Paediatric trauma teams in Australia

BACKGROUND: Trauma teams have been associated with improved survival probability of paediatric trauma patients. The present study seeks to estimate the use of trauma teams in Australian paediatric tertiary referral centres and describe their medical composition, leadership and criteria for activation. METHODS: Australian paediatric tertiary referral centres were identified. A structured questionnaire assessing the presence, composition and means of activation of a trauma team was mailed to the 'Director, Emergency Department' of all identified hospitals. Three months later, all hospitals were contacted by telephone to complete and verify data collection. RESULTS: Questionnaires were distributed to eight hospitals. Seventy-five per cent had an established trauma team. Hospitals without a trauma team claimed to have insufficient doctors to form a team and insufficient trauma caseload to justify a team. All trauma teams were potentially activated by prehospital paramedic data (field triage) and required a combination of anatomical, physiological and mechanistic criteria for activation. The two methods of mobilizing a trauma team were by dispatching a common call onto individual pagers (66%) or a specific trauma pager (33%) carried by trauma team members. Fifty per cent of hospitals had a two-tier, stratified trauma team response. All teams consisted of emergency, surgical and intensive care unit registrars. Trauma team leaders were emergency medicine specialists/registrars (33%), surgical registrars (33%) and non-defined (33%). Consultant surgeons were not members of any trauma team. Eighty-three per cent of trauma teams consisted of more junior members after hours. Fifty per cent of hospitals did not have a surgical registrar on site outside of business hours. Eighty-eight per cent of hospitals engaged in some form of trauma audit. CONCLUSIONS: Trauma teams are utilized by most Australian paediatric tertiary referral centres, with fairly uniform medical composition and criteria for activation. Paediatric surgeons presently have limited leadership roles and membership of Australian paediatric trauma teams.     

Blunt chest trauma in childhood

BACKGROUND: Although thoracic injuries are uncommon in children, their rate of morbidity and mortality is high. The aim of this study was to evaluate the clinical features of children with blunt chest injury and to investigate the predictive accuracy of their paediatric trauma scores (PTS). METHODS: Between September 1996 and September 2006, children with blunt thoracic trauma were evaluated retrospectively. Clinical features and PTS of the patients were recorded. RESULTS: There were 27 male and 17 female patients. The mean age was 7.1 +/- 3.4 years, and the mean PTS was 7.6 +/- 2.4. Nineteen cases were injuries caused by motor vehicle/pedestrian accidents, 11 motor vehicle accidents, 8 falls and 6 motor vehicle/bicycle or motorbike accidents. The following were noted: 28 pulmonary contusions, 12 pneumothoraxes, 10 haemothoraxes, 9 rib fractures, 7 haemopneumothoraxes, 5 clavicle fractures and 2 flail chests, 1 diaphragmatic rupture and 1 pneumatocele case. The cut-off value of PTS to discriminate mortality was found to be < or = 4, at which point sensitivity was 75.0% and specificity was 92.5%. Twenty-seven patients were treated non-operatively, 17 were treated with a tube thoracostomy and two were treated with a thoracotomy. Four patients who suffered head and abdominal injuries died (9.09%). CONCLUSION: Thoracic injuries in children expose a high mortality rate as a consequence of head or abdominal injuries. PTS may be helpful to identify mortality in children with blunt chest trauma. Blunt thoracic injuries in children can be treated with a non-operative approach and a tube thoracostomy.     

Paulista Registry of glomerulonephritis: 5-year data report.

