongue blade and then the blade is twisted. If the tongue-blade cannot be broken without causing pain, the test is considered positive for mandible fractures. Although not reported in the literature, it is possible that patients with certain mid-face fractures would have a positive tongue-blade test. Study Objective: The objective of this study was to determine the sensitivity and specificity of the tongue-blade test in identifying patients with a mandible fracture, LeFort fractures or maxillary sinus fracture. Methods: This prospective study used a convenient, consecutive sample of patients with blunt facial trauma undergoing CT or plain films of the face. A tongueblade test was administered prior to obtaining the imaging results. The imaging results were compared with tongue-blade test results, and statistically significant relationships were identified using Chi2 analysis. Any mandible, maxillary sinus or LeFort fracture was considered a positive imaging result. Results: Over a 12-month period, 144 patients with blunt trauma to the face were evaluated with the tongue-blade test and then underwent CT or plain films of the face. Overall, 16 (11.1%, 95% CI: 6.7-17.7%) patients had mandible fractures, and a positive tongue-blade test identified all of them. Additionally, 37 (27.8%[95% CI: 20.6-36.4%]) patients had maxillary sinus or LeFort fractures, and a positive tongue blade test identified 18 (48.6%). The tongue-blade test elicited pain in 48 patients, and of those, 16(33.3%, p\0.001) had a mandible fracture and 18(38.2%, p\0.05) had a midface fracture on CT. For mandible fractures, the sensitivity of the tongue-blade test was 100% (95% CI: 75.9-100%), and the specificity was 74.8% (95% CI: 66.4-82.0%). For maxillary sinus or LeFort fractures, the sensitivity of the tongue-blade test was 48.6%, and the specificity was 69.8%. Conclusions: We found the tongue-blade test to be a very sensitive in identifying patients with suspected mandible fractures, but does not have adequate sensitivity to be used to identify mid-face fractures. Larger studies should be performed prior to using the tongue-blade test to exclude mandible fracture.
234
Cervical Spine Fractures in the Elderly
Later PR, Geer BM, Pollack ML, York Hospital, York, PA
Objectives: Physicians obtain an estimated 800,000 C-spine x-rays annually with cervical spine injury (CSI) occurring 2.4% of the time. Of these, it has been found that geriatric patients experience more falls than their younger counterparts. Studies indicate that the elderly population falls due to decreased proprioception, vertigo, cardiac etiology leading to syncope, or mechanical falls. Combined with the conditions of an aging body (osteoporosis, decreased elasticity, decreased muscle mass, and decreased coordination), a simple fall can become a life-threatening event. Due to the aging of the American population, it would be beneficial to recognize how the morbidity and mortality of these types of injuries can be reduced or anticipated to insure proper treatment and therapy. The objectives of our study are twofold; first, to evaluate if the mechanism of injury is related to the location of the C-spine fracture in the elderly and second, if these mechanisms of injury are predictive of mortality. Methodology: York Hospital IRB approval was obtained. A retrospective chart review was conducted with data collected from The York Hospital trauma registry, discharge database, and emergency medicine discharge database from January 1995 through February 1, 2005. Patients were included if they wereR65 years old and had radiographic evidence of fracture/dislocation to the C-spine. Patients were excluded if they were less than 65 years old and had isolated ligamentous injury or penetrating trauma wounds. Variables obtained include: age, gender, location of cervical spine fracture, mechanism of injury, disposition, death, hospital length of stay, injury severity score. Data was analyzed using frequencies, chi-square analysis and Fishers Exact test. Limitations: Data was collected retrospectively, small sample size. Results: One hundred thirty-five patients were enrolled with a mean age of 78.6 years. Ninety-seven (71.9%) patients had upper c-spine fractures (C1, C2) and 38 (28.1%) patients had lower c-spine fractures (C3, C4, C5, C6, C7). Some patients had multiple fractures. Overall, there were a total of 181 C-Spines fractures: 120 upper c-spine fractures with 81 (68%) being odontoid fractures, and 71 lower c-spine fractures. Mechanisms of injury were grouped into 4 classifications: 53 (39%) patients had fallen from standing; 52 (38%) motor vehicle collisions; 26 (19%) falls from higher than 5 feet; and 4 (3%) pedestrians struck. The fall from standing group had
S66 Annals of Emergency Medicine
39 (74%) with upper c-spine fractures and 14 (26%) with lower c-spine fractures. The other combined groups had 58 (60%) with upper c-spine fractures and 24 (25%) with lower c-spine fractures. There were 22 (16%) who were discharged to home and 30 (22%) who died. There was no difference in the death rate with 13/53 (24%) of falls from standing and 17/82 (21%) in all other groups. The mean injury severity score (ISS) of all injuries was 16.4. The mean hospital length of stay was 11.2 days with a mean 4.84 ICU days. Conclusion: There was no relationship between the location of C-spine fractures and the mechanism of injury. However, a fall from standing in an elder resulted in significant mortality (24%) and was usually in the upper (C1, C2) cervical spine (74%).
