Savaş ERİŞ, Murat ORAK, Behçet AL, Cahfer GÜLOĞLU, Mustafa ALDEMİR

Factors effecting mortality in patients with gunshot injuries

Amaç: Bu çalışmada birden fazla organda silah yaralanmasına maruz kalan hastalarda mortalitede etkili faktörleri tespit etmeyi amaçladık. Metot: Dicle Üniversitesi Tıp Fakültesi Acil Tıp Kliniğine Ocak 2000 ile Aralık 2004 arasında ASY nedeniyle başvuran 714 hastanın kayıtları geriye dönük olarak incelendi. Sağ kalanlar ve ölenler arasında mortalite üzerine etkisi olabileceğini düşündüğümüz; ileri yaş, cinsiyet, öz kıyım amaçlı olması, uzun namlulu silahla yaralanma, saçma atan silahlarla yaralanma, yakın atış, gecikmiş başvuru zamanı, başvuruda derin anemi ve şok varlığı, ateşli silah giriş sayısı ≥4 olması, yaralanma bölgeleri, ciddi kafa, toraks ve batın yaralanmasının olması, ekstremite vasküler yaralanması, multiple kan transfüzyonu yapılması, GKS, RTS ve PATİ değerleri analiz edildi. Bulgular: Ünivariete istatistiksel analizler neticesinde; öz kıyım amaçlı yaralanma (p=0.001), başvuruda derin anemi (p=0.001) ve şok varlığı (p=0.001), ciddi kafa yalanması (p=0.001), ciddi toraks yaralanması (p=0.001) ve ciddi batın yaralanmasının olması (p=0.001), femoral arter yaralanması (p=0.001), multiple kan transfüzyonu (p=0.009), GKS'nın 0-7 ve 8-12 olması (p=0.001) ve düşük RTS skoru (p=0.001)'nun mortalite üzerinde anlamlı etkisinin olduğunu tespit ettik. Sonuç: Multivarite analiz sonucunda; başvuruda derin anemi varlığı, ciddi kafa travması varlığı, ciddi batın travması olması ve düşük RTS skoru mortaliteyi etkileyen en önemli bağımsız değişkenler olarak bulundu (p

Ateşli silah yaralanmalı hastalarda mortaliteye etkili faktörler

Objective: We planned this study in order to determine the factors affecting mortality in patients with gunshot injuries in more than one organ. Methods: We retrospectively reviewed the hospital records of 714 patients admitted to the Emergency Department of Dicle University, between January 2000 and December 2004. The factors that we considered would affect mortality such as age, sex, attempts suicide, long barreled gun injuries, pellet injuries, contact/near contact shot, delayed admission time, presence of serious anemia and shock during admission, more than four entrance wounds, injury areas, serious cranial, thorax and abdominal injuries, vascular injuries in the extremity, administration of multiple transfusion, and trauma scores as GKS, RTS, PATI were analyzed. Results: As a result of unvaried statistical analyses, we determined that suicide attempts (p=0.001), presence of serious anemia (p=0.001) and shock (p=0.001) during admission, presence of serious cranial (p=0.001), thorax (p=0.001) and abdominal (p=0.001) injury, femoral artery injury (p=0.001), multiple blood transfusion (p=0.009), , GKS 0-7, GKS 8-12 (p=0.001) and low RTS (p=0.001)were significant factors affecting mortality. Conclusion: Multivariate analysis showed that serious anemia during admission, serious cranial injury, serious abdominal injury and low RTS were independently significant in predicting mortality (p<0.05).

