Adherence to National Burn Care Review referral criteria in a paediatric Emergency Department

Introduction

The National Burn Care Review (NBCR) gives guidance on the recognition of potentially complex burns requiring assessment and management in a burn unit. This guidance provides a referral framework for those initiating assessment and management of burns. The effect of close adherence to NBCR guidance on workload is at present unknown.

Objectives

To audit referral patterns of burns in our paediatric Emergency Department (ED) in comparison to NBCR referral criteria. To identify the type of injuries not referred despite meeting criteria, and their outcomes, to assess whether these patients come to any harm short-term. To estimate the effect that closer adherence would have on workload and how our unit proposes to work with the ED to improve its distribution and our patients care.

Methods

A retrospective case-note audit of patients presenting to a paediatric ED with a triage diagnosis of “burn/scald” over a 6-month period between 1st April and 29th September 2008.

Results

190 patients presented with burns during this period, of which 126 (66%) had potentially complex burns. Of these, 93 (74%) were not referred to the burns unit i.e. were “under-referred”. In this group burns to specialized areas in patients under 5 years of age were particularly prevalent. 78 (84%) were reviewed in the ED and received no specialist input. Seven patients suffered minor complications. Only three of these patients (3.2%) required subsequent referral to the burns unit for opinion. None required any further specialist intervention.

Conclusion

Strict adherence to NBCR referral criteria could result in a significant increase in workload for regional burn units with as yet unquantifiable benefit in patient outcomes. Many minor injuries appear to be safely managed in the ED with little adverse outcome. Even small improvements in practice could result in a considerable workload increase for a burns unit. Further prospective research is required, particularly looking at longer-term outcomes. We are hoping to improve educational and clinical links between our EDs and burn unit to improve patient care and distribution of clinical workload. Further national guidance maybe necessary.     

Clinical efficacy and cost effectiveness of intraoperative cell salvage in pelvic trauma surgery

Introduction

Pelvic acetabular injuries are associated with significant blood loss. This is compounded by multiple surgical interventions including definitive fracture fixation, which put patients at further risk of postoperative transfusion. We use intraoperative cell salvage routinely as a blood conservation strategy to address this issue. This is a prospective evaluation of the clinical efficacy and cost effectiveness of using intraoperative cell salvage in patients with pelvic acetabular injuries.

Methods

Data were collected prospectively for all the patients who underwent pelvic acetabular fracture fixation at our institution. A total of 30 patients (25 men, 5 women) with a mean age of 41 years (range: 31–79 years) were assessed over a period of 10 months.

Results

The mean preoperative and postoperative haemoglobin levels were 11.8g/dl and 9.9g/dl respectively. The mean intraoperative blood loss was 1,232.5ml (range: 150–2,693ml). The mean amount of blood salvaged and retransfused through a cell saver was 388ml. Of the 30 patients, 14 (47%) required transfusion after surgery and 26 units of blood were transfused. In terms of cost effectiveness, a total of £2,572 in 30 patients or £86 per patient were saved.

Conclusions

We found intraoperative cell salvage to be clinically efficacious and cost effective in patients with pelvic acetabular injuries.     

Acute total hip replacement for acetabular fractures: A systematic review of the literature

Introduction

Immediate total hip replacement (THR) in patients with acetabular fractures is controversial because of concerns about high complication rates. The current article is a systematic review of the literature on the use of acute THR for the treatment of acetabular fractures.

Materials and methods

This systematic review included studies published in English between 1992 and 2012 of subjects with acetabular fracture undergoing immediate THR. Outcomes of interest included indications; clinical assessment, including walking ability; comparison with control group; associated procedures, and rate of complications, such as loosening or revision surgery.

Results

This review identified six studies, of which only one included a control group. Acute THR was associated with satisfying outcomes with regard to clinical assessment and walking ability. The comparative study assessed the difference between acute THR and delayed THR in acetabular fractures: improved outcomes were observed in the delayed THR group, although the differences between the two groups were not statistically significant.

Discussion

According to data reported in the literature, acute primary THR can be successful in patients with poor bone quality, combined acetabular and femoral neck fractures, or pathological fractures and concurrent osteoarthritis of the hip. Relative indications include old age, delayed presentation, substantial medical comorbidities, and pathologic obesity. Clinical outcomes with acute THR were similar to those with delayed THR. Although the results reported in the six studies reviewed here were satisfying overall, there is limited evidence in this area in the existing literature and future prospective investigations are required.