235
Correlation of the Serum Antithrombin III to Injury Severity in Patients with Severe Trauma
Lee KH, Ji H, Kim S, Oh SB, Kim H, Hwang S, Kim HJ, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
Study Objectives: Antithrombin III (AT-III) is a serum protease inhibitor that inhibits the blood coagulation protease thrombin and is seen to be present in low levels in cases of shock, sepsis, or major trauma. Coagulopathy and hemorrhage are known contributors to trauma prognosis but the actual relationships of AT-III to mortality and to injury severity are unknown. The purpose of this study was to determine the correlation between AT-III and injury severity. Methods: This study was a retrospective analysis of data collection from January 1, 2003, to December 31, 2003. Sixty patients with multiple trauma were studied. The revised trauma score (RTS), the injury severity score (ISS), the systemic inflammatory response syndrome score (SIRS), the acute physiology and chronic health evaluation III (APACHE III), the length of ICU stay, the base-deficit value and the serum lactate were measured to evaluate injury severity. We estimated the relation between the severity of injury and the serum level of AT-III. Results: In patients with multiple trauma, the serum AT-III level was lower in the non-survival group (12.6 mg/dL) than it was in the survival group (17.2 mg/dL) (p=0.004). Among the previous injury severity evaluation system, transfusion for 24 hours had the strongest correlation with AT-III (R=0.546, p=0.000). The base deficit (R=0.418, p=0.001), the length of ICU stay (R=0.415, p=0,030), the APACHE III (R=0.367, p=0.021), and the RTS (R=0.247, p=0.006) were also correlated with AT-III. A logistic regression showed a strong association between the AT-III level and the mortality rate (mortality rate = 1.067 - 0.370 AT-III, p=0.004). Conclusion: In patients with severe trauma, The serum AT-III level was correlated with the RTS, the APACHE III, the number of transfusion units, the severity of shock, and the length of ICU stay. The serum AT-III level also showed a strong correlation with mortality.
236
The Use of Electrocardiograph R-Wave Amplitude Fails to Predict Early Hypovolemia in Humans
McManus JG Jr, Convertino VA, Cooke WH, Holcomb JB, US Army Institute of Surgical Research, San Antonio, TX
Study Objectives: Because hemorrhage continues to be a leading cause of death both on the battlefield and in the civilian setting, development of new approaches for early detection of blood loss for triage, diagnosis, and treatment decisions has continued to be a priority for decreasing mortality in trauma patients. Previous animal and human experiments have suggested that reduction of central volume is either directly or inversely associated with amplitude changes of R-waves on electrocardiograph (ECG) tracings. The purpose of this study was to elucidate the relationship between reductions in central blood volume and R-wave amplitude variations as a possible early predictor of hypovolemia. Methods: Thirteen healthy, normotensive men age 27-52 gave written consent to serve as subjects. All subjects underwent a protocol consisting of a 12 minute baseline period followed by exposure to lower negative body pressure (LNBP) of ÿ15, ÿ30, ÿ45, and ÿ60 mmHg for 12 minutes. Lead II ECG tracing, systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures, heart rate (HR) and estimated stroke volume (SV)were measured at baseline in resting, supine subjects and at an estimated central blood volume loss of O1000 ml with application of ÿ60 mmHg lower body negative pressure (LBNP). The analog waveform was then recorded into a Data Acquisition System (DAQ) and stored at a sampling frequency of 500Hz. The R-wave amplitude was analyzed using Physiological Waveform Marker Validation software by measuring from the start of the R-wave to its peak to eliminate any baseline shift due to respiration. The mean amplitudes
Volume 46, no. 3 : September 2005
233
Use of the Tongue-Blade Test to Identify Patients with Mandible & Maxillary Sinus Fractures
Haydel MJ, Meyers R, Mills L, Louisiana State University Health Science Center at New Orleans, New Orleans, LA; Louisiana State University Health Science Center at New Orleans, New Orleans, LA