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1) Hoyt DB, Potenza BM, Cryer HG, et al. Trauma. In: Greenfield LJ, Mullholland MW, Oldham KT, Zelenock GB, Lilimoe KD eds. Surgery:Scientific Principles and Practise. 2nd edn. Philadelphia: Lippincott-Raven, 1997:267-421.
2) Burch JM, Franciosa RJ, Moore EE. Trauma. In: Schwartz SI, ed. Principles of Surgery. 7th edn. Singapore: McGraw-Hill, 1999:155-222.
3) Taviloğlu K. Travmaya genel yaklaşım. In: Kalaycı G, Acarlı K, Demirkol K, Ertekin C, Mercan S, Özmen V, eds. Sökücü N. Genel Cerrahi. 1. Baskı. İstanbul: Nobel Tıp Kitabevleri Ltd, 2002:297-312.
4) Feliciano DV. Patterns of injury. In: Feliciano DV, Moore E, Mattox KL, eds. Trauma. Connecticut: Stamford, 1996:85-l05.
5) Oymacı E, Kapkaç M, Uçar Y,Ertan H, Özdedeli E,Tokat Y. The effects of gunshot and shotgun wounds to mortality and morbidity. Turkish J Trauma & Emerg Surg 1997; 3:132-136.
6) Grimes WR, Deitch EA, McDonald JC. A clinical review of shotgun wounds to the chest and abdomen. Surg Gynecol Obst 1985; 160:148-152.
7) Gören S, Subaşı M, Tıraşcı Y, Kemaloğlu S. Firearm releated mortality: a review of 444 deaths in Diyarbakir, Turkey between 1996 and 2001. Tohoku J Exp Med 2003; 201:139-145.
8) Elfawal MA, Awad OA. Firearm fatalities in Eastern Saudi Arabia, impact of culture and legislation. Am J Forensic Med Pathol 1997; 18: 391-396.
9) Azmak D, Altun G, Bilge S, Yılmaz A. Firearm fatalities in Edirne, 1984�1997. Forensic Sci Int 1998; 95: 231-239.
10) Martins RS, Siqueira MG, Santos MTS, Zanon-Collange N, Moraes OJS. Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol 2003; 60: 98-104.
11) Aarabi B. Surgical outcome in 435 patients who sustained missile head wounds during the Iran-Iraq war. Neurosurgery 1990; 27: 692-695.
12) Levy ML, Masri LS, Levy KM, et al. Penetrating craniocerebral injuries resultant from gunshot wounds: gangrelated injury in children and adolescents. Neurosurgery 1993; 33: 1018 -1026.
13) Rosenfeld JV. Gunshot injury to the head and spine. J Clin Neurosci 2002; 9: 9-16.
14) Semple PL, Domingo Z. Craniocerebral gunshot injuriesin South Africa'a suggested management strategy. S Afr Med J 2001; 91: 141-145.
15) İnci İ, Özçelik C, Taçyıldız İ, Nizam Ö, Eren N, Özgen G. Penetrating chest injuries: Unusually high incidence of high velocity gunshot wounds in civilian practice. World J Surg 1998; 22: 438-442.
16) Mandal AK, Oparah SS. Unusually low mortality of wounds of the chest: twelve years experience. J Thorac Cardiovasc Surg 1989; 97: 119-125.
17) Feliciano DV, Burch JM, Patrinel VS, Mattox KL, Jordan GL. Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients. Ann Surg 1988; 208: 362-370.
18) Adesanya AA, da Rocha-Afodu JT, Ekanem EE, Afolabi IR. Factors affecting mortality and morbidity in patients with abdominal gunshot wounds. Injury 2000; 31: 397-404.
19) Taçyıldız IH, Aban N, Öztürk A, Arslan Y, Akgün Y. Factors effecting mortality in penetrating abdominal trauma. Turkish Journal of Trauma & Emergency Surgery. 1997; 3: 213-217.
20) Aldemir M, Taçyıldız IH, Girgin S. Predicting factors for mortality in the penetrating abdominal trauma. Acta Chir Belg 2004; 104:429-434.
21) Coupland R. Abdominal wounds in war. Br J Surg 1996; 83: 1505�1511.
22) Morris JA, McKenzie EJ, Edelstein SL. The effect of preexisting conditions on mortality in trauma patients. JAMA 1990; 263:1942-1946.
23) Çıkırıkçıoğlu M, Çağırıcı U, Atay Y, Yağdı T, Telli A, Bilkay Ö. Thoracic gunshot injuries. Turkish Journal of Trauma & Emergency Surgery. 1999; 5: 266-269.
24) Glezer JA, Minard G, Croce MA, Fabian TC, Kudsk KA. Shot gun wounds to the abdomen. Am Surg 1993; 59: 129-132.
25) Dawidson I, Miller E, Litwin MS. Gunshot wounds of the abdomen. A review of 277 cases. Arch Surg 1976; 111: 862-865.
26) Ordog GJ, Wasserberger J, Balasubramaniam S. Shotgun wound ballistics. J Trauma 1988; 28: 624-631.
27) Deitch EA, Grimes WR. Experience with 112 shotgun wounds of the extremities. J Trauma 1984; 24: 600-603.
28) Baker CC, Degutis LC. Predicting outcome in multiple trauma patients. Infect Surg 1986; 5: 243-245.
29) Çelen O, Oğuz S, Doğan M. Abdominal gunshots wounds: Retrospective analysis of 164 patients. Turkish Journal of Trauma & Emergency Surgery. 2001; 4: 258 - 261.
30) Demetriades D,Velmahos G, Cornwell E. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg 1997; 132: 178-183.
31) Fiedler MD, Jones LM, Miller SF, Finley RK. A correlation of response time and the results of abdominal gunshot wounds. Arch Surg 1986; 121: 902-904.
