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The objective of this study was to determine whether elderly acutely injured patients take longer to be transferred from referring hospitals to a regional trauma center than younger patients. We reviewed all trauma patients transferred urgently to a regional trauma center over 2 years. We considered age>or=65 years to be elderly. We performed multivariable linear regression to determine the extra time spent at the referring hospital attributable to elderly status, after adjustment for confounders. For 371 transfers, mean Injury Severity Score was 12, and 12% of patients had hypotension before transfer. Mean time spent at the referring hospital was 233+/-110 min. After adjustment for confounders, including Injury Severity Score and computed tomography (CT) scanning before transfer, elderly patients spent 32 min more at referring hospitals than non-elderly patients (95% confidence interval 1-63 min). We conclude that interhospital transfer of elderly acutely injured trauma patients takes longer than for younger patients. Providers may be less aggressive in treating elderly trauma patients.

We describe the prevalence, primary indications and immediate complications of emergency cricothyrotomy (cric) techniques, in a single institution's Emergency Department (ED) and associated air-medical transport service. This is a retrospective review at an academic, level-one trauma center with an annual ED census of 65,000 and an associated air-medical transport service (AMTS). All patients undergoing cric in the field or in the ED between July 1995 and June 2000 were included. Expert reviewers from Emergency Medicine, Trauma Surgery and the AMTS prospectively defined the complication criteria. All charts with a possible complication underwent a blinded evaluation by reviewers representing each of the three clinical services. Descriptive statistics were used to summarize the data. Fifty crics were performed over 5 years. Seventy-six percent of crics were performed in trauma patients. The prevalence of cric in patients requiring airway management in the ED was 1.1% (95% CI, 0.7-1.6) and 10.9% (95% CI, 6.9-16.1) in the field by the AMTS. The prevalence of complications was 14% (95% CI, 4-32.6) in ED patients and 54.5% (95% CI, 32-75.6) for prehospital patients. The overall inter-rater agreement for complication rate was excellent (kappa =.87). Overall, 77% of crics were performed using the rapid four-step technique (RFST). There were no reports of complications associated with the RFST when performed in the ED. Non-RFST crics in the ED had an associated complication rate of 25% (95% CI, 2.8-60). Emergency cricothyrotomy was performed in approximately 1% of all emergency airway cases in the ED and at a higher rate by the AMTS. The most frequent indications were trauma related. Additionally, the RFST was the most commonly used technique for cric at this institution. The complication rate of cric was significantly higher in the prehospital environment than in the ED.

Gastric perforation is a rare complication of cardiopulmonary resuscitation. The majority of reported cases have been associated with difficult airway management or esophageal intubation. There has been only one previous case report in which this complication could be attributed solely to mouth-to-mouth ventilation. We present a case of simple bystander cardiopulmonary resuscitation that resulted in gastric perforation.

We report a case of spontaneous splenic rupture in a 59-year-old woman who was receiving 15,000 units of heparin subcutaneously (s.c. ) twice a day for deep venous thrombosis (DVT) prophylaxis. Her past medical history included multiple DVT, pulmonary emboli, and ovarian cancer stage III-C with known ascites. The diagnosis of splenic rupture was initially missed because of the ascites. This case illustrates both a previously undescribed complication of s.c. heparin therapy and a failure of ultrasound diagnosis. We emphasize the unique presentation, difficulty in diagnosis, and need for early surgical involvement to ensure the most favorable outcome.