BACKGROUND: The Paulista Registry of Glomerulopathies was created in May 1999 and comprises several centres of S?o Paulo, the most populous Brazilian State, that concentrates people from all regions of the country who look for health care. METHODS: This report includes data from 2086 patients from Brazil submitted to renal biopsy due to the presumed diagnosis of glomerular diseases, registered prospectively since May 1999 until January 2005. Data were collected by the integrants of the 11 centres involved, utilizing a standardized questionnaire. RESULTS: The mean age of the patients was 34.5+/-14.6 years. Primary glomerular diseases were more frequent in males (55.1%) than in females; on the other hand, secondary glomerular diseases were more frequent in females (71.8%). The most common clinical presentation was nephrotic syndrome and the frequency of hypertension, at this time, was 55.5%. There was a predominance of indication of biopsies in the third, fourth and fifth decades of life. The most common primary glomerular diseases were focal and segmental glomerulosclerosis (29.7%), followed by membranous nephropathy (20.7%), IgA nephropathy (17.8%), minimal change disease (9.1%), membranoproliferative glomerulonephritis (7%), crescentic glomerulonephritis (4.1%), advanced chronic glomerulopathy (4%), non-IgA mesangial glomerulonephritis (3.8%), diffuse proliferative glomerulonephritis (2.5%), focal segmental proliferative glomerulonephritis (1%) and others (0.3%). The most frequent secondary glomerular disease was lupus nephritis, corresponding to 66.2% of the cases, followed by post-infectious glomerulonephritis (12.5%), diabetic nephropathy (6.2%), diseases associated to paraproteinaemia (4.9%), hereditary diseases (4.6%), vasculitis (3.2%), malignancies (0.9.%), secondary focal segmental glomerulosclerosis (0.6%) and others (0.9%). CONCLUSION: Focal segmental glomerulosclerosis was the most frequent primary glomerular disease, followed by membranous nephropathy and IgA nephropathy. Lupus nephritis predominated over all the other secondary glomerular diseases.     

The epidemiology of trauma of the genitourinary system after traffic accidents: analysis of a register of over 43,000 victims

OBJECTIVE: To analyse the frequency and type of injury to the genitourinary system, by user category, after traffic accidents. PATIENTS AND METHODS: The register which forms the basis of this study is unique in Europe and includes 43,056 victims of road traffic accidents, and was compiled between 1996 and 2001. The categories of road users included: motorists, motorcyclists, cyclists, pedestrians, van and bus users, and roller skaters. The urological complication rate was analysed for each category. RESULTS: In all, 199 cases of trauma of the genitourinary system (0.46%) were recorded. The most frequent urological complications were renal (43%) and testicular trauma (24%), the former most frequent in motorists (65%) and pedestrians (29%), and the latter in motorcyclists (41%). CONCLUSIONS: An analysis of this register provides better knowledge of the urogenital injuries after traffic accidents. Renal and testicular injuries are the most frequent.     

Evaluation of pre-hospital trauma triage criteria: a prospective study at a Danish level I trauma centre

BACKGROUND: The aim of the present study was to evaluate the precision of our trauma triage protocol [based on the American College of Surgeons, Committee on Trauma (ACS COT)] in identifying severely injured defined as an injury severity score (ISS) > 15. Our hypothesis was that isolated mechanism-of-injury criteria were responsible for a significant over-triage leading to over-use of our trauma team. METHODS: Design: A prospective cohort study. Setting: A level I trauma centre, Aarhus, Denmark. Patients and participants: Among all injured patients admitted during a 6-month period in 2003 we identified severely injured. During the study period, trauma team activations were consecutively registered and triage criteria were prospectively collected. Sensitivity, specificity, positive predictive value, over-triage and under-triage were calculated. RESULTS: Out of 15,162 patients in the emergency department, 848 injured patients were included and 59 (7%) were severely injured. We had 242 trauma team activations with 54 (22%) severely injured. Sensitivity was 92%, specificity 76%, giving an over-triage of 24% and an under-triage of 8%. The positive predictive value was 22%. Among 60 patients with mechanism-of-injury as the only criterion, five were severely injured in contrast to 12 out of 20 patients with mechanism-of-injury combined with physiological and/or anatomical criteria. CONCLUSION: The positive predictive value of our triage protocol was low, only 22%. This was mainly as a result of a significant over-triage from isolated mechanism-of-injury criteria. We recommend revision of the triage protocol and reallocation of our trauma team resources.     

