A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / PURPOSE: Contrast-induced nephropathy (CIN) has been recognized as a potential adverse outcome in patients receiving contrast dye for CT evaluation for over 50 years. Despite the time and resources dedicated to better identifying at-risk patients and implementing preventative measures, contrast induced nephropathy continues to be a significant cause of hospital acquired renal insufficiency. This study was aimed to evaluate the incidence and factors associated with contrast-induced nephropathy in the trauma patient population. MATERIALS AND METHODS: A retrospective institutional review of 563 patients admitted to the trauma service at St. Joseph’s Hospital and Medical Center were evaluated. Data were recorded for each patient including demographics, injury severity score (ISS), clinical prediction score (CPS), laboratory values on admission, 24, 48 and 72 hours including hematocrit, blood urea nitrogen, creatinine and eGFR, IV fluid volume given, contrast volume given, systolic blood pressure (SBP), urine output (UOP), intensive care unit length of stay (ICU LoS) and total hospital length of stay (tot LoS). Contrast induced nephropathy was considered to be present if the patient received contrast material for CT scan and 24-48 hour creatinine increased by an absolute value of 0.5mg/dl or if there was a 25% increase in 24-48 hour creatinine when compared to admission creatinine. Contrast volumes given to each patient before CT scan were determined by the Department of Radiology. RESULTS: As seen in table 1 results of univariate analysis demonstrate the following significant data: CIN vs age (p 0.004), CIN vs ISS (p <0.000), CIN vs CPS (p <0.000), CIN vs ICU length of stay (p 0.006), CIN vs total length of stay (p 0.002), CIN vs SBP (p <0.000), CIN vs IVF volume given in the 2nd 24 hours (p <0.000) and CIN vs IVF volume given in the first 48hrs (p <0.000). Data from multivariate analysis demonstrate the following significant data: CIN vs CPS (p <0.000, CI 1.92E-2 – 3.93E-2), CIN vs SBP (p 0.003 CI 8.61E-4 – 4.41E-3) and CIN vs IVF vol 2nd 24 hours (p 0.001, CI 1.47E-5 – 5.91E-5). The mean data for patients who did and did not develop CIN respectively were CPS: 9.09 and 3.12, SBP 84mmHg and 99mmHg, and IVF vol 2nd 24 hrs 2504ml and 5931ml CONCLUSION: Contrast induced nephropathy continues to be a significant problem in many hospital populations including trauma patients. Certain patient groups including those with higher CPS, hypotension or receiving decreased IV fluids may benefit from aggressive mindfulness of the risk of contrast induced kidney injury and continued investigation is needed to better identify trauma patients at increased risk.

No description available.

M.A. / There is a need to understand the outcomes of trauma in South Africa, as it is a country rife with violent crime. Thus far there has been little research into the aftermath of trauma, yet many trauma centres are coming into existence. A better understanding of the aftermaths of trauma could be integrated into current trauma intervention models so that locally researched models could be utilised by these centres. A grounded qualitative study on the outcomes of violent trauma in the South African context was thus conducted. Existentialism was included as a philosophical underpinning to the formal literature. The formal literature itself deals with the evolution of the cognitive tradition before a detailed explication of the Shattered Assumptions Model is given. This model stresses the role of trauma in disrupting central schemas regarding the manner in which both the self and the world are viewed. The impact of trauma itself in terms of the individual’s thoughts, memories and emotions was also explored. Participants in the study comprised of individuals who had been traumatised and sought counselling at the Rand Afrikaans University Trauma Centre. The participants were interviewed using the semi-structured interview format. Six such interviews took place. Selection of themes to discuss with the respondents was based both on existential theory as well as theory from the technical literature on trauma. The interviews were coded and analysed such that themes could emerge from the data itself. This is consistent with the qualitative tradition of psychological research. It was found that the South African respondents differed markedly with regards to outcomes following traumatisation. Results were discussed in terms of emotional sequelae, cognitive attributions, behavioural modifications as well as pervasive symptoms. Significantly, it was found that most respondents were still emotionally disturbed by their experiences, reporting high levels of fear and anxiety. These results are interpreted within the context of the South African environment where the incidence of violent crime and its resulting trauma is prevalent. The researcher speculates whether the recovery from trauma in South Africa is retarded due to the presence of continued threat. However, the limited external validity of the current study precludes the drawing of any universal conclusions. Further research in the field of the experience and aftermath of trauma in South Africa is recommended, with particular emphasis on the role that continued threat may play.