Background: The tongue-blade test has been used to identify patients with mandible fractures. The patient with a suspected mandible fracture is asked to bite down on a wooden tongue blade and then the blade is twisted. If the tongue-blade cannot be broken without causing pain, the test is considered positive for mandible fractures. Although not reported in the literature, it is possible that patients with certain mid-face fractures would have a positive tongue-blade test. Study Objective: The objective of this study was to determine the sensitivity and specificity of the tongue-blade test in identifying patients with a mandible fracture, LeFort fractures or maxillary sinus fracture. Methods: This prospective study used a convenient, consecutive sample of patients with blunt facial trauma undergoing CT or plain films of the face. A tongueblade test was administered prior to obtaining the imaging results. The imaging results were compared with tongue-blade test results, and statistically significant relationships were identified using Chi2 analysis. Any mandible, maxillary sinus or LeFort fracture was considered a positive imaging result. Results: Over a 12-month period, 144 patients with blunt trauma to the face were evaluated with the tongue-blade test and then underwent CT or plain films of the face. Overall, 16 (11.1%, 95% CI: 6.7-17.7%) patients had mandible fractures, and a positive tongue-blade test identified all of them. Additionally, 37 (27.8%[95% CI: 20.6-36.4%]) patients had maxillary sinus or LeFort fractures, and a positive tongue blade test identified 18 (48.6%). The tongue-blade test elicited pain in 48 patients, and of those, 16(33.3%, p\0.001) had a mandible fracture and 18(38.2%, p\0.05) had a midface fracture on CT. For mandible fractures, the sensitivity of the tongue-blade test was 100% (95% CI: 75.9-100%), and the specificity was 74.8% (95% CI: 66.4-82.0%). For maxillary sinus or LeFort fractures, the sensitivity of the tongue-blade test was 48.6%, and the specificity was 69.8%. Conclusions: We found the tongue-blade test to be a very sensitive in identifying patients with suspected mandible fractures, but does not have adequate sensitivity to be used to identify mid-face fractures. Larger studies should be performed prior to using the tongue-blade test to exclude mandible fracture.
234
Cervical Spine Fractures in the Elderly
Later PR, Geer BM, Pollack ML, York Hospital, York, PA
Objectives: Physicians obtain an estimated 800,000 C-spine x-rays annually with cervical spine injury (CSI) occurring 2.4% of the time. Of these, it has been found that geriatric patients experience more falls than their younger counterparts. Studies indicate that the elderly population falls due to decreased proprioception, vertigo, cardiac etiology leading to syncope, or mechanical falls. Combined with the conditions of an aging body (osteoporosis, decreased elasticity, decreased muscle mass, and decreased coordination), a simple fall can become a life-threatening event. Due to the aging of the American population, it would be beneficial to recognize how the morbidity and mortality of these types of injuries can be reduced or anticipated to insure proper treatment and therapy. The objectives of our study are twofold; first, to evaluate if the mechanism of injury is related to the location of the C-spine fracture in the elderly and second, if these mechanisms of injury are predictive of mortality. Methodology: York Hospital IRB approval was obtained. A retrospective chart review was conducted with data collected from The York Hospital trauma registry, discharge database, and emergency medicine discharge database from January 1995 through February 1, 2005. Patients were included if they wereR65 years old and had radiographic evidence of fracture/dislocation to the C-spine. Patients were excluded if they were less than 65 years old and had isolated ligamentous injury or penetrating trauma wounds. Variables obtained include: age, gender, location of cervical spine fracture, mechanism of injury, disposition, death, hospital length of stay, injury severity score. Data was analyzed using frequencies, chi-square analysis and Fishers Exact test. Limitations: Data was collected retrospectively, small sample size. Results: One hundred thirty-five patients were enrolled with a mean age of 78.6 years. Ninety-seven (71.9%) patients had upper c-spine fractures (C1, C2) and 38 (28.1%) patients had lower c-spine fractures (C3, C4, C5, C6, C7). Some patients had multiple fractures. Overall, there were a total of 181 C-Spines fractures: 120 upper c-spine fractures with 81 (68%) being odontoid fractures, and 71 lower c-spine fractures. Mechanisms of injury were grouped into 4 classifications: 53 (39%) patients had fallen from standing; 52 (38%) motor vehicle collisions; 26 (19%) falls from higher than 5 feet; and 4 (3%) pedestrians struck. The fall from standing group had
S66 Annals of Emergency Medicine
39 (74%) with upper c-spine fractures and 14 (26%) with lower c-spine fractures. The other combined groups had 58 (60%) with upper c-spine fractures and 24 (25%) with lower c-spine fractures. There were 22 (16%) who were discharged to home and 30 (22%) who died. There was no difference in the death rate with 13/53 (24%) of falls from standing and 17/82 (21%) in all other groups. The mean injury severity score (ISS) of all injuries was 16.4. The mean hospital length of stay was 11.2 days with a mean 4.84 ICU days. Conclusion: There was no relationship between the location of C-spine fractures and the mechanism of injury. However, a fall from standing in an elder resulted in significant mortality (24%) and was usually in the upper (C1, C2) cervical spine (74%).
