Management of splenic injuries in a Canadian trauma centre

Objectives

To document the current practice pattern for the treatment of splenic injuries in one Canadian trauma centre and to identify factors that determined which method was employed.

Design

A cohort study.

Setting

A Canadian lead trauma centre.

Patients

A cohort of 100 patients with splenic injury treated at one trauma hospital over 5 years was identified from a prospective trauma database.

Main Outcome Measures

The success rate and failure rate for splenic salvage by splenectomy, splenorrhaphy or observation. Volume of blood transfused, injury severity score (ISS) and method of diagnosis.

Results

The median ISS for the cohort was 34 (36 for splenectomy, 38 for splenorrhaphy and 35 for observation). A blunt mechanism of injury was present in 96%. The diagnosis was made by computed tomography (CT) in 55%. Splenic salvage was accomplished in 51 patients; of these, 44 (86%) were in the observation group, and the success rate was 90% (within the range reported in the literature). Only seven patients underwent splenorrhaphy. CT was performed more frequently in the observation group than in the splenectomy group (82% v. 25%, p < 0.0001). The splenectomy group had more blood tranfused than the successful observation group (mean units 15 v. 3, p = 0.0001) and had a higher median ISS (36 v. 29, p = 0.02). Multivariate analysis revealed that the method of diagnosis (CT v. diagnostic peritoneal lavage) was the strongest factor associated with how the splenic injury was treated.

Conclusions

The finding in this report of an increase in observational treatment of splenic injuries represents a shift in practice from a previous Canadian report and is in keeping with recent published trends from the United States. Future studies are needed to assess whether any strong regional practice pattern variations in the management of blunt splenic injuries exists in other trauma centres across Canada.     

Is outcome worse in a small volume Canadian trauma centre?

The minimum number of seriously injured patients required to maintain clinical competence and achieve acceptable clinical competence in a single trauma centre is unknown. It has been suggested that the probability of survival is improved in hospitals treating greater than 200 trauma patients annually. We sought to determine if probability of survival was lower in our small volume centre. Between 1986 and 1989, 752 (522 male, 230 female; average age, 36 years) trauma patients were admitted to our institution. The major mechanism of injury was blunt (89%). All patients underwent trauma severity scoring. Trauma Score, Injury Severity Score, and a Revised Trauma Score were used to derived the probability of survival by the TRISS method. The mean Injury Severity Score was 23.3 and the mean Trauma Score was 13.2. The overall mortality rate was 15.8%. The Z statistic demonstrated no significant difference between actual and predicted deaths for the 4-year period or for any individual year (range, -1.05 to 1.26, p greater than 0.05). The M statistic was 0.753. We conclude that, despite fewer trauma patient admissions (less than 200 per year), comparable clinical results can be achieved by surgeons dedicated to trauma management.     

Paediatric trauma at an adult trauma centre

BACKGROUND: Trauma in children remains the commonest cause of mortality. The majority of injured children who reach hospital survive, indicating that additional more sensitive outcome measures should be utilized to evaluate paediatric trauma care, including morbidity and missed injury rates. Limited contemporary data have been presented reviewing the care of injured children at an adult trauma centre (ATC). METHODS: A review was undertaken of injured children who warranted activation of the trauma team, treated within the emergency department of an ATC (Royal North Shore Hospital) situated in the Lower North Shore area of Sydney. Data were collected prospectively and patients followed through to death or discharge from the ATC or another institution to which they had been transferred. RESULTS: A total of 93 children were admitted to the ATC between January 1999 and April 2002. Mean age was 9 years 3 months (range 5 weeks-15 years 9 months) and 70% were male. The median injury severity score was 15 (range 1-75) and there were three deaths. Forty-two children were transferred to a paediatric trauma centre (PTC), including three children who had been transferred to the ATC from another hospital. There was one missed injury and one iatrogenic urethral injury. CONCLUSIONS: The majority of children with trauma were treated safely and appropriately at the ATC. The missed injury rate was < 1% and there were no adverse long-term sequelae of initial treatment. Three secondary transfers could have been avoided by more appropriate coordination of the initial referral to a PTC.     

A comparison of fasciotomy wound closure methods following extremity compartment syndrome at a regional trauma centre

Background

Extremity fasciotomy wound closure following acute compartment syndrome is often prohibited by residual swelling, producing wounds that significantly contribute to patient morbidity. The aim of this study was to assess patient and fasciotomy wound outcomes associated with dynamic closure (DYN), delayed primary closure (DPS) and split skin grafting (SSG) techniques.

Methods

A retrospective review of all trauma-related compartment syndrome patients managed between January 2000 and March 2010 was conducted, and a comprehensive patient and wound outcomes analysis was performed.

