Is the trimodal pattern of death after trauma a dated concept in the 21st century? Trauma deaths in Auckland 2004

OBJECTIVE: To determine whether the classical trimodal distribution of trauma deaths is still applicable in a contemporary urban New Zealand trauma system. METHODS: All trauma deaths in the greater Auckland region between 1 January 2004 and 31 December 2004 were identified and reviewed. Data was obtained from hospital trauma registries, coroner autopsy reports and police reports. RESULTS: There were 186 trauma deaths. The median age was 28.5 years and the median Injury Severity Score was 25. The predominant mechanisms of injury were hanging (36%), motor vehicle crashes (31.7%), falls (9.7%), pedestrian-vehicle injury (5.4%), stabbing (4.3%), motorcycle crashes (3.2%), and pedestrian-train injury (2.2%). Most deaths were from central nervous system injury (71.5%), haemorrhage (15.6%), and airway/ventilation compromise (3.8%). Multi-organ failure accounted for 1.6% of deaths. Most deaths occurred in the pre-hospital setting (80.6%) with a gradual decrease thereafter. CONCLUSION: There was a skew towards early deaths. The trimodal distribution of trauma deaths was not demonstrated in this group of patients.     

Orthopaedic trauma care: a two-tier system?

Orthopaedic trauma requiring surgical admission presents to our hospitals right throughout the week. However, the level of service provided to trauma patients appears to fluctuate with more surgery facilities available during weekday "office-hours" with reduced facilities at the weekend. The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) in 1999 laid down guidelines for orthopaedic trauma surgery in elderly patients clearly stating that no elderly patient requiring an urgent operation should have to wait for more than 24 h once fit for surgery. We see no reason to exclude the younger population from such a directive and have hence applied the same standard of "surgery within 24 h of admission" as our index of appropriate practice. Audit of our consultant delivered performance confirmed that while an average 88% of "weekday service" patients admitted Sunday through Thursday achieved this standard, only an average of 64% of weekend service patients admitted on Friday or Saturday achieved the same standard. The purpose of this report is to increase awareness of what we believe to be a widespread dilemma. The day of the week should not dictate the treatment of the patient.     

Trauma system in Greece: Quo Vadis?

IntroductionImplementation of trauma systems has markedly assisted in improving outcomes of the injured patient. However, differences exist internationally as diverse social factors, economic conditions and national particularities are placing obstacles. The purpose of this paper is to critically evaluate the current Greek trauma system, provide a comprehensive review and suggest key actions.MethodsAn exhaustive search of the – scarce on this subject – English and Greek literature was carried out to analyze all the main components of the Greek trauma system, according to American College of Surgeons’ criteria, as well as the WHO Trauma Systems Maturity Index.ResultsRegarding prevention, efforts are in the right direction lowering the road traffic incidents-related death rate, however rural and insular regions remain behind. Hellenic Emergency Medical Service (EKAB) has well-defined communications and emergency phone line but faces problems with educating people on how to use it properly. In addition, equal and systematic training of ambulance personnel is a challenge, with the lack of pre-hospital registry and EMS quality assessment posing a question on where the related services are currently standing. Redistribution of facilities’ roles with the establishment of the first formal trauma centre in the existing infrastructure would facilitate the development of a national registry and introduction of the trauma surgeon subspecialty with proper training potential. Definite rehabilitation institutional protocols that include both inpatient and outpatient care are needed. Disaster preparedness entails an extensive national plan and regular drills, mainly at the pre-hospital level. The lack, however, of any accompanying quality assurance programs hampers the effort to yield the desirable results.ConclusionDespite recent economic crisis in Greece, actions solving logistics and organising issues may offer a well-defined, integrated trauma system without uncontrollably raising the costs. Political will is needed for reforms that use pre-existing infrastructure and working power in a more efficient way, with a first line priority being the establishment of the first major trauma centre that could function as the cornerstone for the building of the Greek trauma system.     

Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma?