235
Correlation of the Serum Antithrombin III to Injury Severity in Patients with Severe Trauma
Lee KH, Ji H, Kim S, Oh SB, Kim H, Hwang S, Kim HJ, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
Study Objectives: Antithrombin III (AT-III) is a serum protease inhibitor that inhibits the blood coagulation protease thrombin and is seen to be present in low levels in cases of shock, sepsis, or major trauma. Coagulopathy and hemorrhage are known contributors to trauma prognosis but the actual relationships of AT-III to mortality and to injury severity are unknown. The purpose of this study was to determine the correlation between AT-III and injury severity. Methods: This study was a retrospective analysis of data collection from January 1, 2003, to December 31, 2003. Sixty patients with multiple trauma were studied. The revised trauma score (RTS), the injury severity score (ISS), the systemic inflammatory response syndrome score (SIRS), the acute physiology and chronic health evaluation III (APACHE III), the length of ICU stay, the base-deficit value and the serum lactate were measured to evaluate injury severity. We estimated the relation between the severity of injury and the serum level of AT-III. Results: In patients with multiple trauma, the serum AT-III level was lower in the non-survival group (12.6 mg/dL) than it was in the survival group (17.2 mg/dL) (p=0.004). Among the previous injury severity evaluation system, transfusion for 24 hours had the strongest correlation with AT-III (R=0.546, p=0.000). The base deficit (R=0.418, p=0.001), the length of ICU stay (R=0.415, p=0,030), the APACHE III (R=0.367, p=0.021), and the RTS (R=0.247, p=0.006) were also correlated with AT-III. A logistic regression showed a strong association between the AT-III level and the mortality rate (mortality rate = 1.067 - 0.370 AT-III, p=0.004). Conclusion: In patients with severe trauma, The serum AT-III level was correlated with the RTS, the APACHE III, the number of transfusion units, the severity of shock, and the length of ICU stay. The serum AT-III level also showed a strong correlation with mortality.
236
The Use of Electrocardiograph R-Wave Amplitude Fails to Predict Early Hypovolemia in Humans
McManus JG Jr, Convertino VA, Cooke WH, Holcomb JB, US Army Institute of Surgical Research, San Antonio, TX
Study Objectives: Because hemorrhage continues to be a leading cause of death both on the battlefield and in the civilian setting, development of new approaches for early detection of blood loss for triage, diagnosis, and treatment decisions has continued to be a priority for decreasing mortality in trauma patients. Previous animal and human experiments have suggested that reduction of central volume is either directly or inversely associated with amplitude changes of R-waves on electrocardiograph (ECG) tracings. The purpose of this study was to elucidate the relationship between reductions in central blood volume and R-wave amplitude variations as a possible early predictor of hypovolemia. Methods: Thirteen healthy, normotensive men age 27-52 gave written consent to serve as subjects. All subjects underwent a protocol consisting of a 12 minute baseline period followed by exposure to lower negative body pressure (LNBP) of ÿ15, ÿ30, ÿ45, and ÿ60 mmHg for 12 minutes. Lead II ECG tracing, systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures, heart rate (HR) and estimated stroke volume (SV)were measured at baseline in resting, supine subjects and at an estimated central blood volume loss of O1000 ml with application of ÿ60 mmHg lower body negative pressure (LBNP). The analog waveform was then recorded into a Data Acquisition System (DAQ) and stored at a sampling frequency of 500Hz. The R-wave amplitude was analyzed using Physiological Waveform Marker Validation software by measuring from the start of the R-wave to its peak to eliminate any baseline shift due to respiration. The mean amplitudes
Volume 46, no. 3 : September 2005