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.     

Duodenal trauma: experience of a trauma center

In the past decade 93 patients with duodenal injury were treated at a trauma center. By chart review, the age, sex, mechanism of injury, time to initial exploration (and the reason for delay), laboratory results, associated injury, extent of duodenal injury, operative repair, use of drains and tube decompression, morbidity, and cause of death were tabulated in order to improve management of these injuries. Of 87 patients surviving until the time of operative repair 73% required no repair (four) or primary closure (59). The remainder had either resection with primary anastomosis (ten), diverticulization (12), or pancreaticoduodenectomy (two). All patients with penetrating trauma were immediately explored. Patients with blunt trauma were explored on the basis of the judgment of house staff and faculty. Overall mortality was 18%. Significant morbidity occurred in 49% of survivors. This urban experience was heavily weighted toward penetrating injury. In this group early death usually resulted from associated vascular injuries. Blunt duodenal injury was less frequently associated with immediate exsanguination. Mortality associated with blunt duodenal injury was usually the result of delayed diagnosis. In blunt duodenal trauma peritoneal lavage is not diagnostic and may often be misleading; in this series 50% of lavages were false negatives. Blunt duodenal trauma, particularly when combined with pancreatic injury or delayed repair, was a lethal combination. A high index of suspicion and aggressive diagnostic evaluation (CT contrast study/amylase) in the emergency department is required in equivocal cases to avoid morbidity and mortality.     

Delivering trauma mastery with an international trauma masters

IntroductionTrauma is a global problem. The goal of optimising multidisciplinary trauma care through speciality education is a challenge. No single pathway exists to educate care providers in trauma knowledge, management and skills.Queen Mary University of London (QMUL) devised an online electronic learning (e-learning) Master’s degree (MSc) in Trauma Sciences in 2011. E-learning is increasingly popular however low progression rates question effectiveness. The further post-graduate impact is unknown.Our goal was to establish whether this program is a successful method of delivering multidisciplinary trauma education to an international community. We hypothesized that graduating students make a global impact in trauma care, education and research.MethodsThe Trauma Sciences MSc programs launched in 2011. Electronic surveys were distributed worldwide to students who successfully completed the program between 2013–2016. Graduation rates, degree/qualification awarded, clinical involvement in trauma management, presentation of MSc work, academic progression and roles in trauma education were explored. Supporting demographics were extracted from the QMUL student database.ResultsA total of 176 students, of 29 nationalities, enrolled in the two year course between 2011 and 2014. Clinical backgrounds included multi-speciality physicians (83.5%), nurses (9.6%) and paramedics (6.8%). 119 (67.6%) graduated within the study period, 108 (60.8%) with the full masters award. Completion was independent of clinical background (p = 0.20) and age (p = 0.99). Highest completion rates were seen in students from Australia and New Zealand, Asia and Europe (p = 0.03).All survey responders were currently providing regular clinical care to trauma patients. 73% (n = 36) were delivering trauma education, many at national or international level. 49% (n = 24) had presented work from the MSc and 23% (n = 11) published their dissertation.12% (n = 6) subsequently enrolled in a PhD program.ConclusionCompared with other e-learning courses this Masters program has an enviable completion rate. Graduates go on to make an international multidisciplinary impact with diverse roles in clinical management, research and trauma education.This programme provides a robust trauma education curriculum. The QMUL Trauma Sciences MSc program is an excellent resource for clinicians participating in any form of trauma care or who wish to augment sub-speciality training in trauma.     

Chest trauma

This article describes the life-threatening chest and mediastinal injuries seen in patients with blunt and penetrating trauma. It describes the clinical features of these injuries and their initial management, and also considers the imaging that can be used to confirm the diagnosis and plan ongoing management. The injuries discussed include tension pneumothorax, massive haemothorax, cardiac tamponade, flail chest and open pneumothorax. The presentation and management of other significant chest injuries, namely traumatic aortic dissection, pulmonary contusion and myocardial contusions, are also described. The article also suggests when cardiothoracic surgical consultation may be useful in the management of these patients.     

Airway trauma

Airway trauma can be considered according to the mechanism of injury, which may guide further management. Trauma may be mechanical, either blunt or penetrating, be due to burns or be iatrogenic as a result of instrumentation of the airway. Immediate airway intervention will be required for obvious airway compromise. Such patients may be difficult to manage, and may be complicated by polytrauma. It is important to appreciate the potential for rapid deterioration in patients with an injury to the aerodigestive tract. Delayed diagnosis can result in poor outcomes from airway and neck trauma, and a structured approach to resuscitation, investigations and ongoing care should be adopted. Iatrogenic airway trauma is not confined to patients in whom intubation is difficult or prolonged, although these are risk factors. Pharyngeal and oesophageal perforation are associated with greater risk of mortality than other iatrogenic airway injuries. Cricoarytenoid joint dysfunction, vocal cord palsy, granuloma, haematoma and tracheal stenosis can all occur as a result of airway instrumentation, and may not be apparent until some time later. Specialist referral of these patients is appropriate, and prompt treatment may improve outcomes. Careful sizing of endotracheal tubes and close monitoring of cuff pressures are important in minimizing airway trauma through intubation.     

Chest trauma

This article summarises major life-threatening injuries in thoracic trauma. Timing, clinical features, necessary investigations and interventions are described within the clinical approach of primary and secondary surveys. Emphasis is on immediate resuscitation with some discussion on further management. Injuries included are tension pneumothorax, open pneumothorax, massive haemothorax, pericardial tamponade, aortic injuries, cardiac injuries, lung contusion, flail chest, diaphragmatic injury, airway injury and oesophageal rupture.