Results

DYN was employed in 109 wounds, DPS in 66 wounds and SSG in 7 wounds. DPS wounds achieved closure in a significantly shorter timescale than other methods (p?=?<0.05). DYN and SSG group wound closure times were comparable; however, SSG techniques were employed later post-fasciotomy. SSG patients had longer hospital stays (p?=?<0.05) and the lowest wound complication rate (0 %). Wound complication rates were significantly higher in the DYN (55 %) and DPS groups (15 %) (p?=?<0.05), and these wounds required a higher number of further surgical procedures. The need for repeated wound debridements was higher in the DYN group than any other (p?=?<0.05).

Conclusions

DPS provided the fastest method of fasciotomy wound closure and the shortest inpatient stay. DYN techniques were associated with higher wound complication rates and the need for further surgical procedures. SSG techniques were associated with low complication rates and fewer surgical procedures and, if applied earlier, could result in shorter inpatient stay.Level of evidence IV, therapeutic study.

     

Population-based prediction of trauma volumes at a Level 1 trauma centre

Objective: With an ageing US population, the demographics of traumatic injuries are being significantly altered. Census projections predict that the number of Americans over age 65 will double in the next 20 years. We used stochastic methods to forecast trauma admissions in order to predict the effects of such demographic changes at our trauma centre.

Methods: Age- and sex-related rates of traumatic admission were determined using population statistics and trauma registry data from 1994 to 1999. These rates were then projected from 2000 to 2025 based on both the Lee–Carter and random walk with drift methods. Stochastic population projections were made and paired with the projected trauma rates, allowing estimation of total trauma volume.

Results: Trauma rates were predicted to increase for most age groups. Trauma admissions are predicted to increase 57% by 2024. By 2019, 50% of trauma admissions will be 60 or older.

Conclusions: Our trauma volume is expected to increase 57% by 2024, an increase of 2% per year. More of this volume will consist of elderly patients, potentially requiring increased health-care resources.     

Outcomes of orthopaedic trauma patients undergoing surgery during the peak period of COVID-19 infection at a UK major trauma centre

BackgroundTo review the clinical outcomes of all patients undergoing emergency orthopaedic trauma surgery at a UK major trauma centre during the first 6 weeks of the COVID-19 related lockdown.MethodsA retrospective review was performed of all patients who underwent emergency orthopaedic trauma surgery at a single urban major trauma centre over the first six-week period of national lockdown. Demographics, co-morbidities, injuries, injury severity scores, surgery, COVID-19 status, complications and mortalities were analysed.ResultsA total of 76 patients were included for review who underwent multiple procedures. Significant co-morbidity was present in 72%. The overall COVID-19 infection rate of the study population at any time was 22%. Sub-group analysis indicated 13% had active COVID-19 at the time of surgery. Only 4% of patients developed COVID-19 post surgery with no mortalities in this sub-group. The overall mortality rate was 4%. The overall complication rate was 14%. However mortality and complications rates were higher if the patients had active COVID-19 at surgery, if they were over 70 years and had sustained life-threatening injuries.ConclusionThe overall survival rate for patients undergoing emergency orthopaedic trauma surgery during the COVID-19 peak was 96%. The rate of any complication was more significant in those presenting with active COVID-19 infections who had sustained potentially life threatening injuries and were over 70 years of age. Conversely those without active COVID-19 infection and who lacked significant co-morbidities experienced a lower complication and mortality rate.     

Epidemiology of patients admitted to a major trauma centre in northern India

Objective： Trauma in India is an increasingly significant problem, particularly in light of rapid development and increasing motorization. Social changes are resulting in alterations in the epidemiology of trauma. The aim of the study was to assess the various epidemiological parameters that influence the cause of injury in the patients admitted to a major trauma centre in northem India. Methods： An observational study of 748 patients chosen by random assortment was carried out over a peri- od of 1 year （August 2008 to July 2009）. Age, sex, injury type and pattern were noted. Injury mode of upper and lower limbs was also noted. Results： Injuries occur predominately in the age group of 15-30 years. Males incurred more injury with male to female ratio of 6：1. The most vulnerable group was motorcycle users. Among the injured, farmers were the most commonly involved. Blunt injuries （94.92%） were much more common than penetrating injuries. Among patients with head injury, two wheelers related accidents were the most common （40.3%）. Most spinal cord injuries were caused by falls from height （51.09%）. Most lower limb fractures were simple type. Compound fractures of the lower limb were more common than up- per limb fractures. Conclusion： Strict enforcement of traffic rules, combined with improved infrastructure and behavior change can decrease the burden of road traffic accidents in India and other developing countries. This study could assist in raising the profile of road traffic accidents as a public health problem which needs to be addressed as a preventable cause of mortality and morbidity, and plan- ning appropriate interventions for this major challenge. Preventive strategies should be made on the basis of these epidemiological trends.     

Penetrating neck injuries: analysis of experience from a Canadian trauma centre.

