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Trauma in Pregnancy: An Updated Systematic Review
The Journal of Emergency Medicine, Vol. 46, No. 2, pp. 321–325, 2014 Copyright Ó 2014 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter
Abstracts , IMPROVED MORTALITY FROM PENETRATING NECK AND MAXILLOFACIAL TRAUMA USING FOLEY CATHETER BALLOON TAMPONADE IN COMBAT. Weppner J. J Trauma Acute Care Surg 2013;75:220–4 The military has promoted the use of a Foley catheter balloon to provide tamponade in the setting of penetrating neck or maxillofacial trauma. However, little evidence besides case reports or series has been published regarding its efficacy. This study was a retrospective cohort analysis of patients with persistent bleeding from neck and maxillofacial trauma between December 2009 and October 2011. Patients were eligible for the cohort if they were seen at a particular forward aid station (FAS)—a center staffed by one physician with six corpsmen with very limited resources—and had persistent bleeding from the wound. A Foley catheter was used if it was available at the time. Over the study period there were 77 patients who met the inclusion criteria, 44 had a Foley catheter placed and 35 had external pressure dressings applied. There was no significant difference in the demographics of the groups, including presenting Glasgow Coma Scale score, anatomical zone of injury, and Injury Severity Score. The first outcome that was evaluated was failure to achieve hemostasis or primary failure. There was no statistical difference in primary failure between the two groups, with 4% of patients in the Foley group and 11% in the external pressure group. All patients with primary failure exsanguinated at the FAS. There was a significant difference in delayed failure between the Foley group (7%) and external pressure group (26%); p < 0.05. Mortality was also significantly higher in the external pressure group (23%) than the Foley group (5%); p < 0.05. The patients that died all died from hemorrhagic shock. The patients who died in the Foley group were all part of the primary failure group. There were 8 patients who died in the external pressure group; 4 of them were in the primary closure group. Of the 4 additional patients, 3 died during transport and 1 died at the receiving facility. [Julia Dixon, MD Denver Health Medical Center, Denver, CO]
1990 to present, the authors characterized the incidence, risk factors, outcomes, and management approaches for various types of trauma in pregnant patients. Data for the review were drawn primarily from population-based studies, of which the majority had retrospective designs. Case reports and case series were also used, but only when more robust studies were not available. Of a total of 1164 abstracts reviewed, 225 were included in this review. Domestic violence (DV) or intimate partner violence (IPV) was the most frequent cause of trauma in pregnant patients, with an estimated incidence rate of 8307 cases per 100,000 live births. Motor vehicle crashes (MVCs) were the most common cause of accidental trauma in pregnancy, with 207 cases per 100,000 live births. ‘‘Falls and slips’’ were the next most common, with 48.9 cases per 100,000 live births, though some studies estimated that 1 of every 4 pregnant women suffer at least one fall during pregnancy. Burns, suicide, homicide, penetrating trauma, accidental poisonings, and electrocution were relatively infrequent. Of note, suicide and homicide were less frequent in pregnant patients than in the general population. Risk factors for DV/IPV included substance abuse, low education level, low socioeconomic status, unintended pregnancy, a history of witnessed DV/IPV as a child, and unmarried status of the pregnant patient. Alcohol use and ‘‘intoxicants’’ were associated with MVCs, and slippery floors, ‘‘hurrying,’’ and carrying heavy objects were risk factors for falls and slips. Likewise, rates of peripartum suicide were higher in females with a history of DV/IPV, substance abuse, fetal demise complicating pregnancy, or recent death of infant. Outcomes from trauma in pregnancy vary by the type of trauma and the severity of injury. In cases of intentional trauma, which include DV/IPV, studies showed a 2.7-fold increased risk of both maternal and fetal mortality, a 5.7-fold increased risk