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 withmandible fractures. The patient with a suspected mandible fracture is asked to bitedown on a wooden tongue blade and then the blade is twisted. If the tongue-bladecannot be broken without causing pain, the test is considered positive for mandiblefractures. Although not reported in the literature, it is possible that patients withcertain 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 thetongue-blade test in identifying patients with a mandible fracture, LeFort fractures ormaxillary sinus fracture.

Methods: This prospective study used a convenient, consecutive sample ofpatients with blunt facial trauma undergoing CT or plain films of the face. A tongue-blade test was administered prior to obtaining the imaging results. The imagingresults were compared with tongue-blade test results, and statistically significantrelationships were identified using Chi2 analysis. Any mandible, maxillary sinus orLeFort fracture was considered a positive imaging result.

Results: Over a 12-month period, 144 patients with blunt trauma to the face wereevaluated with the tongue-blade test and then underwent CT or plain films of theface. Overall, 16 (11.1%, 95% CI: 6.7-17.7%) patients had mandible fractures, and apositive 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 tongueblade 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 thetongue-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 thetongue-blade test was 48.6%, and the specificity was 69.8%.

Conclusions: We found the tongue-blade test to be a very sensitive in identifyingpatients with suspected mandible fractures, but does not have adequate sensitivity tobe used to identify mid-face fractures. Larger studies should be performed prior tousing 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 withcervical spine injury (CSI) occurring 2.4% of the time. Of these, it has been foundthat geriatric patients experience more falls than their younger counterparts. Studiesindicate that the elderly population falls due to decreased proprioception, vertigo,cardiac etiology leading to syncope, or mechanical falls. Combined with theconditions of an aging body (osteoporosis, decreased elasticity, decreased musclemass, 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 howthe morbidity and mortality of these types of injuries can be reduced or anticipated toinsure proper treatment and therapy. The objectives of our study are twofold; first, toevaluate if the mechanism of injury is related to the location of the C-spine fracture inthe elderly and second, if these mechanisms of injury are predictive of mortality.

Methodology: York Hospital IRB approval was obtained. A retrospective chartreview was conducted with data collected from The York Hospital trauma registry,discharge database, and emergency medicine discharge database from January 1995through February 1, 2005. Patients were included if they wereR65 years old and hadradiographic evidence of fracture/dislocation to the C-spine. Patients were excluded ifthey were less than 65 years old and had isolated ligamentous injury or penetratingtrauma wounds. Variables obtained include: age, gender, location of cervical spinefracture, mechanism of injury, disposition, death, hospital length of stay, injuryseverity score. Data was analyzed using frequencies, chi-square analysis and FishersExact test. Limitations: Data was collected retrospectively, small sample size.

Results: One hundred thirty-five patients were enrolled with a mean age of 78.6years. 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 patientshad multiple fractures. Overall, there were a total of 181 C-Spines fractures: 120upper c-spine fractures with 81 (68%) being odontoid fractures, and 71 lower c-spinefractures. Mechanisms of injury were grouped into 4 classifications: 53 (39%) patientshad fallen from standing; 52 (38%) motor vehicle collisions; 26 (19%) falls fromhigher than 5 feet; and 4 (3%) pedestrians struck. The fall from standing group had

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 and30 (22%) who died. There was no difference in the death rate with 13/53 (24%) offalls from standing and 17/82 (21%) in all other groups. The mean injury severityscore (ISS) of all injuries was 16.4. The mean hospital length of stay was 11.2 dayswith a mean 4.84 ICU days.

Conclusion: There was no relationship between the location of C-spine fracturesand the mechanism of injury. However, a fall from standing in an elder resultedin significant mortality (24%) and was usually in the upper (C1, C2) cervicalspine (74%).

Research Forum Abstracts

S66 Annals of Emergency Medicine

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 thatinhibits the blood coagulation protease thrombin and is seen to be present in lowlevels in cases of shock, sepsis, or major trauma. Coagulopathy and hemorrhage areknown contributors to trauma prognosis but the actual relationships of AT-III tomortality and to injury severity are unknown. The purpose of this study was todetermine the correlation between AT-III and injury severity.

Methods: This study was a retrospective analysis of data collection from January1, 2003, to December 31, 2003. Sixty patients with multiple trauma were studied.The revised trauma score (RTS), the injury severity score (ISS), the systemicinflammatory response syndrome score (SIRS), the acute physiology and chronichealth evaluation III (APACHE III), the length of ICU stay, the base-deficit valueand the serum lactate were measured to evaluate injury severity. We estimated therelation 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 thenon-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 for24 hours had the strongest correlation with AT-III (R=0.546, p=0.000). The basedeficit (R=0.418, p=0.001), the length of ICU stay (R=0.415, p=0,030), theAPACHE III (R=0.367, p=0.021), and the RTS (R=0.247, p=0.006) were alsocorrelated with AT-III. A logistic regression showed a strong association between theAT-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 wascorrelated with the RTS, the APACHE III, the number of transfusion units, theseverity of shock, and the length of ICU stay. The serum AT-III level also showed astrong 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 deathboth on the battlefield and in the civilian setting, development of new approaches forearly detection of blood loss for triage, diagnosis, and treatment decisions hascontinued to be a priority for decreasing mortality in trauma patients. Previousanimal and human experiments have suggested that reduction of central volume iseither directly or inversely associated with amplitude changes of R-waves onelectrocardiograph (ECG) tracings. The purpose of this study was to elucidate therelationship between reductions in central blood volume and R-wave amplitudevariations as a possible early predictor of hypovolemia.

Methods: Thirteen healthy, normotensive men age 27-52 gave written consentto serve as subjects. All subjects underwent a protocol consisting of a 12 minutebaseline period followed by exposure to lower negative body pressure (LNBP) of�15, �30, �45, and �60 mmHg for 12 minutes. Lead II ECG tracing, systolic(SAP), diastolic (DAP) and mean (MAP) arterial pressures, heart rate (HR) andestimated stroke volume (SV)were measured at baseline in resting, supine subjectsand at an estimated central blood volume loss of O1000 ml with application of�60 mmHg lower body negative pressure (LBNP). The analog waveform was thenrecorded into a Data Acquisition System (DAQ) and stored at a samplingfrequency of 500Hz. The R-wave amplitude was analyzed using PhysiologicalWaveform Marker Validation software by measuring from the start of the R-waveto its peak to eliminate any baseline shift due to respiration. The mean amplitudes

Volume 46, no. 3 : September 2005