Charles Baxter, in his essay “Dysfunctional Narratives: or: ‘Mistakes Were Made,’” implies that all trauma narrative is synonymous with “dysfunctional narrative,” or narrative that leaves all characters unaccountable. He writes: “In such fiction, people and events are often accused of turning the protagonist into the kind of person the protagonist is, usually an unhappy person. That’s the whole story. When blame has been assigned, the story is over.” For Baxter, trauma narrative lets everyone “off the hook,” so to speak. He would say that we write about our bitter lemonade to make excuses for our poor choices, and “audiences of fellow victims” read our tales, because their lemonade and their choices carry equal bitterness, and they require equal excuses. While trauma narrative can soothe us, as can other narrative genres, we should not dismiss trauma fiction because of a sweeping generalization. Trauma fiction also allows us to explore the missing parts of our autobiographical narratives and to explore the effects of trauma—two endeavors not fully possible without fiction. As explained in more detail later, the human mind requires narrative to formulate an identity. Trauma disrupts this process, because “trauma does not lie in the possession of the individual, to be recounted at will, but rather acts as a haunting or possessive influence which not only insistently and intrusively returns but is, moreover, experienced for the first time only in its belated repetition.” Because literature can speak what “theory cannot say,” we need fiction to speak in otherwise silent spaces. Fiction allows us to express, analyze, and comprehend what we could not otherwise.

Background: Upper extremity fractures due to gunshot trauma are frequently treated at the level I trauma unit of Groote Schuur Hospital. There is no gold standard for the classification and management of such complex upper extremity fractures available to date and only few retrospective case studies on gunshots of the humerus were available. Interobserver agreement studies reported low levels of intra- and inter-rater reliability (IRR) for the classification of proximal humerus fractures using Neer and AO/OTA classification. The complexity of the fractures, the inconsistency of classification systems outcomes and the wide variety of treatment modalities demand evidence-based medicine. Aim: The primary aim was to assess the inter- and intraobserver agreement between surgeons in the classification and treatment of humerus fractures caused by gunshot trauma in a gunshot violence endemic area. The secondary aims were to analyse interobserver agreement with respect to debridement, removal of the bullet, the use of external fixators in patients with gunshot humerus fractures and to evaluate the effect of clinical scenarios surrounding surgical decision-making. Methods: This is an agreement study performed with a fixed panel of 32 observers who answered a set of 14 questions regarding classification and treatment by rating multiple X-ray views of a fixed set of 22 cases. The panel included junior registrars, senior registrars, orthopaedic trauma specialist and upper extremity specialists. Cases were extracted from the electronic Trauma Health Record between June 2014 and July 2016. Observers reviewed 16 midshaft and 6 proximal humerus fractures cases at 2 sessions with a 2-week interval. Descriptive statistics, Cohen's and Fleiss Kappa and rate of agreement were used to analyse data. Kappa was interpreted according to Landis and Koch guidelines. Results: There was slight yet significant overall interobserver agreement on the AO classification (k=0.20); the highest interobserver agreement ('fair') was achieved by the upper extremity specialists and senior registrars (k=0.28, 0.27). Overall interobserver reliability of agreement on preferred treatment was similar to classification agreement (k=0.18). Only trauma specialists achieved fair agreement with a significant difference compared to senior registrars and upper extremity specialists (k=0.26, 95%CI 0.21-0.32). Overall intraobserver reliability was fair for classification and moderate for treatment (k=0.39, 0.42). There was fair overall agreement on debridement of the wound (k=0.26) and removal of the bullet (k=0.31) and close to poor agreement for the use of temporary external fixators (k=0.03). Vascular injury was rated as influential factor on decision-making by the majority of observers (53.7%), followed by bilateral (37.1%) and other fractures (26.8%). Conclusions: This is the first intra- and interobserver agreement study that evaluated classification and treatment of gunshot humerus fractures in the light of a broader spectrum of patient- and fracture-related factors. Consistent with previous studies, there was low interobserver agreement for the classification and treatment of proximal humerus fractures, thereby contributing to the field of knowledge with specific evidence regarding gunshot trauma. Future research should further assess predictive factors in surgical decision-making and analyse global preferences in order to develop evidence-based classification and treatment guidelines for the management of patients with humerus fractures.