of low birth weight, and higher rates of spontaneous abortion, neonatal intensive care unit admission, preterm birth, and peripartum depression. Regarding MVCs, improper seatbelt use was associated with adverse outcomes, namely placental abruption. Likewise, after an MVC the risk of cesarean delivery rose, but the risk of preterm labor (PTL) and perinatal death was increased only if delivery occurred immediately after the MVC. According to the authors, increased incidence of PTL and perinatal death can be attributed to the severity of trauma in these cases. With respect to falls and slips, fractures of the lower extremities were the most common associated injuries. However, in one study among patients who were hospitalized after a fall while pregnant, there were higher rates of preterm labor, placental abruption, fetal distress, and fetal hypoxia, as compared to randomly selected controls. In cases of burns
Comment: This study is limited both by its retrospective design and very small sample size. Furthermore, its generalizability is very much in question. That said, this article at least lays the groundwork for a randomized prospective study to determine the utility of this technique in the prehospital management of these injuries. , TRAUMA IN PREGNANCY: AN UPDATED SYSTEMATIC REVIEW. Mendez-Figueroa H, Dahlke JD, Vrees RA, et al. Am J Obstet Gynecol 2013;209:1–10 Trauma is thought to complicate one in 12 pregnancies. In this systematic review of English-language literature from 321
322 and electrocution in pregnancy, data were sparse. Some studies have suggested that maternal and fetal mortality approach 100% for burns $ 40% of total body surface area, with any associated smoke inhalation injury increasing mortality risk. Likewise, case series of electrocutions in pregnancy suggested that fetal mortality rates approach 75% in severe electrocution, though minor electrocutions in the home have no effect on birth outcomes. In penetrating trauma, entrance wounds anterior and inferior to the uterine fundus were noted to have lower risk of maternal visceral injury but higher risk of fetal injury. [Jasmeet Dhaliwal, MD, MPH Denver Health Medical Center, Denver, CO] Comment: This review article summarizes a broad range of literature on trauma in pregnancy. One of the sobering findings, and one that emergency physicians must keep in mind whenever caring for pregnant trauma patients, is the high incidence of domestic violence. There are many other salient points for emergency physicians, including the importance of early multispecialty involvement, prioritization of maternal resuscitation, and the safe use of limited workups in minor trauma.
, LITHIUM IN THE PREVENTION OF SUICIDE IN MOOD DISORDERS: UPDATED SYSTEMATIC REVIEW AND META-ANALYSIS. Cipriani A, Hawton K, Stockton S, et al. BMJ 2013;346:f3646 This meta-analysis evaluated whether or not lithium, when compared to placebo or other psychotropic drugs, reduced the incidence of self-harm, suicide events, or allcause mortality in individuals with mood disorders. Mood disorders included were unipolar depression, bipolar disorder, schizoaffective disorder, dysthymia, and rapid cycling. To be included, patients must have been treated ‘‘long term,’’ which was defined as at least 12 weeks. All ages (pediatric and adult) were included. When comparing lithium to placebo, lithium was more successful at preventing suicides (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.03– 0.66), and reducing all-cause mortality (OR 0.38, 95% CI 0.15–0.95), but did not show statistically significant benefits in preventing self-harm. When comparing lithium to other mood-stabilizing drugs, the only statistically significant result was that lithium was associated with less self-harm than carbamazepine (OR 0.14, 95% CI 0.02–0.83). There was no difference between lithium and any other drug in reducing death or suicide. [Jenelle Holst, MD Denver Health Medical Center, Denver, CO] Comment: Although limited by the quality of the studies included in the larger analysis, this meta-analysis suggests that the use of lithium is still warranted in the management of patients with serious mood disorders. This is an important finding, as the drug does have a narrow therapeutic window and if other less toxic agents were equally efficacious, they might be preferred.