Conclusion

Data reported in the literature indicate that immediate THR can be successful in appropriately selected elderly patients or patients with extensive osteoporosis, combined acetabular and femoral neck fractures or pathological fractures. There is currently a limited evidence base for THR in patients with acetabular fractures; therefore, physicians’ practice and expertise are the most useful tools in clinical practice.     

Acetabular fractures before and after the introduction of seatbelt legislation

Objectives

To compare the incidence and severity of acetabular fractures and associated injuries before and after seatbelt legislation.

Design

A retrospective study.

Setting

Two major trauma centres, which are teaching hospitals.

Patients

Three hundred and ninety-three patients who sustained acetabular fractures during the 5 years before and 5 years after seatbelt legislation was enacted. Of these, the fractures in 198 patients (50.4%) resulted from a motor vehicle accident.

Main Outcome Measures

The number and severity of acetabular fractures and associated injuries.

Results

There has been a significant reduction in the number of acetabular fractures (p = 0.005) since seatbelt use became mandatory, and the complexity of the fractures has decreased. There has also been a marked reduction in associated injuries, such as fractures of other bones, and head, chest and abdominal injuries (p < 0.001).

Conclusion

The seatbelt law has been a useful preventive measure, resulting in a reduction in the incidence of acetabular fractures and associated injuries.     

Gunshot wounds to the spine in post-Katrina New Orleans

Background

Gunshot wounds (GSW) to the spine represent a major health concern within today's society. Our study assessed the epidemiologic characteristics of patients with GSW to the spine treated in New Orleans.

Patients and methods

A retrospective chart review was performed from January 2007 through November 2011 on all the patients who were seen in the emergency room and diagnosed with a gunshot wound to the spine. Epidemiologic factors, as well as the results of admission toxicology screening, were noted. Outcome analysis was performed on patients undergoing conservative versus operative management for their injuries. Clinical outcomes were assessed using the ASIA classification system. Complications related to initial injury, neurosurgical procedures, and hospital stay were noted.

Results

A total of 147 patients were enrolled. Of those diagnosed with a GSW to the spine, 88 (59.8%) received an admission toxicology screen. Seventy-three (83%) patients out of those tested had a positive screen, with the most common substances detected being cannabis, cocaine, and alcohol. In regards to management, 127 (87%) patients were treated conservatively and only one (0.7%) patient improved clinically from ASIA D to E. Of the 20 patients who underwent surgery, one (5%) patient had clinical improvement post-operatively from ASIA C to D.

Conclusions

This study evaluates the largest number of patients with GSW to the spine per year treated in a single centre, illustrating the violent nature of New Orleans. In this urban population, there was a clear correlation between drug use and suffering a GSW to the spine. Surgical intervention was seldom indicated in these patients and was predominately used for fixation of unstable fractures and decompression of compressive injuries, particularly below T11. Minimally invasive techniques were used successfully at our institution to minimize the risk of post-operative CSF leak.     

Low energy fractures of the acetabulum

Introduction

Acetabular fractures due to high energy injuries are common and well documented; those secondary to low energy mechanisms are less well described. We undertook a retrospective study of the acetabular fracture referrals to our unit to evaluate the proportion of injuries resulting from a low energy mechanism.

Methods

A total of 573 acetabular fractures were evaluated from 1 January 2005 to 31 December 2008. The plain radiography and computed tomography of those sustaining a low energy fracture were assessed and the fracture patterns classified.

Results

Of the 573 acetabular fractures, 71 (12.4%) were recorded as being a result of a low energy mechanism. The male-to-female ratio was 2.4:1 and the mean patient age was 67.0 years (standard deviation: 19.1 years). There was a significantly higher number of fractures (p<0.001) involving the anterior column (with or without a posterior hemitransverse component) than in a number of previously conducted large acetabular fracture studies.

Conclusions

Our results demonstrate that low energy fractures make up a considerable proportion of acetabular fractures with a distinctly different fracture pattern distribution. With the continued predicted rise in the incidence of osteoporosis, life expectancy and an aging population, it is likely that this type of fracture will become increasingly more common, posing difficult management decisions and leading to procedures that are technically more challenging.     

Analysis of usage and associated cost of external fixators at an urban level 1 trauma centre

Objective

To determine the usage, indication, duration, and cost associated with external fixation usage. Additionally, to show the significant cost associated with external fixator use and reinvigorate discussions on external fixator reuse.

Design, setting, and patients

A retrospective review of a prospectively gathered trauma database was undertaken to identify all patients treated with external fixation frames for pelvic and lower extremity injuries between September 2007 and July 2010.

Main outcome and measures

We noted the indications for frame use, and we determined the average duration of external fixation for each indication. The cost of each frame was calculated from implant records.