Introduction: Multiple studies suggest that severely injured patients treated at trauma centers have a lower mortality compared to patients treated at non-trauma centers. In many trauma systems, a significant proportion of patients continue to be transported from the scene to a non-trauma center (undertriaged); only a fraction of these patients are subsequently transferred to trauma center care. Although previous analyses have attempted to examine the mortality associated with transfer and with undertriage, these studies were not population-based, and therefore potentially underestimated the mortality cost of undertriage at the system level. Methods: In this dissertation, we developed an algorithm to convert ICD-10 diagnosis codes to Injury Severity Score. This algorithm allowed us to utilize population-based data to examine the outcomes of all severely injured patients surviving to reach an emergency department in Ontario. We examined whether, among severely injured patients, transfer from a non-trauma center to a trauma center is associated with increased mortality compared to direct transport from the scene. In addition, we used an instrumental variable analysis to produce a population-based estimate of the mortality cost of undertriage in a subset of patients injured in motor vehicle collisions. Results: Patients requiring transfer to trauma center care have significantly higher mortality at 30 days than patients transported directly from the scene of injury (Odds ratio 1.24; 95% CI, 1.10-1.40). Among patients involved in motor vehicle collisions, only 45% were transported directly to a trauma center. In this subset of patients, those triaged directly to a trauma center had significantly lower mortality at 24 hours (Odds ratio 0.58, 95% CI 0.41-0.84) and 48 hours (Odds ratio 0.68, 95% CI 0.48-0.96) compared to undertriaged patients. There was a trend towards decreased mortality among patients triaged to a trauma center at 7 days and 30 days. Conclusions: Undertriage and transfer after major trauma are associated with substantial increase in mortality compared to direct transport to a trauma center. These data suggest a need to design strategies to improve access to trauma center care in Ontario.

Introduction: Multiple studies suggest that severely injured patients treated at trauma centers have a lower mortality compared to patients treated at non-trauma centers. In many trauma systems, a significant proportion of patients continue to be transported from the scene to a non-trauma center (undertriaged); only a fraction of these patients are subsequently transferred to trauma center care. Although previous analyses have attempted to examine the mortality associated with transfer and with undertriage, these studies were not population-based, and therefore potentially underestimated the mortality cost of undertriage at the system level. Methods: In this dissertation, we developed an algorithm to convert ICD-10 diagnosis codes to Injury Severity Score. This algorithm allowed us to utilize population-based data to examine the outcomes of all severely injured patients surviving to reach an emergency department in Ontario. We examined whether, among severely injured patients, transfer from a non-trauma center to a trauma center is associated with increased mortality compared to direct transport from the scene. In addition, we used an instrumental variable analysis to produce a population-based estimate of the mortality cost of undertriage in a subset of patients injured in motor vehicle collisions. Results: Patients requiring transfer to trauma center care have significantly higher mortality at 30 days than patients transported directly from the scene of injury (Odds ratio 1.24; 95% CI, 1.10-1.40). Among patients involved in motor vehicle collisions, only 45% were transported directly to a trauma center. In this subset of patients, those triaged directly to a trauma center had significantly lower mortality at 24 hours (Odds ratio 0.58, 95% CI 0.41-0.84) and 48 hours (Odds ratio 0.68, 95% CI 0.48-0.96) compared to undertriaged patients. There was a trend towards decreased mortality among patients triaged to a trauma center at 7 days and 30 days. Conclusions: Undertriage and transfer after major trauma are associated with substantial increase in mortality compared to direct transport to a trauma center. These data suggest a need to design strategies to improve access to trauma center care in Ontario.

