142 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Abstracts of the Literature VOLUME 6, NUMBER 4

ABSTRACTS OF THE LITERATURE

United Kingdom

ACUTE COMPARTMENT SYNDROME MASKEDBY INTRAVENOUS MORPHINE FROM APATIENT-CONTROLLED ANALGESIA PUMP

A case report is presented of a patient who was admitted tothe hospital with an open-oblique midshaft fracture of the tibia.The patient was treated with debridement and irrigation, andthen stabilized with a solid, unreamed intramedullary nail. Thewound was left open, and delayed primary closure wasplanned. After the surgery the patient was allowed to self-administer morphine through a patient-controlled analgesia(PCA) pump, receiving 131 mg over the next 36 hours. Thenursing staff recorded the patient’s subjective pain scores onlyduring the first night.

The patient was scheduled to return to surgery 36 hourslater. At that time, the patient’s calf was noted to be firm andswollen, with elevated intracompartmental pressures in all 4compartments. The patient was treated with a fasciotomy andsplit skin grafting. The patient had no long-term complica-tions.

In reviewing the case, the authors noted that a rigidly stabi-lized long-bone fracture should not require large amounts ofanalgesia and that significant pain should have alerted them tothe possibility of a compartment syndrome. The fact that thepatient could self-administer enough morphine to relieve paincontributed to the delayed diagnosis. Although PCA offerspatients many benefits, PCA should not be considered a time-saving device that indirectly reduces patient contact time.Traditional postoperative pain management methods rely onthe nursing staff to monitor the patient’s analgesic needs andthis helps the staff to be more readily aware of potential prob-lems. The authors acknowledge that PCAs are an acceptablemeans of providing pain relief, but they make the followingadditional recommendations: (1) the use of PCA in patientswho are prone to compartment syndrome can lead to delayeddiagnosis; (2) patients with PCA should still receive adequatenursing and medical staff monitoring; and (3) syringe pumpscould be limited to a 4-hour maximum dose limit of 20 mg ofmorphine.

(Harrington P, Bunola J, Jennings AJ, Bush DJ, Smith RM.Acute compartment syndrome masked by intravenous mor-phine from a patient-controlled analgesia pump. Injury2000;31:387-9.)

Reviewer: JSH

United States

NONOPERATIVE MANAGEMENT OF SPLENICINJURIES—HAVE WE GONE TOO FAR?

A retrospective study of patients with blunt trauma to thespleen was conducted to evaluate (1) the outcome of splenicinjuries treated by nonoperative management of splenicinjuries (NOMSI), (2) risk factors that can predict failure ofNOMSI, and (3) accuracy of splenic injury grading by com-puted tomography (CT) against operative grading.

NOMSI is currently used in almost 70% of patients withdocumented blunt trauma to the spleen, and the only absolutecriterion that mandates an operative intervention is hemody-namic instability. Failures of NOMSI could result in complica-tions. Because physicians are under increasing pressure to dis-charge patients early, some of the complications could poten-tially occur after discharge.

This study showed that a combination of physiologic andradiographic parameters could identify patients at risk forNOMSI failure. By identifying patients at high risk forNOMSI failure, the authors believe the threshold may be low-ered for proceeding to operative management and the length ofinhospital observation may be increased for those at risk.

NOMSI is not an easy approach and is probably best han-dled by experienced trauma centers. Close monitoring, serialclinical examinations, and familiarity with the course ofsplenic injuries are required. Surgeons who treat such patientsshould be familiar with the American Association for theSurgery of Trauma grading system of splenic injuries, whichranges from Grade I (lacerations less than 1 cm) to Grade V(shattered spleens).

In 56 patients who were evaluated for NOMSI, 27 (48%)were successfully managed with a nonoperative approach.Forty-five patients were studied with a comparison betweenCT and operative grading of splenic injury. A strong corre-lation was found; in 36 patients (80%) the CT and operativegrading were identical. Of the remaining patients, 8 had adifference of 1 grading point and only 1 had a difference of2 points. The authors believe that the new-generation heli-cal CT scans provide accurate information that can reliablyassist in clinical decisions for the management of splenicinjuries.

The results of this study indicate 2 independent risk factorsof failure of NOMSI: a Grade III and above CT grade ofsplenic injury and a transfusion with more than 1 unit of blood.The combination of these 2 risk factors predicted NOMSI fail-ure in 97% of the cases. In the absence of these 2 factors, theauthors predicted successful NOMSI in 97% of cases with a3% failure rate.

