Combined Abdominal and Spine Injuries after High Energy Flexion-Distraction Trauma

Abstract Combined abdominal (AT) and spine (ST) trauma in the multiply traumatized patient (MT) requires optimal clinical management. At the Traumacenter Murnau, Germany all multiply injured patients (injury severity score ≥ 16) are registered in a large prospective database (DGU-Tramaregister). From 1 January 2002 until 31 December 2004, 731 multiply injured patients (ISS ≥ 16) were admitted to the Trauma Center Murnau. In this population, ST was diagnosed in 287 patients (39%), AT was diagnosed in 100 patients (14%), and in 35 patients (5%) a combined ST and AT was observed. The most frequent injury mechanism in patients with a combined ST and AT was high-energy flexion-distraction trauma caused by motor vehicle accident with seat belt fastened passengers, bicycle accident, and fall from great height. In the cohort group of 35 patients, 29 required either abdominal or spinal operation. In 23 patients the AT and in 18 patients the ST necessitated operation. In 14 patients both the AT and ST called for surgery. The AT was predominately treated with splenectomies, resections and suturing of the intestine. The ST resulted in 14 posterior and four postponed anterior stabilizations of the thoracolumbar and four anterior fusions of the cervical spine. Mean age of these patients was 37 years in comparison to 47 years in the control group (MT without combined AT and ST). ISS of patients with combined AT and ST was 38 points compared to 26 points in the control group, and mortality was 7% in the combined group compared to 14% in the control group. The present study documents that damage control principles applied to patients sustaining the complex combination of AT and ST can result in low mortality rates despite the severity of this injury.     

Trauma care systems in Japan

The trauma care system in Japan was set up in the 1960s in response to social problems caused by traffic accidents and has since been altered extensively. First-aid and patient transfer are performed by emergency personnel belonging to a fire station. Instead of 'western-style trauma centres', three types of facilities exist: (1) primary emergency care facilities for treating mild cases not requiring hospitalisation; (2) secondary emergency hospitals directed to treating moderately severe disease or injury; (3) tertiary emergency hospitals corresponding to the emergency departments of university hospitals, or lifesaving emergency centres, able to manage the most severe cases such as myocardial infarction, cerebrovascular accident and polytrauma. Although the quantity of emergency facilities and hospitals appears sufficient, the quality of emergency care needs to be improved. This could be accomplished by the unification of small hospitals to create larger hospitals, and/or by the establishment of trauma centres, as well as by improvements in relevant education and training.     

Trauma care system in China

With the development of modern society, high-energy trauma has become an increasing tendency, which brings a great challenge for trauma care. A well-running trauma care system that is composed by pre-hospital and in-hospital care has been proved to decrease the death and disability rate of trauma patients. However, establishment of trauma care system in China is still at the initial stage. Trauma care systems in China and developed countries represented by the United States and Germany are introduced respectively in this article. Construction of regional and hierarchical trauma center, training of specific trauma care team and performance of integrative trauma rescue model are recommended in China.     

Trauma: the impact of repeat imaging

Background

Patients referred to trauma centers often undergo an extensive diagnostic work-up before transfer. The purpose of our study was to quantify and examine the effects of repeat imaging in this population.

Methods

A prospective cohort study of 410 patient transfers was performed. Repeat imaging was conducted at the discretion of the accepting surgeon for multiple reasons. Two groups were compared, those who did and those who did not require repeat imaging.

Results

Overall, 53% of referrals received repeat imaging, at an average cost of $2,985 per patient. This group was older (42 vs 37 y; P < .05), more severely injured (injury severity score, 12 vs 9; P < .05), and experienced longer delays before transfer (244 vs 192 min; P < .05). By using logistic regression analysis, injury severity score was found to be an independent predictor of the need for repeat imaging (P = .003).

Conclusions

Severely injured trauma patients often receive films that ultimately require duplication, resulting in transfer delay, unnecessary morbidity, and increased resource use. Targeted education and development of centralized radiology systems could alleviate some of the burden of unnecessary imaging.     

