The pregnant trauma patient

Trauma is the leading non-obstetric cause of maternal death. Optimal management of the pregnant trauma patient requires a multidisciplinary approach. The anaesthetist and critical care physician play a pivotal role in the entire continuum of fetomaternal care, from initial assessment, resuscitation and intraoperative management, to postoperative care that often involves critical care support and patient transfer. Primary goals are aggressive resuscitation of the mother and maintenance of uteroplacental perfusion and fetal oxygenation by the avoidance of hypoxia, hypotension, hypocapnia, acidosis and hypothermia. Recognizing and understanding the mechanisms of injury, the factors that may predict fetal outcome, and the pathophysiological changes that can result from trauma, will allow early identification and treatment of fetomaternal injury. This in turn should improve morbidity and mortality. A framework for the acute care of the pregnant trauma patient is presented.     

Assessment of the pregnant trauma patient

Although less than 10% of pregnant patients are likely to experience some type of physical trauma, injury is the leading non-obstetric cause of maternal mortality. The assessment and resuscitation of the injured pregnant patient must take into account the specific needs of both the mother and the foetus. This paper will review the physiology of pregnancy, discuss recent changes in assessment and resuscitation, and identify special injuries and issues specific to the pregnant trauma patient.     

Orthopaedic trauma during COVID-19: Is patient care compromised during a pandemic?

BackgroundThe Coronavirus disease-2019 (COVID-19) placed unprecedented pressure on the healthcare system. Many institutions implemented a government-mandated restructured set of safety and administrative protocols to treat urgent orthopaedic trauma patients. The objective of this study was to compare two cohorts of patients, a COVID group and non-COVID control group, and to evaluate the effectiveness of safety measures outlined in the Rutgers Orthopaedic Trauma Patient Safety Protocol (ROTPSP). Secondary outcomes were to elucidate risk factors for complications associated with fractures and COVID-19.MethodsPatients treated for orthopaedic traumatic injuries were retrospectively identified between March and May 2020, and compared to a series of patients from the same time period in 2018. Main outcome measures included surgical site infections (SSI), length of stay (LOS), post-operative LOS (poLOS), presentation to OR time (PORT), and length of surgery.ResultsAfter review, 349 patients (201 non-COVID, 148 COVID) undergoing 426 surgeries were included. Average LOS (11.91 days vs. 9.27 days, p = 0.04), poLOS (9.68 days vs. 7.39 days, p = 0.03), and PORT (30.56 vs. 25.59 h, p < 0.01) was significantly shorter in the COVID cohort. There were less SSI in the COVID group (5) compared to the non-COVID group (14) (p = 0.03). Overall complications were significantly lower in the COVID group. Patients receiving Cepheid tests had significantly shorter LOS and poLOS compared to patients receiving the RNA and DiaSorin tests (p < 0.01 and p < 0.01, respectively). The Cepheid test carried the best benefit-to-cost ratio, 0.10, p < 0.05.ConclusionThe restructuring of care protocols caused by COVID-19 did not negatively impact perioperative complication rates, PORT or LOS. Cepheid COVID test type administered upon admission plays an integral role in a patient's hospital course by reducing both length of stay and hospital costs. This information demonstrates we can continue to treat orthopaedic trauma patients safely during the COVID-19 pandemic by utilizing strict safety protocols.     

Orthopaedic trauma patient non-adherence to follow-up visits at a level 1 trauma center serving an urban and rural population

ObjectiveTo assess key demographic and psychosocial variables that may be associated with non-adherence to clinic visits following orthopaedic trauma injuries to patients in an urban and rural population.MethodsThis retrospective review included all operative and non-operative patients presenting to a Level I academic trauma center serving an urban and rural population in the Midwest following an orthopaedic injury. The study tracked patient attendance to scheduled orthopaedic trauma follow-up clinic visits after a scheduled visit in the clinic following a trauma-related injury.ResultsData were obtained for 5816 unique orthopaedic trauma patients who had 21,066 post-treatment follow-up visits scheduled. 1627 “no-show” appointments were recorded. Factors associated with no-shows included male sex, age between 26 and 35 years, self-reported race other than white, employment listed as disabled, household income below $25,000, education less than a high school level, uninsured, Medicaid insured, and relationship status reported as single.ConclusionsIn the present study, key demographic and psychosocial factors were significantly associated with patient adherence to scheduled follow-up appointments after treatment for orthopaedic trauma. Identifying patients at higher risk for nonadherence will allow healthcare teams to educate patients, providers, and staff, link patients to resources to enhance adherence, and work with their institutions to develop and implement protocols for improving adherence to follow-up appointments.     

Orthopaedic management of the patient with osteopetrosis

Osteopetrosis is a sclerosing bone dysplasia characterized by hard, brittle bone secondary to dysfunctional osteoclast resorption. The three main forms are malignant autosomal recessive, intermediate autosomal recessive, and benign autosomal recessive. These various clinical manifestations ultimately are caused by genetic mutations affecting acidification of Howship's lacuna. Common radiographic features include a generalized sclerosis, rugger jersey spine, and endobone formation. Medical problems include cranial nerve palsies and pancytopenia. Because cortical and cancellous bone thickness is increased, medullary canals and cranial nerve foramina are overgrown with bone. Patients typically present with such orthopaedic problems as frequent fractures, coxa vara, osteoarthritis, and osteomyelitis. Management with open reduction and internal fixation and with intramedullary fixation of fractures is difficult but possible. Reported results of total hip and total knee arthroplasties are excellent.     