Konstanz, Univ., Magisterarb., 2005.

Despite trauma being widespread through the U.S. population and being associated with a multitude of negative life outcomes, trauma is not systematically being detected or considered during treatment or other service administration. To minimize the risk of re-traumatization and attempt to ameliorate the effects of past trauma, trauma informed care (TIC) is being implemented. TIC is an approach that attempts to educate individuals, particularly service providers, about the impact of trauma, as well as how to most effectively provide care for an individual who has experienced trauma. When implementing TIC trainings, it is important to establish a need for the trainings by determining if service providers are already knowledgeable about TIC and do not need training, and it is important to monitor service provider’s familiarity throughout the trainings to determine if the trainings are being effective. To determine if there is a need for the trainings, an initial survey was conducted to determine how familiar service providers were with TIC. In order to assess if the TIC training is educating service providers, we assessed the familiarity of service providers with trauma informed care. In order to monitor this familiarity, a survey was e-mailed from October 2015 to October 2018 every six months to service providers who were then instructed to complete the survey and forward it to anyone they thought may be interested in completing it. In the survey, they were asked to indicate how familiar they are with TIC: not familiar, somewhat familiar, or familiar. While these surveys were being distributed, TIC trainings were being held for the organizations in which the service providers were employed. In October 2015, at the start of TIC trainings, only 44.8% of survey providers reported being familiar with TIC while 20% reported not being familiar with TIC at all (n = 105). In October 2018, after TIC training had been implemented, 93.8% of service providers reported being familiar with TIC and 0.0% reported not being familiar with TIC at all (n = 64). These results indicate that there was a need for TIC training in these organizations due to the lack of familiarity the service providers reported at the first survey, and the TIC training may be contributing to the education of service providers which may be leading to more effective care being administered.

Maternal trauma is the leading non-obstetric cause of maternal and fetal death. Because the anatomy of a pregnancy is distinct, and highly transient, the pregnant woman and her fetus are both susceptible to injuries which are not seen in the typical trauma patient. The pregnant uterus, the placenta, and the fetus are all relatively poorly supported, as compared with non-transient abdominal or thoracic organs, which can lead to injuries such as uterine rupture, placental abruption, and fetal trauma or death. The leading cause of maternal trauma is automotive collision, and other common causes include violence, falls, and other accidents. Automotive collision is often researched with more traditional physical experiments such as post-mortem crash testing, but this form of study is exceedingly difficult with the pregnant subject due to ethical and logistical issues. Computational simulations of automotive collisions have received much attention as a method of performing experiments without the use of physical specimens, and have been successful in modeling trauma. These simulations benefit from constitutive relationships which effectively describe the biomechanical and structural behaviors of biological tissues. Internal state variable models driven by microstructural data offer the potential for capturing a myriad of material behaviors intrinsic to many biological tissues. The studies presented include many advances in the existing research of maternal trauma. These studies include advanced biomechanical and microstructural characterization of the placenta, the organ commonly injured in maternal trauma, to capture stress state and strain rate dependencies, as well as microstructural evolution across stress states. The studies also describe the construction of a finite element mesh of a near-term pregnant woman and fetus from medical images. This finite element mesh was implemented in a simulation of maternal trauma based on one of the only post mortem studies of pregnant cadavers ever reported in the literature. The results are a significant advancement for trauma simulation research.