The aim of this study was to determine factors that predict mortality in patients with traumatic inferior vena cava (IVC) injuries and to review the current management of this lethal injury. A 7-year retrospective review of all trauma patients with IVC injuries was performed. Factors associated with mortality were assessed by univariate analysis. Significant variables were included in a multivariate regression analysis model to determine independent predictors of mortality. Statistical significance was determined at P ≤ 0.05. A literature review of traumatic IVC injuries was performed and compared with our institutional experience. Thirty-six IVC injuries were identified (mortality, 56%; mechanisms of injury, 28% blunt and 72% penetrating). There was no difference in mortality based on mechanism of injury. Injuries with closer proximity to the heart were associated with increased mortality (P < 0.001). Univariate analysis demonstrated that non-survivors had a higher injury severity scale, a lower systolic blood pressure in the emergency department, a lower Glasgow coma score (GCS), and were more likely to have thoracotomies performed in the emergency department or operating room. Multivariate analysis revealed that only GCS (P = 0.03) was an independent predictor of mortality. Typical factors predicting mortality were identified in our cohort of patients, including GCS. The mechanism of injury is not associated with survival outcome, although mortality is higher with injuries more proximal to the heart. The form of management by IVC level is reviewed in our patient population and compared with the literature.

IntroductionThe aim of our study is to determine factors that predict mortality in patients with traumatic inferior vena cava (IVC) injuries.MethodsA retrospective review of all patients admitted to the University of California, Irvine Medical Center from July 1996 to March 2003 with IVC injuries was performed. Factors associated with mortality were assessed by univariate analysis. Significant variables by univariate analysis were included in a multivariate regression analysis to determine factors predicting mortality. All values are presented as the mean ±SEM, statistical significance was determined at p ≤ 0.05.ResultsFrom July 1996 to March 2003, there were 10,584 trauma admissions. Thirty-six IVC injuries were identified (mean age 28.4 ± 2.4, injury severity score (ISS) = 25.5±2.3, 86% man and 14% woman), accounting for a 0.34% incidence of IVC injuries among all trauma admissions. Of all trauma laparotomies performed, 3.9% included management of IVC injuries.The mortality rate for patients with IVC injury was 56% (n=20), accounting for 5.9% of all trauma deaths. The mechanism of injury in our patient population was blunt 60%, and penetrating 40% [GSW (78%), SW (22%)]. There was no difference in mortality based on mechanism of injury (p=0.7 Fisher's exact test). Univariate analysis demonstrated that non-survivors had a significantly higher defined ISS (32.3±3. vs.16.9±2., p≤0.001) and had lower systolic blood pressure in the emergency department (ED SBP 46±11 mm Hg vs 93±6.2 mm Hg, p=0.001). Multivariate analysis of these factors revealed both ISS (p=0.01) and ED SBP (p=0.006) to be independent predictors of mortality.ConclusionISS and ED SBP predict mortality in patients with traumatic IVCI. The mechanism of injury does not affect survival.

Objectives. To measure inter-rater agreement of overall clinical appearance of febrile children aged less than 24 months and to compare methods for doing so.Study Design and Setting. We performed an observational study of inter-rater reliability of the assessment of febrile children in a county hospital emergency department serving a mixed urban and rural population. Two emergency medicine healthcare providers independently evaluated the overall clinical appearance of children less than 24 months of age who had presented for fever. They recorded the initial ‘gestalt’ assessment of whether or not the child was ill appearing or if they were unsure. They then repeated this assessment after examining the child. Each rater was blinded to the other’s assessment. Our primary analysis was graphical. We also calculated Cohen’s κ, Gwet’s agreement coefficient and other measures of agreement and weighted variants of these. We examined the effect of time between exams and patient and provider characteristics on inter-rater agreement.Results. We analyzed 159 of the 173 patients enrolled. Median age was 9.5 months (lower and upper quartiles 4.9–14.6), 99/159 (62%) were boys and 22/159 (14%) were admitted. Overall 118/159 (74%) and 119/159 (75%) were classified as well appearing on initial ‘gestalt’ impression by both examiners. Summary statistics varied from 0.223 for weighted κ to 0.635 for Gwet’s AC2. Inter rater agreement was affected by the time interval between the evaluations and the age of the child but not by the experience levels of the rater pairs. Classifications of ‘not ill appearing’ were more reliable than others.Conclusion. The inter-rater reliability of emergency providers’ assessment of overall clinical appearance was adequate when described graphically and by Gwet’s AC. Different summary statistics yield different results for the same dataset.

Objectives To measure inter-rater agreement of overall clinical appearance of febrile children aged less than 24 months and to compare methods for doing so. Study Design and setting We performed an observational study of inter-rater reliability of the assessment of febrile children in a county hospital emergency department serving a mixed urban and rural population. Two emergency medicine healthcare providers independently evaluated the overall clinical appearance of children less than 24 months of age who had presented for fever. They recorded the initial ‘gestalt’ assessment of whether or not the child was ill appearing or if they were unsure. They then repeated this assessment after examining the child. Each rater was blinded to the other’s assessment. Our primary analysis was graphical. We also calculated Cohen’s κ, Gwet’s agreement coefficient and other measures of agreement and weighted variants of these. We examined the effect of time between exams and patient and provider characteristics on inter-rater agreement. Results We analyzed 159 of the 173 patients enrolled. Median age was 9.5 months (lower and upper quartiles 4.9-14.6), 99/159 (62%) were boys and 22/159 (14%) were admitted. Overall 118/159 (74%) and 119/159 (75%) were classified as well appearing on initial ‘gestalt’ impression by both examiners. Summary statistics varied from 0.223 for weighted κ to 0.635 for Gwet’s AC2. Inter rater agreement was affected by the time interval between the evaluations and the age of the child but not by the experience levels of the rater pairs. Classifications of ‘not ill appearing’ were more reliable than others. Conclusion The inter-rater reliability of emergency providers' assessment of overall clinical appearance was adequate when described graphically and by Gwet’s AC. Different summary statistics yield different results for the same dataset.

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