Trauma education and assessment

Trauma education has evolved over the past 30 years from an unstructured preceptorship to standardised courses offered worldwide. The Advanced Trauma Life Support (ATLS) course has formed the backbone of trauma management philosophy and has spawned a series of courses aimed at specific patient populations and health care groups. Trauma education and assessment for advanced trainees has taken the form of formal clinical fellowships. In addition to clinical experience, a number of tools have been validated in aiding trauma education including use of videotape review and simulation technology. Future emphasis on development and validation of teaching and assessment techniques could improve trauma education and secondarily impact trauma outcomes worldwide.     

Trauma care systems in India

Trauma-care systems in India are at a nascent stage of development. Industrialised cities, rural towns and villages coexist, with almost complete lack of organised trauma care. There is gross disparity between trauma services available in various parts of the country. Rural India has inefficient services for trauma care, due to the varied topography, financial constraints and lack of appropriate health infrastructure. There is no national lead agency to co-ordinate various components of a trauma system. No mechanism for accreditation of trauma centres and professionals exists. Education in trauma life-support (TLS) skills has only recently become available. A nation-wide survey encompassing various facilities has demonstrated significant deficiencies in current trauma systems.Although injury is a major public-health problem, the Government of India has failed to recognise it as a priority. Significant efforts to develop trauma-care systems across the country are seen mainly in the private sector. New initiatives under National Health Policy 2002 are expected to result in improvement in the systems, but the allocation of funds remains grossly inadequate for any significant impact on the outcome.     

A Survey on Trauma Systems and Education in Europe

Purpose  To assess the current stage of trauma system development and trauma surgery training in Europe. Methods  Email-based survey from 53 physicians representing 25 European countries. Results  On a scale of 0–10, the mean (SD) score for trauma system development was 5.4 (2.4) and for trauma surgery specialization 4.1 (2.9). There was a significant positive correlation between trauma system development and trauma surgery specialization (p = 0.018). Countries with ties to the Austro-German surgical tradition had higher scores both in trauma system development (p = 0.003) and in trauma surgery specialization (p = 0.000), whereas the size, economic performance or geographical location were not associated with either. Conclusions  Despite the great variation from country to country, three trends in developing trauma care and education can be identified: trauma system development based exclusively on major (life-threatening) trauma care (the old United States model), combining trauma and emergency surgery into a single regionalized system (the acute care surgery model), or maintaining the orthopedic surgery-orientated all-inclusive trauma care model as practiced in most central European countries today. Although each country and region might proceed along their own line depending on local circumstances, some kind of general guidelines and recommendations at least at the European Union level would be urgently needed.     

Trauma case management: improving patient outcomes

BACKGROUND: The purpose of the study was to measure the effect of trauma case management (TCM) on patient outcomes, using practice-specific outcome variables such as in-hospital complication rates, length of stay, resource use and allied health service intervention rates. METHODS: TCM was provided 7 days a week to all trauma patient admissions. Data from 754 patients were collected over 14 months. These data were compared with 777 matched patients from the previous 14 months. RESULTS: TCM greatly improved time to allied health intervention (p<0.0001). Results demonstrated a decrease in the occurrence of deep vein thrombosis (p<0.038) and a trend towards decreased patient morbidity, unplanned admissions to the intensive care unit and operating suite. A reduced hospital stay LOS, particularly in the paediatric and 45-64 years age group was noted. Six thousand six hundred twenty-one fewer pathology tests were performed and the total number of bed days was 483 days less than predicted from the control group. CONCLUSION: The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution. This initiative demonstrates that TCM results in improvements to quality of care, trauma patient morbidity, financial performance and resource use.     

Finnish Trauma Audit 2004: current state of trauma management in Finnish hospitals

There is great variation in the organisation of trauma care in European countries. The state of trauma care in Finnish hospitals has not been appropriately reviewed in the past. The aim of the present study conducted by the Finnish Trauma Association (FTA) was to assess the number of Finnish hospitals admitting severe trauma patients, and to evaluate the organisation and training of trauma care in those hospitals. In 2004, a telephone survey to all the Finnish hospitals was conducted, and information on the number of severe trauma patients treated per month, the organisation of acute trauma care, and the existence of multidisciplinary trauma care training was collected. Thirty-six Finnish hospitals admitted trauma patients. The range of estimated number of severely injured trauma patients treated in individual hospitals per month varied from 0.5 to 12, resulting in an estimated number of 1000-1300 patients with severe trauma treated in Finland every year (19-25/100.000 inhabitants). About 20% of the hospitals had a trauma team, and 25% had a systematic trauma education program. Only one hospital had established multidisciplinary and systematic trauma team training. The case load of severe trauma patients is low in most Finnish hospitals making it difficult to obtain and maintain sufficient experience. Too many hospitals admit too few patients, and only a few hospitals have been working on updating their trauma management protocols and education. There is an obvious need for leadership, discussion, legislation and initiatives by the professional organisations and the government to establish a modern trauma system in Finland.     