Resources for managing trauma in rural New South Wales, Australia

BACKGROUND: Trauma bypass is not always appropriate in the management of rural trauma because of the large distances and travel times. Rural hospitals in New South Wales, Australia are an essential component of the statewide integrated trauma system. The present study profiles the trauma resources of base hospitals in rural New South Wales. METHODS: A structured questionnaire, addressed to the 'Director, Emergency Department' was distributed to all rural base hospitals in New South Wales. Follow-up telephone interviews were administered to complete data collection. RESULTS: Fourteen hospitals were identified. General and orthopaedic surgeons provided trauma care in all hospitals. Forty-three per cent of hospitals had resident subspecialty surgeons. Fifty per cent of hospitals had a formal hospital trauma team. In the remaining hospitals, the most common reason (86%) stated for the absence of a formal trauma team was a lack of personnel to provide 24 h immediate response to all trauma presentations. Seventy-one per cent of hospitals are staffed by a single doctor after hours. All hospitals had 24 h access to plain radiography and blood products. 86% had 24 h access to ultrasound and computed tomography, although always on an 'on-call' basis after hours. All hospitals had the capability to maintain ventilated patients, averaging two ventilated beds per hospital. An average of two trauma patients per hospital per month is transferred to a larger institution. Sixty-four per cent of hospitals participated in a trauma retrievals for their surrounding areas. Seventy-one per cent of hospitals engaged in quality assurance activities regarding trauma outcomes. CONCLUSIONS: Formal responses to major trauma in rural base hospitals in New South Wales are often restricted by a lack of specialist medical personnel. Nevertheless, the majority of hospitals have the resources to manage major trauma.     

Trauma teams in Australia: a national survey

Background: Trauma teams have been associated with improved trauma patient outcomes. The present study seeks to estimate the use of trauma teams in Australian hospitals and describe their medical composition, leadership and criteria for activation. Methods: Australian public hospitals with more than 100 beds, an emergency department and offering surgical services were identified. A survey assessing the presence, composition and means of activation of a trauma team was mailed to the ‘Director, Emergency Department’ of all identified hospitals. Three months later, all hospitals were contacted by telephone to complete and verify data collection. Results: Questionnaires were distributed to 130 hospitals. After exclusion of hospitals that did not receive patients with traumatic injuries, and dedicated paediatric tertiary referral centres, 111 hospitals remained for analysis. Of these, 56% had an established trauma team, while 71% of hospitals without a trauma team claimed to have insufficient doctors to form one team. Ninety‐five per cent of trauma teams were potentially activated by prehospital paramedic data (field triage). For 92% of trauma teams a combination of anatomical, physiological and mechanistic criteria were required for activation. The most common methods of mobilizing a trauma team were by dispatching a common call onto individual pagers (31%) or by paging trauma team members individually (31%). Fifty‐eight per cent of trauma team leaders were emergency medicine specialists/registrars, while 8% of trauma teams were led by surgeons/registrars. Consultant surgeons were members of 23% of trauma teams and 74% of trauma teams consisted of more junior members after hours. Some form of trauma audit was engaged in by 64% of hospitals. Conclusions: Trauma teams are yet to be utilized by many Australian hospitals that provide trauma care. Australian surgeons presently have limited leadership roles and membership in trauma teams. Trauma audit can be more widely adopted in Australian hospitals.     

Major genitourinary-related bicycle trauma: Results from 20 years at a level-1 trauma center

BackgroundEpidemiological studies have shown that bicycle trauma is associated with genitourinary (GU) injuries. Our objective is to characterize GU-related bicycle trauma admitted to a level I trauma center.Materials and methodsWe queried a prospective trauma registry for bicycle injuries over a 20-year period. Patient demographics, triage data, operative interventions and hospital details were collected.ResultsIn total, 1659 patients were admitted with major bicycle trauma. Of these, 48 cases involved a GU organ, specifically the bladder (n = 7), testis (n = 6), urethra (n = 3), adrenal (n = 4) and/or kidneys (n = 36). The median age of cyclists with GU injuries was 29 (range 5–70). More men were injured versus women (35 versus 13). GU-related bicycle trauma involved a motor vehicle in 52% (25/48) of injuries. The median injury severity score for GU-related bicycle trauma was 17 (range 1–50). The median number of concomitant organ injuries was 2 (range 0–6), the most common of which was the lungs (13/48, 27%) and ribs (13/48, 27%). The majority of GU injured cyclists were admitted to an ICU (15/48, 31%) or hospital floor (12/48, 25%). Operative intervention for a GU-related trauma was low (12/48, 25%). The most common GU organ injured was the kidney (36/48, 75%) however most were managed nonoperatively (33/36, 92%). Bladder injuries most often required operative intervention (6/7, 86%). Mortality following GU-related bicycle trauma was low (2/48, 4%).ConclusionsIn a large series of bicycle trauma, GU organs were injured in 3% of cases. The majority of cases were managed non-operatively and mortality was low.     