OBJECTIVE: To study the demographics and treatment outcome of penetrating neck injuries presenting to a major trauma centre in order to develop a treatment protocol. DESIGN: A case review. SETTING: A trauma centre at a tertiary care institution. PATIENTS: One hundred and thirty consecutive patients who had 134 neck wounds penetrating the platysma and presented to the trauma service between 1979 and 1997. INTERVENTION: Surgical exploration or observation alone. MAIN OUTCOME MEASURES: The location of injury, patient management, number of significant injuries, duration of hospital stay and outcome. RESULTS: Injuries were caused by stab wounds in 124 patients (95%) and gunshot wounds in 6 (5%). The location of injury was zone I (lower neck) in 20 cases (15%), zone II (midportion of the neck) in 108 (81%) and zone III (upper neck) in 5 (4%). The location was not recorded in 1 case. Fifty patients were managed by observation alone and 80 were managed surgically. Neck exploration in 48 asymptomatic patients was negative in 32 (67%). Significant injuries, including major vascular (12), nerve (13) and aerodigestive tract (19) injuries, were identified in 34 patients. Two of the 130 patients (1.5%) died of major vascular injuries. Seventy-six percent of significant injuries, including all zone II major vascular injuries, were symptomatic on presentation. The mean (and standard deviation) hospital stay for asymptomatic patients treated with observation alone and surgical exploration was similar (3.5 [6.02] versus 4.3 [5.46] days respectively, p = 0.575). Long-term disability, all neurologic in nature, was documented in 3 patients managed by observation alone and 6 patients managed by surgical exploration. CONCLUSIONS: Penetrating neck trauma, in particular stab wounds to zone II in asymptomatic patients, is associated with low morbidity and mortality. A selective management protocol with investigations directed by symptoms is the most appropriate approach for the patient population and resource base in this setting.     

The hospital cost of road traffic accidents at a South African regional trauma centre: A micro-costing study

Background

Road traffic crashes are responsible for a vast amount of death and disability in developing countries. This study uses a bottom up, micro-costing approach to determine the cost of road traffic related crashes in South Africa.

Methods

Using the data from one hundred consecutive RTC related admissions to a regional hospital in South Africa we performed a bottom up costing study. To calculate costs patients were reviewed every 48 h and all interventions were recorded for each individual patient. Prices of interventions were obtained from hospital pricelists. A total cost was calculated on an individual basis.

Results

The total cost of in-patient care for these patients was US $6,98,850. Upper limb injuries were the most expensive, and the total cost increased with the number of body regions injured. The biggest expenditure was on ward overheads ($2,81,681). Ninety operations were performed – the total cost of theatre time was $1,48,230 and the cost of orthopaedic implants was $1,26,487.

Conclusion

The cost of care of a RTC victim is significant. In light of the high numbers of RTC victims admitted over the course of the year this is a significant cost burden for a regional hospital to bear. This cost must be taken into account when allocating hospital budgets.     

Aldosteronism after severe trauma

Ten severely injured patients treated in an intensive care unit were investigated for secondary hyperaldosteronism. An increase in plasma aldosterone level was regularly found after trauma. Peak values, 253.3 +/- 196.0 ng/l, were registered immediately after admission to the hospital. The aldosterone concentrations then fell to 180.0 +/- 193.0 ng/l on the first day and 97.2 +/- 73.8 ng/l on the second day after the trauma. The reaction subsided within three days and subsequently plasma aldosterone concentrations remained within normal limits. Plasma renin concentrations were within normal limits during the eight post-traumatic days. High initial aldosterone values were recorded, especially in the thermally burned patients. In one case sodium depletion caused a prolonged secondary increase in the plasma aldosterone level.     

Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre

AimsOngoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes.MethodsA total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure.ResultsFixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double.ConclusionThis study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.     

The epidemiology of BCVI at a single state trauma centre

Background

Blunt carotid and vertebral artery injury (BCVI) is a relatively uncommon but potentially devastating injury. The aim of our study was to highlight the incidence, patterns, presentation and associations of BCVI at our institution.

Methods

Retrospective data between 1st January 2003 and 31st December 2006 was obtained from The Alfred Hospital's health information system, patient medical records and the Department of Neurosurgery's database. Injuries were graded using the Denver grading scale.

Results

67 patients (0.64%) out of 10,417 minor and major trauma admissions, were diagnosed with BCVI. 33 (49%) sustained blunt carotid and 34 (51%) sustained blunt vertebral injuries. Motor vehicle accident (MVA) was the cause in 43 out of 67. 35% had associated head injury whilst 57% had concurrent cervical spine fractures. Odds ratio analysis showed that MVA victims with concomitant upper cervical spine injury were 22.9 times more likely to suffer BCVI than those without such risk factors. Approximately 50% of patients had a Glasgow coma score of 14 or less (GCS ≤ 14). Grade 4 BCVI was most common. Stroke occurred in 22 (32%) and mortality in 14 (20%).

Conclusion

BCVI although infrequent, is a serious injury. Our study suggests that MVA patients with cervical spine fractures especially of the upper C-spine are at much higher risk of BCVI than those without such injuries.