Abstracts , MRI OF SUSPECTED LOWER EXTREMITY MUSCULOSKELETAL INFECTION IN THE PEDIATRIC PATIENT: HOW USEFUL IS BILATERAL IMAGING? Metwalli ZA, Kan JH, Munjal KA, et al. AJR Am J Roentgenol 2013;201:427–32 Magnetic resonance imaging (MRI) is widely utilized for the evaluation of suspected musculoskeletal infections in children, as limitations in the physical examination of children make accurate localization of suspected infection site challenging. Up to two-thirds of cases of osteomyelitis in children occur in the lower extremities. This study sought to identify the frequency of bilateral infections and the impact on management that resulted from having such information available to clinicians. The authors retrospectively identified 165 pediatric patients (average age 7.5 years, range 0–18 years), 65% of whom were male, at a single children’s hospital, over a 1-year period in 2010, that underwent MRI imaging of the bilateral lower extremities. The primary indication for imaging in this study was to evaluate for infection, and studies of children imaged for other reasons were excluded. MRI identified ipsilateral osteomyelitis in 54/165 patients (33%), with 6/54 patients (11%) having contralateral findings, including bilateral osteomyelitis (1/54, 2%), and contralateral myositis (3/54, 6%). Clinical correlation with the patient’s hospital course was evaluated and in no case did contralateral/bilateral findings on MRI change surgical or medical management of the patient. Of the 111 patients that had MRI negative for osteomyelitis, the most frequently encountered alternative diagnoses were septic arthritis (12/ 111, 11%), myositis (25/111, 23%), occult fracture (10/111, 9%), and stress reaction (12/111, 11%). Importantly, no cases of contralateral septic arthritis were identified either with MRI or surgically, and medical or surgical management of MRI findings of the ipsilateral lower extremity did not result in any adverse outcomes to the contralateral lower extremity. Overall, the authors demonstrated a relatively high rate of contralateral findings on MRI in patients both with and without osteomyelitis, but these findings did not alter patient management. [Brian Jekich, MD Denver Health Medical Center, Denver, CO] Comment: Osteomyelitis in children is a challenging diagnosis that cannot be missed. Performing MRI with a wide field of view to include the bilateral lower extremities is technically feasible and may provide additional clinical information. However, screening for bilateral osteomyelitis is of low yield and unlikely to impact clinical management of the patient. This study was limited by its small size and retrospective design. , INDIVIDUALIZATION OF ABDOMINOPELVIC CT PROTOCOLS WITH LOWER TUBE VOLTAGE TO REDUCE I.V. CONTRAST DOSE OR RADIATION DOSE. Hough DM, Yu L, Shiung MM, et al. AJR Am J Roentgenol 2013;201:147–53 The dose of radiation from a computed tomography (CT) scan has decreased with newer scanners and lower tube potential. Lower tube potential allows for patient-specific doses of radiation due to the increased iodine signal with this technology. This study developed a protocol to further reduce the dose of
Abstracts , IMPROVED MORTALITY FROM PENETRATING NECK AND MAXILLOFACIAL TRAUMA USING FOLEY CATHETER BALLOON TAMPONADE IN COMBAT. Weppner J. J Trauma Acute Care Surg 2013;75:220–4 The military has promoted the use of a Foley catheter balloon to provide tamponade in the setting of penetrating neck or maxillofacial trauma. However, little evidence besides case reports or series has been published regarding its efficacy. This study was a retrospective cohort analysis of patients with persistent bleeding from neck and maxillofacial trauma between December 2009 and October 2011. Patients were eligible for the cohort if they were seen at a particular forward aid station (FAS)—a center staffed by one physician with six corpsmen with very limited resources—and had persistent bleeding from the wound. A Foley catheter was used if it was available at the time. Over the study period there were 77 patients who met the inclusion criteria, 44 had a Foley catheter placed and 35 had external pressure dressings applied. There was no significant difference in the demographics of the groups, including presenting Glasgow Coma Scale score, anatomical zone of injury, and Injury Severity Score. The first outcome that was evaluated was failure to achieve hemostasis or primary failure. There was no statistical difference in primary failure between the two groups, with 4% of patients in the Foley group and 11% in the external pressure group. All patients with primary failure exsanguinated at the FAS. There was a significant difference in delayed failure between the Foley group (7%) and external pressure group (26%); p < 0.05. Mortality was also significantly higher in the external pressure group (23%) than the Foley group (5%); p < 0.05. The patients that died all died from hemorrhagic shock. The patients who died in the Foley group were all part of the primary failure group. There were 8 patients who died in the external pressure group; 4 of them were in the primary closure group. Of the 4 additional patients, 3 died during transport and 1 died at the receiving facility. [Julia Dixon, MD Denver Health Medical Center, Denver, CO]