BACKGROUND: Controversy exists regarding the interpretation of diagnostic peritoneal lavage results. This is especially true in the evaluation of patients sustaining penetrating trauma, specifically stab wounds to the lower chest and abdomen. Ideally one wants to avoid missed injuries and minimize unnecessary operations. METHODS: This is a retrospective review of 195 patients sustaining stab wounds to the anterior lower chest and abdomen at Parkland Memorial Hospital between 1993 and 2005, looking at missed injuries and false positive rates using red cell counts of 100,000, 10,000, and the standard criteria for blunt trauma including >500 white blood cells (WBCs), amylase, and/or bile. RESULTS: The first analysis used >100,000 red blood cells (RBCs)/mm3 as a positive value. The false positive rate was 12.2%. The second analysis used >10,000 RBCs/mm3 as a positive value with a false positive rate of 44%. When considering the entire study population (195 patients), the false positive rate increased when using the lower number (>10,000) from 2.5% to 15.8% (p < 0.001). There were no missed injuries when using >100,000 red cells and/or >500 white cells, the presence of bile or amylase. CONCLUSION: Decreasing the red blood cell count from >100,000 to >10,000 as the criteria for operating on patients with stab wounds to the anterior lower chest and/or abdomen will significantly increase the number of nontherapeutic procedures. Based on this study, >100,000 RBCs/mm3 appears to be a valid and safe number to use when evaluating these patients, particularly when used with other positive criteria such as increased white cells, bile, and amylase.     

Is the Trauma Mortality Prediction Model (TMPM-ICD-9) a valid predictor of mortality in pediatric trauma patients?

Background/Purpose

Researchers are constantly challenged to identify optimal mortality risk adjustment methodologies that perform accurately in pediatric trauma patients. This study evaluated the new Trauma Mortality Prediction Model (TMPM-ICD-9) in pediatric trauma patients.

Methods

Data were analyzed on 107,104 pediatric trauma patients included in the NTDB® in 2010 who had both a valid ISS and probability of death using TMPM-ICD-9. Discrimination was compared using the area under the receiver operator characteristic curve (AUC) and by age, blunt vs penetrating, intent, Glasgow Coma Scale (GCS), and number of injuries.

Results

The AUC for TMPM-ICD-9 demonstrated excellent discrimination in predicting mortality versus ISS overall, 11 to 17 years of age (0.96 vs 0.93), by injury type, intent, and in the lowest GCS scores. The TMPM-ICD-9 showed superior discrimination over ISS in patients with more than two injuries.

Conclusions

The TMPM demonstrated superior discrimination compared to ISS. The TMPM shows promise of a much needed and simple to use risk adjustment tool with application to both adult and pediatric patients. Researchers should continue to validate this tool in robust pediatric data sets.     

In-house trauma attendings: is there a difference?

INTRODUCTION: Outcomes of patients who met trauma activation criteria were examined before and after implementation of in-house attending call. MATERIALS AND METHODS: Outcomes for the out-of-house period (OH) (February 1, 2001 to October 31, 2002) were compared with the in-house period (IH) (November 1, 2002 to June 30, 2004). Measures included overall mortality, length of stay (LOS) in the hospital, intensive care unit (ICU) and emergency department, and preventable deaths. RESULTS: A total of 2,019 trauma activations were studied (1,036 OH, 983 IH). The groups were equivalent on admission. There was no difference in hospital LOS, ICU LOS, ventilator days, or overall mortality. Preventable deaths occurred in 8.1% of the OH group and in 1.0% of the IH group (P < .02). CONCLUSIONS: Aggregate statistics and the use of surrogate markers to determine outcomes may not accurately portray the impact of attending surgeons on the quality of care. Implementation of in-house call resulted in a decreased incidence of preventable deaths.     

Chronic epididymitis: is epididymectomy a valid surgical treatment?