Epidemiology of spine trauma in an Irish regional trauma unit: a 4-year study

Currently there is a lack of information on the full spectrum of spine trauma presenting to medical services in a defined geographic area. This study analyses the aetiology and demographics of a cohort of spine trauma in the West of Ireland. A regional trauma unit has been investigated for a 51-month period. Two hundred and eighty-five cases admitted with spine trauma were documented. The annual incidence of traumatic spinal injury was 19.54 cases/100,000 persons per year. Falls and low-energy trauma are shown to constitute a significant proportion of all cases (60.35%). Injury at greater than one level is frequently present. The highest peak of injury occurred in the 20-24-year-old age group (11.58%). A second peak occurred at 75-79 years of age (7.37%). The commonest cause of neurological injury was falls (n=9; 64.3%). This spine trauma register has provided valuable insights into the patterns of injury encountered in spine trauma patients in this region. It may act as a blueprint for a national spine trauma register and highlights the importance of patient education and injury prevention strategies.     

Ultrasound detection of blunt urological trauma: a 6-year study

The objective of this study was to assess the utility of emergency ultrasonography in the detection of blunt urological injury. A retrospective review was conducted of all consecutive emergency blunt trauma ultrasonograms (US) obtained at a level I trauma centre from January 1995 to January 2001. Among the 4320 emergency ultrasonograms performed, 596 patients (14%) had intraabdominal injury and, of these, 99 patients (17%) had urological injuries. The sensitivity of ultrasound for all urological injuries was 67%, and specificity was 99.8%. For isolated urological injuries, sensitivity and specificity were 55.6 and 99.8%, respectively. Ultrasound was most accurate in the detection of grade III renal injuries, identifying 14/15 (93%), and 13 underwent laparotomy. For isolated urological injuries, 15 of 25 (60%) patients with a true-positive US underwent laparotomy compared to 3 of 20 (15%) with a false-negative US. Isolated urological injury was significantly associated with an ultrasonographic pattern of free fluid in the left upper quadrant and the left pericolic gutter (odds ratio=55.1; P<0.001), followed by isolated fluid in the left pericolic gutter (odds ratio=8.6; P=0.04). Although emergency ultrasonography is useful in the triage of patients with blunt urological trauma, it may miss significant urological injury requiring further intervention. As most renal injuries may be managed non-operatively, further studies such as contrast-enhanced CT or angiography should be obtained in the stable patient with suspected blunt urological injury.     

An ecological view of psychological trauma and trauma recovery

This paper presents an ecological view of psychological trauma and trauma recovery. Individual differences in posttraumatic response and recovery are the result of complex interactions among person, event, and environmental factors. These interactions define the interrelationship of individual and community and together may foster or impede individual recovery. The ecological model proposes a multidimensional definition of trauma recovery and suggests that the efficacy of trauma-focused interventions depends on the degree to which they enhance the person-community relationship and achieve ecological fit within individually varied recovery contexts. In attending to the social, cultural and political context of victimization and acknowledging that survivors of traumatic experiences may recover without benefit of clinical intervention, the model highlights the phenomenon of resiliency, and the relevance of community intervention efforts.     

Prehospital triage and survival of major trauma patients in a Dutch regional trauma system: relevance of trauma registry