1990 to present, the authors characterized the incidence, risk factors, outcomes, and management approaches for various types of trauma in pregnant patients. Data for the review were drawn primarily from population-based studies, of which the majority had retrospective designs. Case reports and case series were also used, but only when more robust studies were not available. Of a total of 1164 abstracts reviewed, 225 were included in this review. Domestic violence (DV) or intimate partner violence (IPV) was the most frequent cause of trauma in pregnant patients, with an estimated incidence rate of 8307 cases per 100,000 live births. Motor vehicle crashes (MVCs) were the most common cause of accidental trauma in pregnancy, with 207 cases per 100,000 live births. ‘‘Falls and slips’’ were the next most common, with 48.9 cases per 100,000 live births, though some studies estimated that 1 of every 4 pregnant women suffer at least one fall during pregnancy. Burns, suicide, homicide, penetrating trauma, accidental poisonings, and electrocution were relatively infrequent. Of note, suicide and homicide were less frequent in pregnant patients than in the general population. Risk factors for DV/IPV included substance abuse, low education level, low socioeconomic status, unintended pregnancy, a history of witnessed DV/IPV as a child, and unmarried status of the pregnant patient. Alcohol use and ‘‘intoxicants’’ were associated with MVCs, and slippery floors, ‘‘hurrying,’’ and carrying heavy objects were risk factors for falls and slips. Likewise, rates of peripartum suicide were higher in females with a history of DV/IPV, substance abuse, fetal demise complicating pregnancy, or recent death of infant. Outcomes from trauma in pregnancy vary by the type of trauma and the severity of injury. In cases of intentional trauma, which include DV/IPV, studies showed a 2.7-fold increased risk of both maternal and fetal mortality, a 5.7-fold increased risk of low birth weight, and higher rates of spontaneous abortion, neonatal intensive care unit admission, preterm birth, and peripartum depression. Regarding MVCs, improper seatbelt use was associated with adverse outcomes, namely placental abruption. Likewise, after an MVC the risk of cesarean delivery rose, but the risk of preterm labor (PTL) and perinatal death was increased only if delivery occurred immediately after the MVC. According to the authors, increased incidence of PTL and perinatal death can be attributed to the severity of trauma in these cases. With respect to falls and slips, fractures of the lower extremities were the most common associated injuries. However, in one study among patients who were hospitalized after a fall while pregnant, there were higher rates of preterm labor, placental abruption, fetal distress, and fetal hypoxia, as compared to randomly selected controls. In cases of burns
Comment: This study is limited both by its retrospective design and very small sample size. Furthermore, its generalizability is very much in question. That said, this article at least lays the groundwork for a randomized prospective study to determine the utility of this technique in the prehospital management of these injuries. , TRAUMA IN PREGNANCY: AN UPDATED SYSTEMATIC REVIEW. Mendez-Figueroa H, Dahlke JD, Vrees RA, et al. Am J Obstet Gynecol 2013;209:1–10 Trauma is thought to complicate one in 12 pregnancies. In this systematic review of English-language literature from 321
322 and electrocution in pregnancy, data were sparse. Some studies have suggested that maternal and fetal mortality approach 100% for burns $ 40% of total body surface area, with any associated smoke inhalation injury increasing mortality risk. Likewise, case series of electrocutions in pregnancy suggested that fetal mortality rates approach 75% in severe electrocution, though minor electrocutions in the home have no effect on birth outcomes. In penetrating trauma, entrance wounds anterior and inferior to the uterine fundus were noted to have lower risk of maternal visceral injury but higher risk of fetal injury. [Jasmeet Dhaliwal, MD, MPH Denver Health Medical Center, Denver, CO] Comment: This review article summarizes a broad range of literature on trauma in pregnancy. One of the sobering findings, and one that emergency physicians must keep in mind whenever caring for pregnant trauma patients, is the high incidence of domestic violence. There are many other salient points for emergency physicians, including the importance of early multispecialty involvement, prioritization of maternal resuscitation, and the safe use of limited workups in minor trauma.