Chronic scrotal pain (≥3 months) is multi-factorial in nature and difficult to treat. Epididymectomy for chronic epididymal pain is rarely performed because of perceived poor outcome. We retrospectively audited our results, when published 'cure' following testicular denervation is 97%. The records of 32 males (35 consecutive epididymectomies) were retrospectively analysed. Thirteen had previous scrotal surgery. Eight (group one) had palpable painful epididymal abnormalities on clinical examination, nine (group two) had ultrasonic abnormalities but no palpable abnormality and 15 (group three) had neither. Pain response was recorded as: cured, improved, recurred or no change/worse. The mean time to operation was 23.83 months (2–121) and follow-up was 15.57 months (1–84). There were no significant aetiological differences between groups. In group one, 87.5% were cured with the remainder improved. Sixty-seven per cent of group two had a satisfactory outcome. Of group three, 20% were cured and a further 33% improved. Prior scrotal surgery, duration of symptoms and age were not predictive of outcome (Kruskal-Wallis) in terms of pain relief. Epididymectomy for structural abnormalities had excellent results. Those with chronic pain, normal examination and ultrasound had at best, a 55% chance of improvement. This group must be counselled about the low risk of success. The identification of the optimal surgical management of this difficult problem requires a multi-national registry study.     

Barrier precautions in trauma: is knowledge enough?

OBJECTIVES: The risk of blood and body fluid exposure and, therefore, risk of blood-borne disease transmission is increased during trauma resuscitations. Use of barrier precautions (BPs) to protect health care workers (HCWs) from exposure and infection has been codified in hospital rules and in national trauma education policy. Despite these requirements, reported rates of BP compliance vary widely. The reasons for noncompliance are not known. This study assesses self-reported rates of BP usage during resuscitations among trauma professionals, explores reasons for noncompliance, and compares self-reported compliance rates with actual observed compliance rates. METHODS: A survey regarding BPs was distributed to all HCWs involved in trauma resuscitations at our Level I trauma center. All surgical and emergency medicine residents as well as attending faculty from both disciplines and nursing staff were included in this study. A total of 161 surveys were distributed and 123 were returned. RESULTS: Most HCWs (114 of 123 [93%]) reported at least one exposure (usually intact skin contact) to blood or other body fluids. A considerable variation in the type of BP used was reported for those HCWs who reported use of BPs "all of the time." Of the HCWs who reported universal use of BPs, reported usage rates were as follows: gloves, 105 of 123 (85%); eyewear (no side protectors), 58 of 123 (47%); eyewear (side protectors), 20 of 123 (16%); gowns, 22 of 123 (18%); and masks, 5 of 123 (4%). The two most common reasons for noncompliance were "time factors" (61%) and "BPs are too cumbersome" (29%). Observed compliance rates were statistically significantly lower than self-reported rates in all BPs except gloves (p < 0.02). CONCLUSION: The wide variation in BP use and the gap between perceived and actual usage that we have observed suggest that the effectiveness of current educational approaches to ensure BP use is inadequate.     

Trauma deaths in the first hour: are they all unsalvageable injuries?

BACKGROUND: With the advent of trauma systems, time to definitive care has been decreased. We hypothesized that a subset of patients who are in extremis from the time of prehospital transport to arrival at the trauma center, and who ultimately die early after arrival, may in fact have a potentially salvageable single-organ injury. METHODS: We reviewed all deaths that occurred in the first hour after hospital admission. Trauma registry, medical records, and autopsy reports for 556 patients were evaluated. RESULTS: The median time to arrival was 39 minutes, and the median Injury Severity Score was 29. Blunt injuries (53%) were most commonly auto-accident injuries (134 of 285 patients; 47%). Penetrating wounds (42%) were mostly gunshot wounds to the chest (73 of 233 patients; 31%). For patients with initial vital signs, the most common cause of death was isolated brain injury (26 patients; 28%). Possibly survivable injuries (single organ or vessel) occurred in 35 (38%) patients, of which 4 were isolated spleen injuries (4%). CONCLUSIONS: Some patients with potentially survivable single organ injuries did not have associated head injuries. An aggressive approach is warranted on patients with detectable vital signs on at least one occasion in the field but who arrive at the trauma center in extremis.     

Wii-habilitation: Is there a role in trauma?