Trauma care systems in Australia

The management of orthopaedic trauma in Australia varies from the urban model common to most developed countries to a model determined by the vast distances of the island continent. The effectiveness of this system is largely dependent on the retrieval system and treatment protocols of severe injuries often revolve around prolonged contamination of traumatic wounds. The place of the Royal Flying Doctor Service (RFDS) in providing the "Mantle of Safety" for remote and rural Australia is highlighted.     

Trauma care in Germany

Trauma Care in Germany fulfils all requirements to deal with injured young and mobile individuals as well as with an increasing number of injured elderly patient. Furthermore, it is prepared to cope with mass casualties of injured. As a public task the Trauma System in Germany is well organized and follows clear cut demands. To perform technical and medical therapy at highest available level as soon as possible, a ground system of physician staffed ambulances is supported by a network of physician-staffed HEMS all over Germany. Therefore, enormous efforts in financing, basic research and quality management have been undertaken during recent years to create such a sophisticated rescue system.     

Trends in Trauma: A Rural Experience

In last 20 years a progressive increase in the cases of road traffic accidents is seen in the institution. In this study efforts have been made to study epidemiology of trauma & how to help the trauma victims in a better way. To study the changing trends in incidence & presentation of trauma victims. To recommend preventive measures based on the analysis. The present study was carried out in MGIMS, Sewagram, Wardha from 2001 to 2003. For this study which is retrospective and prospective, a total of 986 cases of surgical trauma were studied. Present study showed that in this rural area accidents account for maximum trauma admissions & major trauma only in 20 %. Out of 986 patients, 78.8 % required repair of wounds, 3.8 % required exploratory laparotomy and 16.3 % had orthopedic interventions. Overall mortality rate was 2.9 %. It was found that general care in wards was good in terms of trauma results of rural areas. These results may vary when compared with specialized trauma centers in cities; however after a period of few years cost effectiveness of trauma centers in terms of benefits needs an assessment*.     

Trauma recidivists: surprisingly better outcomes than initially injured trauma patients

Background

The purpose of this study was to determine if there was a difference in hospital outcomes between trauma recidivists (RCID) and nonrecidivists (NRCID).

Methods

Outcomes of RCID and NRCID were compared. A recidivist was defined as a patient with a history of hospital evaluation for injury within the prior 5 years. Patients with good functional status had a Glasgow Outcome Score of 4 to 5.

Results

Of the 2,127 patients admitted, 466 (22%) were RCID. NRCID were more likely to have Injury Severity Score >25 (12% vs 8.6%; P = .04) than RCID. Eighty-eight percent of RCID were discharged with a good functional status compared with 83% of RCID (P = .02). NRCID were more likely to be admitted to a critical care unit (43% vs 36%; P = .01), but there was no significant difference in hospital mortality.

Conclusion

RCID were less severely injured and had better hospital outcomes than NRCID.     

The evolution of an integrated State Trauma System in Victoria, Australia

The incidence of major trauma and associated fatalities in the State of Victoria, Australia, have declined over 20 years following the successful implementation of strategies to modify environmental and behavioural factors that contribute to motor vehicle injuries. However, several system deficiencies in the management of major trauma patients had remained unresolved. To investigate these shortfalls the State Government of Victoria established a task force in 1997 to review trauma and emergency services. The task force adopted the principle of "the right patient to the right hospital in the shortest time" and in 2000 began to deploy an integrated State Trauma System. Implementation of such a system required the designation of specific hospitals of various levels to care for trauma patients; the concentration of trauma expertise at these centres; integration and coordination between the service providers; development of agreed triage and transfer protocols and improved education, training and research programs. A statewide major trauma database was established to enable system monitoring and facilitate further enhancements. The Victorian experience with the development of an integrated trauma system should aid in the development of similar systems nationally and internationally and is described in this paper.