Background and aims Since 1999, the Dutch trauma care has been regionalized into ten trauma systems. This study is the first to review such a trauma system. The aim was to examine the sensitivity of prehospital triage criteria [triage revised trauma score (T-RTS)] in identifying major trauma patients and to evaluate the current level of trauma care of a regionalized Dutch trauma system for major trauma patients.Patients and methods Major trauma patients (n=511) (June 2001–December 2003) were selected from a regional trauma registry database. The prehospital T-RTS was computed and standardized W scores (Ws) were generated to compare observed vs expected survival based on contemporary US- and UK-norm databases.Results The T-RTS showed low sensitivity for the prehospital identification of major trauma patients [34.1% (T-RTS≤10)]. Nevertheless, 78.0% of all major trauma patients were directly managed by the trauma center. These patients were more severely injured than their counterparts at non-trauma-center hospitals (p<0.001). No significant difference emerged between the mortality rates of both groups. The Ws {−0.46 calculated on the US model [95% confidence interval (CI) ranging from −1.99 to 1.07]} [0.60 calculated on the UK model (95% CI ranging from −1.25 to 2.44)] did not differ significantly from zero.Conclusion The trauma center managed most of the major trauma patients in the trauma system but the triage criteria need to be reconsidered. The level of care of the regional trauma system was shown to measure up to US and UK benchmarks.     

Role of the trauma nurse coordinator in Hong Kong

Background: Trauma is one of the leading causes of death for all ages in Hong Kong. In 2003, the Hospital Authority designated five hospitals as trauma centres. Five Trauma Nurse Coordinators (TNCs) were employed to facilitate multidisciplinary care and to coordinate all aspects of quality improvement for injured patients. The present paper investigates the characteristics and roles of TNCs in Hong Kong. Methods: A questionnaire was developed and sent to all TNCs in HK to ascertain information about demographic characteristics, education, job training, roles and the TNCs’ position within the organizational structure. Results: The TNCs were 30–40 years of age (four females); are experienced registered graduate nurses; hold post‐registration certificates or diplomas in emergency/critical care; and have 11–18 years nursing experience. All TNCs have pursued masters degrees, with two completed. Four of the TNCs had received formal training on computerized data management, abbreviated injury scale coding and trauma nurse coordination. TNCs averaged 2.5 years experience in their post. TNCs manage the trauma registry, are involved in clinical patient management, quality assurance activities, professional and public education and research. Conclusion: TNCs play an important role in trauma management in Hong Kong.     

A comparison of severely injured trauma patients admitted to level 1 trauma centres in Queensland and Germany

Background: The allocation of a trauma network in Queensland is still in the developmental phase. In a search for indicators to improve trauma care both locally as state‐wide, a study was carried out comparing trauma patients in Queensland to trauma patients in Germany, a country with 82.4 million inhabitants and a well‐established trauma system. Methods: Trauma patients ≥15 years of age, with an Injury Severity Score (ISS) ≥ 16 admitted to the Princess Alexandra Hospital (PAH) and to the 59 German hospitals participating in the Trauma Registry of the German Society for Trauma Surgery (DGU‐G) during the year 2005 were retrospectively identified and analysed. Results: Both cohorts are comparable when it comes to demographics and injury mechanism, but differ significantly in other important aspects. Striking is the low number of primary admitted patients in the PAH cohort: 58% versus 83% in the DGU‐G cohort. PAH patients were less physiologically deranged and less severely injured: ISS 25.2 ± 9.9 versus 29.9 ± 13.1 (P < 0.001). Subsequently, they less often needed surgery (61% versus 79%), ICU admission (49% versus 92%) and had a lower mortality: 9.8% versus 17.9% of the DGU‐G cohort. Conclusions: Relevant differences were the low number of primary admissions, the lesser severity of injuries, and the low mortality of the patients treated at the PAH. These differences are likely to be interrelated and Queensland's size and suboptimal organization of trauma care may have played an important role.     

Pancreatic trauma in children

Background/Purpose

The aim of this study was to determine the etiology, associated injuries, and outcome of children with pancreatic injuries.

Methods

A retrospective review was conducted of children under 16 years with pancreatic trauma admitted to the Children’s Hospital at Westmead (CHW) from January 1983 to September 2002. Deaths were reported to the New South Wales Paediatric Trauma Death Registry (State Registry) from January 1988 to September 2002.

Results

Sixty-five cases were identified: 46 patients were admitted to CHW, and 22 deaths were reported to the State Registry (including 3 deaths at CHW). The median age was 6 years (range, 1 to 14 years). Boys accounted for 60% (n = 40) of cases, decreasing to 50% (n = 11) of those that died. Motor vehicle injuries (MVI) were the most common mechanism, accounting for 40% of survivors and 77% of those who died. Children were restrained incorrectly in 48% of all cases and in 67% of those who died. Significantly more children who died had head, chest, and abdominal visceral injuries, compared with those who survived. Death occurred as a result of head injuries in 68%, with only 3 deaths directly attributed to pancreatico-duodenal injuries.