The authors urge caution with the liberal use of NOMSI. Ifa patient had high-grade injuries requiring transfusions ofmore than 1 unit of blood, these factors should lower thethreshold for operation or intensify the level of patient obser-

Int J Trauma Nurs 2000;6:142-4.Copyright © 2000 by the Emergency Nurses Association.

1075-4210/2000/$12.00 + 0 65/3/110569

doi:10.1067/mtn.2000.110569

OCTOBER-DECEMBER 2000 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Abstracts of the Literature 143

vation. In the “Invited Critique” at the end of the article, it wasrecommended that: (1) a national (or at least multi-institution-al) registry is needed to document the proportion of patientswho die or suffer considerable morbidity after NOMSI; (2)nonoperative management is the preferred option in childrenand should be considered in most stable adults; and (3)splenectomy remains a desirable option in the management ofpatients for whom resources are not optimal for successfulnonoperative management. Surgeons who chose splenectomyunder such circumstances should not be criticized.

(Velmahos GC, Chan LS, Kamel E, Murray JA, Yassa N,Kahaku D, et al. Nonoperative management of splenicinjuries—Have we gone too far? Arch Surg 2000;35:674-81.)

Reviewer: JMW

AVOIDING HYPOTHERMIA IN THE TRAUMAPATIENT

Hypothermia is a common problem in trauma patients, andit is associated with several deleterious effects. The risk factorsfor developing hypothermia, the multiple organ system effectsassociated with hypothermia, and the prevention and treatmentmethods for hypothermic trauma patients are reviewed.

Risk factors. The authors identified alcohol intoxication,spinal cord injuries, extremes of age, and head injury and asso-ciated medical conditions, such as hypothyroidism and hypo-glycemia, as risk factors. General anesthesia additionallyimpairs the ability to maintain normothermia by impairingthermoregulatory mechanisms and altering the threshold forshivering.

Organ effects. Among the undesirable effects of hypother-mia in the trauma patient are reduced platelet function,decreased kinetics of coagulation factors, metabolic acidosis,and impaired cellular immune response. Cardiovascular effectssuch as cardiac depression, myocardial ischemia, unstableangina, peripheral vasoconstriction, and ventricular tachycar-dia were noted to be more common in these patients. Elevatedoxygen consumption and energy expenditure with rewarmingshould be considered when planning care.

Prevention and treatment measures. Convective warmingdevices were identified as efficacious and inexpensive means toprevent and treat perioperative hypothermia. High-capacityintravenous infusion heating devices were noted to also beeffective at maintaining thermal homeostasis in patients withhigh fluid requirements.

(Smith CE, Yamat RA. Avoiding hypothermia in the traumapatient. Curr Op Anaesthesiol 2000;13:167-74.)

Reviewer: MK

THE EFFECT OF ORGANIZED SYSTEMS OFTRAUMA CARE ON MOTOR VEHICLE CRASHMORTALITY

A cross-sectional time-series analysis of crash mortalitydata was performed to determine the rates of death resultingfrom motor vehicle crashes (MVC) before and after imple-menting an organized system of trauma care. The study wasdone to determine whether trauma systems had an effect onmortality rates resulting from MVC. The Fatality Analysis

Reporting System was accessed for data for the years 1979through 1995 and from all 50 United States and the District ofColumbia. The subjects consisted of all front-seat passengervehicle occupants aged 15 to 74 years.

During the study period, 22 states had both designated trau-ma centers and triage policies enforced by legislation. Thestudy found that the mortality rate did not change during thefirst 10 years after implementation of a trauma system; after thefirst 10 years, mortality resulting from MVC began todecrease; and 15 years after implementation, mortality haddecreased by 8% (after adjusting for other confounding vari-ables).

The authors concluded that implementation of an organizedsystem of trauma care decreases MVC mortality. They notedthat the effect was not evident for 10 years, which may beexplained by the development and maturation of triage proto-cols, ongoing quality assurance, the organization of traumacenters, and interhospital transfer agreements.

(Nathens AB, Jurkovich GJ, Cummings P, Rivara FP, MaierRV. The effect of organized systems of trauma care on motorvehicle crash mortality. JAMA 2000;283:1990-4.)

Reviewer: KO

MOTOR-VEHICLE OCCUPANT FATALITIES ANDRESTRAINT USE AMONG CHILDREN AGED 4-8YEARS, UNITED STATES, 1994-1998

The Centers for Disease Control and Prevention (CDC)analyzed 1994-1998 data from the Fatality Analysis ReportingSystem to characterize fatalities, restraint use, and seating posi-tion among occupants aged 4 to 8 years who were involved infatal crashes. During the study period, there were 14,411 childoccupants aged 4 to 8 years who were involved in fatal crash-es, of which 2549 (17%) children died. Approximately 500child occupants died each year during the study period.Restraint use among fatally injured children in 1994 was35.2% (177 of 503), and in 1998 the restraint use was 38.1%(201 of 527). The proportion of children seated in the backseatof a vehicle involved in a crash was 50.1% (252 of 503) in 1994and 53.7% (283 of 527) in 1998.