Results

341 lower extremity and pelvic fractures were treated with external fixation frames during the study period. Of these, 92% were used as temporary external fixation. The average duration of temporary external fixation was 10.5 days. The cost of external fixation frame components was $670,805 per year. The average cost per external fixation frame was $5900.

Conclusions

The majority of external fixators are intended as temporary frames, in place for a limited period of time prior to definitive fixation of skeletal injuries. As such, most frames are not intended to withstand physiologic loads, nor are they expected provide a precise maintenance of reduction. Given the considerable expense associated with external fixation frame components, the practice of purchasing external fixation frame components as disposable “single-use” items appears to be somewhat wasteful.

Level of evidence

Level II.     

Assessment of medical resource utilization for Taiwanese children hospitalized for intracranial injuries

Background

Compared to adults, children and adolescents are at greater risk for traumatic brain injury (TBI), with increased severity and prolonged recovery when compared to adults. It is a challenge to provide care for those children who are at risk for complications of TBI under health care resource constraints.

Aim

To investigate hospitalization among children with intracranial injuries in terms of incidence and factors related to length of stay (LOS) and medical cost.

Methods

Data from the National Health Insurance Research Database from 2007–2009 were used. In total 8632 children aged <=18 years with acute traumatic intracranial injuries caused by accidents were discharged from hospitals in Taiwan. The associations between patient and hospital covariates (e.g., age, gender, accreditation level of hospital, surgical intervention, and number of comorbid conditions) and log-transferred hospitalization cost and length of stay (LOS) were examined with multivariable regression analysis and mediation analyses.

Results

The incidence rate of hospitalization for acute intracranial injury was 63.3/100,000 per year. Motor vehicle crashes and falls accounted for 63.5% and 23.8% of intracranial injuries, respectively. The mean LOS for children was 5.0 days (median, 3 days), incurring a mean direct medical cost of $US 916.70 (median, $356.2). Boy sustained more injury (64.1%) and greater medicals cost ($965) occurred in boys. Patients with subarachnoid subdural and extradural haemorrhage tended to have a longer LOS and incur greater medical costs. Surgical intervention and type of healthcare institution were also significant predictors for medical costs. Additionally, LOS was the dominant mediator for the relationship between predictor and medical cost.

Conclusions

Acute intracranial injuries among children incur a substantial health care burden. Therefore, health authorities need to optimally allocate medical resources in care.     

Modified Kocher-Langenbeck approach in combined surgical exposures for acetabular fractures management

Background:

Displaced fractures of the acetabulum are best treated with anatomical reduction and rigid internal fixation. Adequate visualization of some acetabular fracture types may necessitate extensile or combined anterior and posterior approaches. Simultaneous anterior iliofemoral and posterior Kocher-Langenbeck (K-L) exposures with two surgical teams have also been described. To assess whether modified Kocher-Langenbeck (K-L) approach can substitute standard K-L approach in the management of elementary acetabular fractures other than the anterior wall and anterior column fractures and complement anterior surgical approaches in the management of complex acetabular fractures.

Materials and Methods:

20 patients with transverse and associated acetabular fractures requiring posterior exposure were included in this prospective study. In 9 cases (7 transverse, 1 transverse with posterior wall, and 1 posterior column with posterior wall), stabilization was done through modified K-L approach. In 11 cases (3 transverse and 8 associated fractures), initial stabilization through iliofemoral approach was followed by modified K-L approach.

Results:

The average operative time was 183 min for combined approach and 84 min for modified K-L approach. The postoperative reduction was anatomical in 17 patients and imperfect in 3 patients. The radiological outcome was excellent in 15, good in 4, and poor in one patient. The clinical outcome was excellent in 15, good in 3 and fair and poor in 1 each according to modified Merle d’Aubigne and Postel scoring system.

Conclusion:

We believe that modified K-L approach may be a good alternative for the standard K-L approach in the management of elementary fractures and associated fractures of the acetabulum when combined with an anterior surgical approach. It makes the procedure less invasive, shortens the operative time, minimizes blood loss and overcomes the exhaustion and fatigue of the surgical team.     

Retroperitoneal pelvic packing for haemodynamically unstable pelvic fractures in children and adolescents: A level-one trauma-centre experience

Purpose

This study aims to review the outcomes of haemodynamically unstable paediatric patients with pelvic fractures undergoing protocol intervention of retroperitoneal pelvic packing (RPP) with external fixation and angiography.

Methods

From 2004 to 2011, consecutive patients younger than 19 years treated in our centre for haemodynamically unstable pelvic fractures were retrospectively reviewed. From 2008, protocol intervention triad of external fixation, RPP, and angiography with embolization was implemented.