32) Britt LD, Weireter LJ, Riblet JL, Asensio JA, Maull K. Priorities in the management of profound shock. Surg Clin North Am 1996; 76: 645-660.
33) MacKenzie EJ. Injury severity scales: Overview and directions for future research. Am J Emerg Med 1984; 2: 537-549.
34) Carillo C, Fogler RJ, Shaftan GW. Delayed gastrointestinal reconstruction following massive abdominal trauma. J Trauma 1993; 34: 233-235.
35) Boon JM, Asobayire WM. Gun shot injuries-an analysis of an epidemic in a South African secondary level public sector hospital, Geneeskunde. The Medicine Journel. 2001: 43: 16-19.
36) Rakunt C, İyigün Ö. Kafa travmaları. In: Şahinoğlu AH ed. Yoğun Bakım Sorunları ve Tedavi İlkeleri. 2. baskı. Ankara: Türkiye Klinikleri, 2003: 347-406.
37) Yagmur Y, Guloglu C, Aldemir M, Orak M. Falls from flat-roofed houses: a surgical experience of 1643 patients. Injury 2004; 35: 425-428.
38) Kennedy F, Gonzalez P, Dang C, Fleming A, Sterling-Scott R. The Glasgow coma scale and prognosis in gunshot wounds to the brain. J Trauma 1993; 35: 75-77.
39) Benzel EC, Day WT, Kesterson L, et al. Civilian craniocerebral gunshot wounds. Neurosurgery 1991; 29: 67-71.
40) Dove DB, Stahl WM, DelGuercio LRM. A five year review of deaths following urban trauma. J Trauma 1980; 20: 760-766.
41) Danne P, Brazenor G, Cade R, et al. The major trauma management study: an analysis of the efficacy of current trauma care. Anz J Surg 1998: 68: 50-57.
42) Gabble BJ, Cameron PA, Finch CF. The status of the Glasgow Coma Scale. Emerg Med (fremantle).2003;15:353-560.
43) Özgüç H. Travmada skorlama sistemleri. In: Şahinoğlu AH, ed. Yoğun Bakım Sorunları ve Tedavi İlkeleri. 2. baskı. Ankara: Türkiye Klinikleri, 2003: 430-433.
44) LoCicero J, Mattox KL. Epidemiolojy of chest trauma. Surg Clin North Am 1989; 69: 15-19.
45) Er M, Işık AF, Kurnaz M. Çobanoğlu U. Sağay S. Yalçınkaya İ. Clinical results of four hundred and twenty-four cases with chest trauma. Turkish Journal of Trauma & Emergency Surgery. 2003; 4: 267-274.
46) Crawford WO. Pulmonary injury in thoracic and nonthoracic trauma. Radiol Clin North Am 1973; 11: 527-541.
47) Nast-Kolb D, Waydhas C, Gippner-Steppert C, et al. Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries. J Trauma 1997; 42: 446-455.
48) Fasol R, Zilla P, Irvine S, Von Oppell U. Thoraco-abdominal injuries in combat casualties on the Cambodian border. Thorax Cardiovasc Surg 1988; 36: 33-6.
49) Mattox KL. Indications for thoracotomy: deciding to operate. Surg Clin North Am 1989; 69: 47-58.
50) Zalstein S, Cameron PA. Helicopter emergency medical services: their role in integrated trauma care. Aust N Z J Surg 1997; 67: 593-598.
51) McCullough J. The nation's changing blood supply system. JAMA 1993; 269: 2239-2245.
52) Adesanya AA, Afolabi IR, da Rocha-Afodu JT. Civilian abdominal gunshot wounds in Lagos. J R Coll Surg Edinb 1998; 43: 230-234.
53) Tegegne A. Abdominal missile injuries at Gonder Hospital, Northwestern Ethiopia. Ethiop Med J 1991; 29: 81-86.
54) Dellinger EP, Oreskovich MR, Wertz MJ, Hamasaki V, Lennard ES. Risk of infection following laparotomy for penetrating abdominal injury. Archives of Surgery 1984; 119: 20-27.
55) Nichols RL, Smith JW, Klein DB, Trunkey DD, Cooper RH, Adinolfi MF, Mills J. Risk of infection after penetrating abdominal trauma. N Engl J Med 1984; 311:1065-1070.
56) Çetinkaya Z, İlhan SY, Bülbüller N, Doğru O, Akkuş MA, Caboğlu S. Abdominal firearm injuries. Turkish Journal of Trauma & Emergency Surgery. 1998; 3: 206-210.
57) Dawidson I, Miller E, Litwin MS. Gunshot wounds of the abdomen. Archives of Surgery 1976; 111: 862-865.
58) Thomsen JL, Albrektsen SB. An investigation of the pattern of firearm fatalities before and after the introduction of New Legislation in Denmark. Med Sci Law 1991; 31: 162-166.
59) Persad IJ, Reddy RS, Saunders MA, Patel J. Gunshot injuries to the extremities: experience of a U.K. trauma centre. Injury 2005; 36: 407-411.
60) Eftekhar B, Zarei MR, Ghodsi M, MoezArdalan K, Zargar M, Ketabchi E. Comparing logistic models based on modified GCS motor component with other prognostic tools in prediction of mortality: Results of study in 7226 trauma patients. Injury. 2005; 36: 900-904.
61) Kuhls DA, Malone DL, McCarter RJ, Napolitano LM. Predictors of mortality in adult trauma patients: the Physiologic Trauma Score is equivalent to the Trauma and Injury Severity Score. J Am Coll Surg 2002:194: 695-704.