The CDC concluded that during the 4-year study period,child occupant death rates did not decrease, restraint useamong fatally injured child occupants changed little, and theproportion of fatally injured children seated in the backseatof a motor vehicle involved in a crash remained fairly con-stant.

The CDC recommends that child occupants who have out-grown child safety seats should be placed in booster seats toraise the child to allow the belt to fit properly and the childshould be in the backseat, which is the safest part of the vehi-cle. At the time of this publication, no state required the use ofbooster seats and only 3 states required that children be seatedin the backseat of a passenger vehicle.

(Centers for Disease Control and Prevention. Motor-vehi-cle occupant fatalities and restraint use among children aged4-8 years United States, 1994-1998. MMWR Morb MortalWkly Rep 2000;49(07):135-7.

Reviewer: JSH

144 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Abstracts of the Literature VOLUME 6, NUMBER 4

MECHANISMS AND PATTERNS OF INJURIESRELATED TO LARGE ANIMALS

A retrospective review was conducted of the medicalrecords of patients admitted to 2 east Texas medical centersfrom October 1992 to September 1999. One hundred forty-fivepatients were selected that had an E-code indicating mecha-nism of injury associated with an encounter with a large ani-mal. Various demographic and clinical data were collected, andthe results were evaluated with statistical programs.

Patients were admitted for horse-related injures (79patients, 55%), bull-related injuries (47 patients, 32%), misad-ventures with cows (16 patients, 11%), and wild animal attacks(3 patients, 2%). There were 111 male patients (77%) and 34female patients (23%). Falls were the most common mecha-nism of injuries (from horse, 57%; from bull, 30%). The bullsstepping on or trampling the victim produced bull-relatedinjuries. Cow-related injuries tended to occur more often inolder farmers who were kicked by the cow.

The authors noted that large animals are of sufficient sizeand can move with enough force that they can generate forcesand velocity similar to motor vehicle collisions. The bodyregions injured were dependent on the animal involved. With

horses, the victims were commonly injured in the head or cran-iofacial region; with bull and cows, the torso was more fre-quently injured. The authors found that large animal injuriesfrequently involved multiple body regions and that patientswith upper-extremity injuries had a significantly higher per-centage of torso and head or craniofacial injuries. This findinghas resulted in the authors revising field triage and trauma alertcriteria.

(Norwood S, McAuley C, Vallina VL, Fernandez LG,McLarty JW, Goodfried G. Mechanisms and patterns ofinjuries related to large animals. J Trauma 2000;48:740-4.)

Reviewer: JSHReviewers:JMW — Jane M. Wick, RN, BSN, Operating Room Trauma

Nurse, Legacy Emanuel Hospital and Health Center, Portland,Ore.

JSH — Judith Stoner Halpern, RN, MS, CEN, Editor.KO — Kristin Oberg, RN, MSN, EMT-P, Flight Nurse, Life

Star, Hartford Hospital, Hartford, Conn.MK — Mary Karlet, PhD, CRNA, Program Director, Nurse

Anesthesia Program, Duke University School of Nursing,Durham, NC

Attention International TravelersIf you have plans to travel internationally in the near future and your itinerary includes working with or

visiting medical care providers in another country, consider sharing your experience with the readers of theInternational Journal of Trauma Nursing. We invite descriptions and stories that help us to understand hownursing care will vary in a multicultural environment. What are the most pressing clinical challenges facedby our peers in other areas of the world? How have nurses responded to meeting those needs or individu-alized their care? Who are those “special people” who stand out in their practice?

Readers will be interested in general issues, such as educational preparation of providers, typical workschedules, or work responsibilities. There is a special interest in trauma in other countries, such as the mostcommon mechanisms of injury, incidence, and standard treatment. A constant request is to share informa-tion about injury prevention efforts that have been tried and whether the efforts have been found to be successful.

To discuss questions regarding content or style, authors may contact Judith Stoner Halpern, RN, MS,CEN, Editor, at (616) 381-3494, via fax (616) 344-0338, via e-mail at ijned@net-link.net, or in writing at 1400Low Rd., Kalamazoo, MI 49008. Authors may send completed manuscripts and photographs to the sameaddress.