Orthopaedic trauma education: visions for the future through the OTA. Orthopaedic Trauma Association.

As the trauma center system continues to expand, not only will the requirement for more and better trained trauma surgeons increase, but the means of educating them will need to become more standardized. The general surgeons recognized this many years ago, but orthopaedic trauma has lagged in its efforts to present a coordinated academic and clinical program to residents and fellows. The Orthopaedic Trauma Association has made a move to develop guidelines which may be used by training programs in an effort to improve the educational standards of this subspecialty. The recruitment and retention of young orthopaedic trauma surgeons remains an issue.     

Hypothermia in the trauma patient

Hypothermia is a common finding in severely injured patients. Historically described as a consequence of wartime casualties where cold exposure was common, this topic has resurfaced in the trauma literature because of the increasing recognition of the morbidity and mortality associated with hypothermia. Hypothermia, along with acidosis and coagulopathy, has been identified as a component of the "lethal triad" in injured patients, and has been shown to contribute to increased mortality in these patients. Decreases in core temperature during the course of initial evaluation and resuscitation are common, and can contribute to poor outcomes in the injured patient. As induced hypothermia has been shown to be beneficial in some clinical situations, recent animal studies have attempted to investigate whether hypothermia in the trauma patient has any beneficial effects. This review examines the incidence and pathophysiology of hypothermia, and discusses mechanisms of heat loss and rewarming techniques that can be utilized in the trauma patient.     

Orthopaedic outcomes: combat and civilian trauma care

Important advances have been made in the management of complex trauma through careful scientific analysis of outcomes. Outcomes analysis in combat extremity trauma is exemplified and highlighted by scholarly work in the treatment of catastrophic lower extremity trauma. The success of this line of research in civilian trauma is exemplified by the Lower Extremity Assessment Project (LEAP) study on the outcomes of civilian lower extremity trauma. This highly successful effort was followed by the Military Extremity Trauma Amputation/Limb Salvage (METALS) study. Current ongoing analysis of both the LEAP and METALS studies by the Major Extremity Trauma Research Consortium seeks to compare and contrast the similarities and differences of both studies and to advance evidence-based patient-centered care. The effects of psychological trauma on the injured individual underscore the global effect of severe trauma and the need for a multidisciplinary approach to trauma care. Statistical modeling is being used to analyze outcomes to further the ability to scientifically and definitively determine the best practices for patient care.     

Major trauma in pregnant women during the summer

BACKGROUND: Pregnant women represent a major challenge in trauma care because of the risks to both mother and child and because of the difficulties in following standard protocols. METHODS: We analyzed data for all pregnant women admitted to the hospital in Canada over 7 years to test whether major trauma still clustered in the summer despite their aversion toward alcohol, recklessness, and extreme sports. RESULTS: A total of 2,618 pregnant women sustained major trauma. The prevalence of pregnancy was marginally lower in summer than in winter (decrease, 3%; 95% confidence interval, 2-4%), whereas the incidence of major trauma in pregnant women was significantly higher in summer than in winter (increase, 12%; 95% confidence interval, 3-21%; p = 0.005). No evidence of offsetting decreases in severity appeared in analyses of length of stay, number of surgical procedures, or mortality. CONCLUSION: We suggest that normal lifestyle choices contribute to an increased risk of major trauma during pregnancy and merit greater awareness throughout the year.     

Acute appendicitis in the pregnant patient

Acute appendicitis is the most common surgical problem in pregnancy requiring emergent intervention. To establish a contemporary patient profile and formulate an effective management strategy, a retrospective review was conducted of 84 pregnant patients who underwent laparotomy with a preoperative diagnosis of acute appendicitis. Gestational stage at presentation included the first trimester in 27 patients (32%), the second trimester in 37 patients (44%), the third trimester in 13 patients (16%), and the puerperium in 7 patients (8%). Fifty-four patients (64%) had pathologically proven acute appendicitis; the incidence did not vary by trimester. Other intra-abdominal conditions were detected in 15 patients (18%). There were no significant differences between patients with positive and negative laparotomies (or among trimesters) regarding frequency of presenting symptoms and signs or laboratory results. Operation occurred within 24 hours of symptom onset in 19 of 54 (35%) instances of proven acute appendicitis. Perforation occurred in 23 of 54 patients (43%), all of whom had symptoms exceeding 24 hours (p less than 0.0005). Five instances of perinatal death and one case of extreme perinatal morbidity were associated with negative laparotomies; only one of these was attributed to operation itself. No adverse long-term maternal morbidity or mortality occurred. Wound infection developed in seven cases of acute appendicitis (six perforated) and two negative explorations. We conclude that (1) gestational physiologic changes obscure the accurate diagnosis of acute appendicitis; (2) the natural history of acute appendicitis is not affected by trimester of presentation; and (3) adverse sequelae of acute appendicitis are obviated by prompt operative exploration and prevention of appendiceal perforation.     

Orthopaedic trauma workload in the former homeland of the Transkei, South Africa

The Bedford Orthopaedic Centre is situated in Umtata at the heart of the former homeland of the Transkei in the Eastern Cape of South Africa. It acts as an orthopaedic and trauma referral hospital for a mainly rural population approaching 4 million. This article focuses on the workload of the hospital over a 4-month period and like many hospitals in South Africa we highlight the difficulties it faces with the trauma epidemic.