, LITHIUM IN THE PREVENTION OF SUICIDE IN MOOD DISORDERS: UPDATED SYSTEMATIC REVIEW AND META-ANALYSIS. Cipriani A, Hawton K, Stockton S, et al. BMJ 2013;346:f3646 This meta-analysis evaluated whether or not lithium, when compared to placebo or other psychotropic drugs, reduced the incidence of self-harm, suicide events, or allcause mortality in individuals with mood disorders. Mood disorders included were unipolar depression, bipolar disorder, schizoaffective disorder, dysthymia, and rapid cycling. To be included, patients must have been treated ‘‘long term,’’ which was defined as at least 12 weeks. All ages (pediatric and adult) were included. When comparing lithium to placebo, lithium was more successful at preventing suicides (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.03– 0.66), and reducing all-cause mortality (OR 0.38, 95% CI 0.15–0.95), but did not show statistically significant benefits in preventing self-harm. When comparing lithium to other mood-stabilizing drugs, the only statistically significant result was that lithium was associated with less self-harm than carbamazepine (OR 0.14, 95% CI 0.02–0.83). There was no difference between lithium and any other drug in reducing death or suicide. [Jenelle Holst, MD Denver Health Medical Center, Denver, CO] Comment: Although limited by the quality of the studies included in the larger analysis, this meta-analysis suggests that the use of lithium is still warranted in the management of patients with serious mood disorders. This is an important finding, as the drug does have a narrow therapeutic window and if other less toxic agents were equally efficacious, they might be preferred.
Abstracts , MRI OF SUSPECTED LOWER EXTREMITY MUSCULOSKELETAL INFECTION IN THE PEDIATRIC PATIENT: HOW USEFUL IS BILATERAL IMAGING? Metwalli ZA, Kan JH, Munjal KA, et al. AJR Am J Roentgenol 2013;201:427–32 Magnetic resonance imaging (MRI) is widely utilized for the evaluation of suspected musculoskeletal infections in children, as limitations in the physical examination of children make accurate localization of suspected infection site challenging. Up to two-thirds of cases of osteomyelitis in children occur in the lower extremities. This study sought to identify the frequency of bilateral infections and the impact on management that resulted from having such information available to clinicians. The authors retrospectively identified 165 pediatric patients (average age 7.5 years, range 0–18 years), 65% of whom were male, at a single children’s hospital, over a 1-year period in 2010, that underwent MRI imaging of the bilateral lower extremities. The primary indication for imaging in this study was to evaluate for infection, and studies of children imaged for other reasons were excluded. MRI identified ipsilateral osteomyelitis in 54/165 patients (33%), with 6/54 patients (11%) having contralateral findings, including bilateral osteomyelitis (1/54, 2%), and contralateral myositis (3/54, 6%). Clinical correlation with the patient’s hospital course was evaluated and in no case did contralateral/bilateral findings on MRI change surgical or medical management of the patient. Of the 111 patients that had MRI negative for osteomyelitis, the most frequently encountered alternative diagnoses were septic arthritis (12/ 111, 11%), myositis (25/111, 23%), occult fracture (10/111, 9%), and stress reaction (12/111, 11%). Importantly, no cases of contralateral septic arthritis were identified either with MRI or surgically, and medical or surgical management of MRI findings of the ipsilateral lower extremity did not result in any adverse outcomes to the contralateral lower extremity. Overall, the authors demonstrated a relatively high rate of contralateral findings on MRI in patients both with and without osteomyelitis, but these findings did not alter patient management. [Brian Jekich, MD Denver Health Medical Center, Denver, CO] Comment: Osteomyelitis in children is a challenging diagnosis that cannot be missed. Performing MRI with a wide field of view to include the bilateral lower extremities is technically feasible and may provide additional clinical information. However, screening for bilateral osteomyelitis is of low yield and unlikely to impact clinical management of the patient. This study was limited by its small size and retrospective design. , INDIVIDUALIZATION OF ABDOMINOPELVIC CT PROTOCOLS WITH LOWER TUBE VOLTAGE TO REDUCE I.V. CONTRAST DOSE OR RADIATION DOSE. Hough DM, Yu L, Shiung MM, et al. AJR Am J Roentgenol 2013;201:147–53 The dose of radiation from a computed tomography (CT) scan has decreased with newer scanners and lower tube potential. Lower tube potential allows for patient-specific doses of radiation due to the increased iodine signal with this technology. This study developed a protocol to further reduce the dose of