Active learning in head and neck trauma: outcomes after an innovative educational course

Excellence in teaching and learning is fundamental to the provision of quality training for doctors and for this a sound knowledge of the principles of adult learning theory is important. We present an educational course in head and neck trauma skills for emergency medicine (EM) registrars, using the pedagogical principle of active learning. Our aim was to provide trainees with skills in the evaluation and management of hard and soft tissue injuries to the head, neck, and mouth. Active learning has been shown to provide a superior experience in classrooms, creating a ‘deep’ understanding of the material. To maximise learning, we used these principles to develop small group seminars led by a diverse range of teachers that allowed trainees to acquire hands-on skills. Questionnaires that were completed before and after the course showed an appreciable educational impact. We conclude that innovative teaching methods facilitate the sharing of knowledge that will benefit patient care.     

Isokinetic quadriceps symmetry helps in the decision to return to running after anterior cruciate ligament reconstruction

BackgroundAfter anterior cruciate ligament reconstruction (ACLR), the decision to allow a return to running is empirical, and the post-operative delay is the most-used criterion. The Quadriceps isokinetic-strength Limb Symmetry Index (Quadriceps LSI), with a cutoff of 60%, could be a useful criterion.ObjectiveTo determine the association between a Quadriceps LSI ≥ 60% and return to running after ACLR.MethodsOver a 10-year period, we retrospectively included 470 patients who underwent ACLR. Four months after ACLR, participants performed an isokinetic test; quadriceps concentric peak torque was used to calculate the Quadriceps LSI at 60?/s. With a Quadriceps LSI ≥ 60%, a return to running was suggested. At 6 months after ACLR, participants were clinically evaluated for a return to sport and post-operative middle-term complications. A multivariable predictive model was built to assess the efficiency diagnosis of this cutoff in order to consider cofounding factors. Quadriceps LSI cutoff ≥ 60% was assessed with sensitivity, specificity and the area under the receiver operating characteristic curve (AUC).ResultsAccording to our decision-making process with the 60% Quadriceps LSI cutoff at 60?/s, 285 patients were authorized to return to running at 4 months after ACLR and 185 were not, but 21% (n = 59) and 24% (n = 45), respectively, were not compliant with the recommendation. No iterative autograft rupture or meniscus pathology occurred at 6 months of follow-up. On multivariable logistic regression analysis, a return to running by using the 60% Quadriceps LSI cutoff was associated with undergoing the hamstring strand procedure (odds ratio 2.60, 95% confidence interval [CI] 1.75–3.84; P < 0.0001) and the absence of knee complications (1.18, 1.07–1.29; P = 0.001) at 4 months. The sensitivity and specificity of the 60% Quadriceps LSI cutoff were 83% and 70%, respectively. The AUC was 0.840 (95% CI 0.803–0.877).ConclusionsUsing the 60% cutoff of the isokinetic Quadriceps LSI at 4 months after ACLR could help in the decision to allow a return to running.     

Quantitative assessment of bony orbital volume symmetry: CT analysis in the uninjured caucasian population

There is a surprising lack of evidence documenting the volumetric symmetry of the bony orbit. This paper establishes reference values for orbital volume (OV) and symmetry in the 25 - 40 year old caucasian population. Secondarily, this paper sets a landmark for the tolerances in OV that can be expected when reconstructing the bony defects which may occur from trauma. A standardised method of quantitative OV measurement was developed using CT sinus examinations acquired for indications unrelated to orbital trauma. Sex, ethnicity, age, right and left OV were recorded. Data for 100 patients was obtained (50 male, 50 female). Mean left OV was 23.1cm³ and mean right OV was 23.3cm³. Left and right OV were strongly positively correlated (correlation coefficient: 0.96). Mean female OV was 21.6cm³ and mean male OV was 24.8cm³. On average, male OV is 3.2cm³ larger than female OV. The mean difference between left and right OV was 0.5cm³ in females and 0.6cm³ in males. The intra-class coefficient score between the two assessors was 0.973 (excellent). There is strong positive correlation between left and right OV in this study population. Previous work suggests that orbital volume loss less than 1cm³ would not lead to significant clinical symptoms of orbital fracture. When orbital reconstruction is undertaken, this study suggests that a volume symmetry difference of <0.5cm³ in females and <0.6cm³ in males would be consistent with the variation seen in the study population of uninjured caucasian 25-40 year olds and is therefore a reasonable goal of surgical management.     

The prevalence of non-accidental trauma among children with polytrauma: A nationwide level-I trauma centre study

ObjectiveWe aimed to investigate the prevalence and characteristics of non-accidental trauma (NAT) in children with polytrauma treated at level-I trauma centres (TC).Summary of backgroundData 6–10% Of children who present at the emergency department with injuries, sustain polytrauma. Polytrauma may result from either accidental (AT) or NAT, i.e. inflicted or neglect. The prevalence of NAT among children with polytrauma is currently unclear.MethodsThis is a retrospective study that included children (0–18 years) with an Injury Severity Score >15, who presented at one of the 11 Level-I trauma centers (TC) in the Netherlands between January 1, 2010 and January 1, 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect-team. Cases in which conclusions were unavailable and there was no clear accidental cause of injuries were reviewed by an expert panel.ResultsThe study included 1623 children, 1452 (89%) were classified as AT, 171 (11%) as NAT; 39 (2,4%) inflicted and 132 (8,1%) neglect. Of pre-school aged children (<5 years) 41% sustained NAT (OR26.73, 95%CI 17.70–40.35), 35/342 (10%) inflicted and 104/342 (31%) neglect. Admission due to ‘cardiopulmonary arrest’ was the result of inflicted trauma (30% vs 0%,p < 0.001). NAT had a higher mortality rate (16% vs 10%, p = 0.006). Indicators of NAT were: (near-)drowning (OR10.74, 95%CI 5.94–19.41), burn (OR8.62, 95%CI 4.08–18.19) and fall from height (OR2.18, 95%CI 1.56–3.02).ConclusionsNAT was the cause of polytrauma in 11% of children in our nationwide level-I TC study; 41% of these polytrauma were the result of NAT experienced by preschool-aged children. Our data show the importance of awareness for NAT.     

持续性颅内压监测在颅脑外伤治疗的效果探讨

目的对急性重型颅脑外伤患者在临床治疗中实施持续性颅内压监测的价值进行研究。方法选择本院在2017年8月—2018年8月期间收治的确诊为重型颅脑外伤的患者共计28例作为研究对象,按照硬币法将这些患者划分为两个小组,对照组14例,实验组14例。采用常规治疗方式对对照组加以治疗,采用持续性颅内压监测对实验组加以治疗,对两组患者的治疗效果进行比较。结果对照组的预后神经功能NHISS评分为(15.83±0.31)分、预后GOS评分为(3.19±0.15)分,实验组的预后神经功能NHISS评分为(11.18±0.45)分、预后GOS评分为(4.90±0.17)分。实验组预后神经功能NHISS评分、GOS评分均明显优于对照组,且差异具有统计学意义(P<0.05)。结论在急性重型颅脑外伤患者的临床治疗中应用持续性颅内压监测具有重要作用,其能够对患者的治疗予以有效指导,提升患者的治疗效果。     

Abdominal stab wound injury in children: Do we need a different approach?

Background

Penetrating stab wounds in children are relatively rare and no clear recommendations for the optimal evaluation have been devised. An acceptable traditional approach to the patient with an abdominal stab wound who does not require urgent surgery is selective nonoperative management and serial exams. The use of routine computed tomography remains an actively utilized investigation for these patients at many institutions.