Rehabilitation forms an essential component of the therapeutic continuum in multiply injured patients. Effective rehabilitation programmes assist patients in optimising their level of physical, psychological and social function, while also reducing the length of patient stay, re-admission rates and use of primary care resources.A recent report from the National Audit Office on trauma care within the UK highlighted rehabilitation as an area of trauma patient care that frequently fell short of the standards expected. The current decline in the economy is likely to impact upon the financial resources available to address these concerns particularly recognising the high dependency on human resources. As a result, those involved in the rehabilitation of injured patients will need to develop new, innovative, cost-effective strategies to improve the current rehabilitation programmes available.These programmes need to intervene early and provide task-orientated training along with high repetition intensity. Such programmes not only test patient motivation, but also frequently demand a high degree of therapist supervision. Efforts logically should therefore focus on designing interventions that engage and motivate patients and encourage increased therapist-independent patient rehabilitation.Virtual reality (VR) offers a possible solution. VR is a technology that allows the user to directly interact with a computer-simulated environment. This technology, developed initially for military training, has now become widely available through video games. The potential for VR interfaces to create an environment that encourages high repetition intensity has been exploited by numerous vocational training programmes, such as laparoscopic surgical skill training. It is now conceivable that computer-based rehabilitation programmes could be developed using current, widely available, affordable virtual reality platforms, such as the Nintendo^® Wii.This review aims to discuss the use of modern computer technology in patient rehabilitation and how this may be applied to trauma patients.     

Blunt breast trauma: is there a standard of care?

The incidence of female blunt breast trauma (FBBT) is unknown, and there are no established treatment guidelines. The purpose of this study was to establish the incidence of FBBT, define associated injuries, and develop a treatment algorithm. This is a retrospective analysis of FBBT at a Level I trauma center from October 2000 through December 2008. The incidence, mechanism, and severity of injury, associated injuries, therapeutic interventions, and clinical outcomes were evaluated. A total of 14,499 patients were evaluated. Of these, 13,637 were blunt trauma victims and 5,305 were female blunt trauma victims. One hundred and eight (2%) were diagnosed with FBBT. Although the average injury severity score (ISS) was 12.3 for all FBBT patients, 60 per cent of patients had an ISS > 15. Ninety-four per cent were caused by motor vehicle crashes, with the most common injuries being long bone fractures (45%) and rib fractures (44%). One hundred and one (93.5%) of the injuries were simple hematomas managed expectantly; seven patients (6.5%) had expanding hematomas with radiological evidence of active bleeding that ultimately required invasive procedures, with six of them undergoing arteriogram and four successfully embolized. One patient was taken directly to the operating room for surgical ligation of a bleeding vessel. These data represent the largest series of breast injuries ever reported. Because FBBT is a marker for severe associated injuries, our treatment algorithm recommends that women with radiological evidence of active bleeding who are hemodynamically stable be evaluated with a chest arteriogram plus or minus embolization. However, unstable patients with no other source of hemorrhage should undergo definitive urgent operative repair. All other patients should be managed expectantly.     

Urban versus rural trauma recidivism: is there a difference?

Purpose

Understanding the characteristics of trauma recidivists may allow trauma centers to tailor prevention programs. We hypothesized that there would be an increased incidence of violent injuries and falls in the urban vs. rural recidivists, respectively.

Methods

Trauma admissions from 2000 to 2011 were queried for incidences of recidivism. Age (<65 or ≥65 years), gender, Injury Severity Score (ISS, <9 or ≥9), mortality, and injury cause (fall, violence, or other) were analyzed with univariate analyses to test for differences between urban and rural patients. Significant variables were then included in a binary logistic model and further stratified based on environment.

Results

There were a total of 19,600 trauma admissions from 2000 to 2011, representing 18,711 unique patients, with 1,690 admissions (8.6 %) attributed to 801 recidivists (4.3 %). The overall percentages of recidivist trauma admissions attributed to urban and rural patients were 8.6 and 6.9 %, respectively (p < 0.001). When adjusting for age ≥65 years as well as falls and violent injuries, patients from urban environments were at 1.12 times higher odds of being a recidivist than their rural counterparts [odds ratio (OR) 1.12; 95 % confidence interval (CI) 1.01–1.25; p = 0.039]. When stratified into rural and urban groups, falls and violent injuries were significant in both groups of recidivist admissions; however, age ≥65 years was only significant in rural recidivist admissions.

Conclusion

An urban trauma admission had 12 % higher odds of being attributed to a recidivist than its rural counterpart, when controlling for age and mechanism of injury (MOI). Age ≥65 years was a significant variable in rural but not urban recidivist admissions. Characterizing the recidivist may allow for targeted prevention and intervention programs to decrease repeat hospital visits.