Conclusions

Pancreatic injuries remain uncommon in children. The most frequent mechanism was MVI, with incorrect use of passenger restraints an important contributing factor. Whereas mortality was mainly caused by other injuries, 3 deaths were directly attributable to pancreato-duodenal trauma.     

Military trauma training performed in a civilian trauma center

BACKGROUND: In 1996, Congress passed legislation requiring the Department of Defense to conduct trauma training in civilian hospitals. In September of 1998 an Army team composed of surgeons, nurses, emergency medical technicians (EMTs), and operating room technicians (OR techs) trained in a civilian level 1 trauma center. This study analyzes the quality of the training. METHODS: The training period was 30 days. Before and after training all members completed a questionnaire of their individual and team ability to perform at their home station, at the civilian hospital, and in the combat setting. Surgeons maintained an operative log, which was compared with their prior year's experience. Primary trauma cases (PTCs) met Residency Review Committee criteria as defined category cases and were done acutely. Other personnel tracked the percentage of supporting soldier tasks (SSTs) they performed or were exposed to during the training period. RESULTS: Review of the questionnaires revealed a significant increase in confidence levels in all areas tested (P < 0.005). The three general surgeons performed a total of 42 PTCs during the 28 call periods, or 1.5 PTCs per call period. During the prior year, the same three general surgeons performed 20 PTCs during 114 call periods for 0.175 cases per call period (P = 0.003). The maximum number of PTCs performed during one call period at the civilian center was 4, compared with 5 PTCs performed by one Army surgeon during the Somalia 1993 mass casualty event. Performance of or exposure to SSTs was 71% for the EMTs, 94% for the nurses, and 79% for the OR techs. CONCLUSIONS: A 1-month training experience at a civilian trauma center provided military general surgeons with a greater trauma experience than they receive in 1 year at their home station. Other personnel on the team benefited by performing or being exposed to their SSTs. Further training of military teams in civilian trauma centers should be investigated.     

Value of computed tomographic angiography in neck and extremity pediatric vascular trauma

Purpose

We sought to define the sensitivity and specificity of computed tomographic angiography (CTA) in pediatric vascular injuries.

Methods

All neck and extremity CTAs performed in pediatric patients at a level 1 trauma center were reviewed from 2001 to 2007.

Results

Overall, 78 patients were identified with an average age of 15.0 ± 4.0 (0-18 years). Males outnumbered females 3.6:1. CTA was performed for 41 penetrating and 37 blunt traumas. Most penetrating injuries were due to missile wounds (71%) or stab wounds (17%). Eleven major vascular injuries resulted from penetrating trauma. For penetrating trauma, CTA was 100% sensitive and 93% specific. CTA for penetrating trauma had a positive predictive value (PPV) of 85% and negative predictive value (NPV) of 100%. Most blunt injuries were due to motor vehicle accidents (57%), followed by pedestrian hit by car (27%). Eight major vascular injuries resulted from blunt trauma. For blunt trauma, CTA was 88% sensitive and 100% specific. CTA for blunt trauma had a PPV of 100% and an NPV of 97%. The accuracy for penetrating and blunt trauma was 95% and 97%, respectively.

Conclusions

CTA is highly sensitive, specific, and accurate for pediatric neck and extremity vascular trauma.     

Recall of traumatic memories following cerebral vascular accident

We present a case of delayed post-traumatic stress disorder (PTSD) in a WWII combat veteran who developed symptoms following medical retirement. Following a subsequent cerebral accident (CVA) Mr. J experienced intrusive thoughts, recalled forgotten war memories, began avoiding reminders of war (e.g., stopped teaching marksmanship), and experienced dissociative episodes in which he felt as though he was in hand-to-hand combat. Mr. J's example suggests that the disinhibiting sequelae of CVA's, and other neuropsychological deteriorations that are likely to occur with poor health and advancing age, may influence expression of PTSD symptoms.