Results

Before 2008, only 2 boys with fall injuries received intervention. One received initial angiography showing extravasation near iliac bifurcation. Laparotomy proceeded without embolization for multiple visceral injuries, but he succumbed postoperatively. The other had persistent bleeding after external fixation but became stabilized after embolization. After 2008 protocol implementation, 5 youngsters received the triad of interventions for unstable pelvic fractures. Mean age was 15.4 yrs. The mean injury severity score was 42 (18–66) with 62.5% mean probability of survival (6.8–98.8%). The mean operating time for RPP was 23 mins (20–35 mins). One boy died of rapid exanguination intraoperatively. The other 4 youngsters recovered for rehabilitation.

Conclusion

Fall from heights is a major cause for severe pelvic injuries in our locality. RPP is a simple effective procedure to include in protocol intervention for pelvic fractures. This case series suggests it helps improve haemostasis and survival in unstable young patients, although larger cohorts will be necessary to validate this.     

Contemporary Referral Pattern for Robotic Prostatectomy

Background and Objectives:

In spite of the current widespread application of robotic surgery in the treatment of prostate cancer, it remains unclear whether current patterns of use are based on patient benefit or driven by marketing. We sought to investigate this possibility by analyzing the source of our patient population for robot-assisted laparoscopic prostatectomy (RALP).

Methods:

We reviewed 200 consecutive patients who underwent robotic prostatectomy by a single surgeon (RA) at our institution. The source of referral for each patient was analyzed along with individual patient characteristics to identify whether only low-risk or unusually ideal candidates were referred.

Results:

Of the 200 patients, 90.5% were referred by a urologist with only 5.5% being referred by another urologist at our institution. Only 10 patients cited media or marketing sources as the reason for self-referral, and <10 were referred by primary care physicians or other acquaintances. This referral pattern did not change between the first and second 100 patients. Referred patients included those up to 80 years of age, up to 51kg/m² in body mass index, and up to Gleason 9 on biopsy, with 36% of those referred by urologists having some history of previous abdominal or prostate surgery.

Conclusion:

The referral pattern for RALP at our institution may reflect a growing acceptance of robotic surgery among urologists in our region and is unlikely driven by patient-directed marketing. Additionally, urologists may also be more confident in the role of RALP as evidenced by their referral of even complex and higher-risk patients.     

Technique of laparoscopic-assisted total proctocolectomy and ileal pouch anal anastomosis in children and adolescents: a single center's 8-year experience

Background

Laparoscopic techniques have been applied to restorative proctocolectomy since the early 2000s. We have employed a technique for laparoscopic-assisted total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) for the treatment of children with ulcerative colitis (UC).

Methods

A total of 68 children underwent laparoscopic-assisted TPCs at our institution from June 2003 to February 2011. The patients ranged from 5 to 22 years of age. We progressively modified our surgical approach in positioning, equipment use, and operative technique.

Results

A total of 68 children underwent laparoscopic-assisted TPC within the 8-year time period. Two major complications occurred (2/68 = 3%) consisting of 1 duodenal injury and 1 small bowel injury. There were 6 minor complications (6/68 = 9%), including 5 stoma revisions and 1 port site hernia. There were no superficial wound infections. There were no reported cases of pouch fistulas, anastomotic breakdown, or neurovascular injuries.

Conclusions

Our surgical technique is safe and effective in treating children with UC.     

Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

Introduction

Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation.

Methods

This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients.

Results

The average time to operation was 4 days. Average blood loss was 110 mL. Operative time averaged 95 min. Maximum fracture displacement averaged 10 mm preoperatively and 1.3 mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d’Aubigné score, functional outcome was good to excellent in all patients.

Discussion and conclusion

Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures.     

Fractures of the posterior wall of the acetabulum: Treatment using internal fixation of two parallel reconstruction plates

Objectives

Our aim was to evaluate the efficacy of the treatment method using internal fixation of parallel reconstruction plates for the posterior wall of the acetabulum fractures.

Design

Randomised, prospective.

Setting

Level I trauma centre. Patients/participants: 57 patients with posterior wall fractures of the acetabulum in our department from 2007 to 2010 were treated operatively using this technique. Intervention: internal fixation of two parallel reconstruction plates was used in this study. One of the plates was near the border of acetabulum. The other was parallel to the former one and was located to stress concentrated area. Main outcome measurements: The clinical outcome was evaluated using the clinical grading system and radiological outcome was evaluated according to the criteria described by Matta. In addition, complications were researched in this study.

Results

The percentages of the clinical excellent-to-good and fair-to-poor results were 93.0% and 7%, respectively. We found that clinical outcome had no correlation with age, operation time from injury to operation, nor had correlation with hip dislocation, comminuted fracture condition and marginal compression fracture. Anatomical reduction was significantly correlated with excellent-to-good clinical outcome. Necrosis of the femoral head and heterotopic ossification were prone to decline the outcome of acetabular fractures despite good fracture reduction.

Conclusions

the internal fixation of two parallel reconstruction plates facilitated rigid fixation and avoided fracture fragment injury, was an effective and reliable alternative method to treat fractures of the posterior wall of the acetabulum.     

Critical review of pelvic fractures associated with external iliac artery lesion: A series of six cases

Introduction

Bleeding associated with pelvic fracture mostly comes from the pre-sacral and lumbar venous plexus, or directly from the fracture site. Bleeding as a consequence of arterial lesion is less common (15–20%), and that resulting from lesion of the external iliac artery (EIA) is extremely rare. The mortality rate associated with iliac artery injury ranges from 38% to 72%. Total body CT-scan with contrast medium, angiography or packing can be performed when there is arterial injury. In some cases, embolisation can stop bleeding; however, when there is involvement of the aorta, common iliac artery or EIA, immediate surgery is mandatory. The aim of this study was to report our experience of pelvic fractures associated with EIA lesion.

Materials and methods

Six patients with pelvic fracture and associated rupture of the EIA have been observed at our unit from 2004 to 2009. According to Tile classification there were three cases of type C and two cases of type B fracture. One case was a two-column acetabular fracture. Angiography was performed in all cases.

Results

Three patients died on the day of trauma: two after angiography, and one after surgery of vascular repair. Three patients survived: two underwent a hemipelvectomy, and one underwent hip disarticulation.

Discussion

Haemodynamic instability in patients with pelvic ring fracture is usually because of venous bleeding from the pre-sacral and lumbar plexus, or from the fracture site. Arterial injury is present in around 20% of cases. EIA lesions require immediate surgical treatment to restore blood flow. Depending on the type of injury, vascular surgery can be associated with pelvic fracture stabilisation.

Conclusions

Pelvic ring fracture associated with an EIA lesion is extremely rare, with few cases reported in the literature. Angiography is used for diagnosis, and immediate surgical treatment is required to restore blood flow. Associated injuries and open fracture can lead to fatal complications or amputation. Rates of mortality and severe disability are extremely high.     

A systematic review of the features that indicate intentional scalds in children

Background

Most intentional burns are scalds, and distinguishing these from unintentional causes is challenging.

Aim

To conduct a systematic review to identify distinguishing features of intentional and unintentional scalds.

Methods

We performed an all language literature search of 12 databases1950–2006. Studies were reviewed by two paediatric/burns specialists, using standardised methodology. Included: Primary studies of validated intentional or accidental scalds in children 0–18 years and ranked by confirmation of intentional or unintentional origin. Excluded: neglectful scalds; management or complications; studies of mixed burn type or mixed adult and child data.

Results

258 studies were reviewed, and 26 included. Five comparative studies ranked highly for confirmation of intentional/unintentional cause of injury. The distinguishing characteristics were defined based on best evidence. Intentional scalds were commonly immersion injuries, caused by hot tap water, affecting the extremities, buttocks or perineum or both. The scalds were symmetrical with clear upper margins, and associated with old fractures and unrelated injuries. Unintentional scalds were more commonly due to spill injuries of other hot liquids, affecting the upper body with irregular margins and depth.

Conclusions

We propose an evidence based triage tool to aid in distinguishing intentional from unintentional scalds, requiring prospective validation.     

Interhospital transfer of blunt multiply injured patients to a level 1 trauma center does not adversely affect outcome

Background

Stops at nontrauma centers for severely injured patients are thought to increase deaths and costs, potentially because of unnecessary imaging and indecisive/delayed care of traumatic brain injuries (TBIs).

Methods

We studied 754 consecutive blunt trauma patients with an Injury Severity Score greater than 20 with an emphasis on 212 patients who received care at other sites en route to our level 1 trauma center.

Results

Referred patients were older, more often women, and had more severe TBI (all P < .05). After correction for age, sex, and injury pattern, there was no difference in the type of TBI, Glasgow Coma Scale (GCS) upon arrival at the trauma center, or overall mortality between referred and directly admitted patients. GCS at the outside institution did not influence promptness of transfer.

Conclusions

Interhospital transfer does not affect the outcome of blunt trauma patients. However, the unnecessarily prolonged stay of low GCS patients in hospitals lacking neurosurgical care is inappropriate.