Journal of Trauma Management & Outcomes - Latest articles

Strategic emergency department design: An approach to capacity planning in healthcare provision in overcrowded emergency rooms

2008-11-17

Healthcare professionals and the public have increasing concerns about the ability of emergency departments to meet current demands. Increased demand for emergency services, mainly caused by a growing number of minor and moderate injuries has reached crisis proportions, especially in the United Kingdom. Numerous efforts have been made to explore the complex causes because it is becoming more and more important to provide adequate healthcare within tight budgets. Optimisation of patient pathways in the emergency department is therefore an important factor. This paper explores the possibilities offered by dynamic simulation tools to improve patient pathways using the emergency department of a busy university teaching hospital in Switzerland as an example.

A new approach and first steps to strengthen trauma management and road safety in North Vietnam

2008-10-28

Background: In Vietnam, the number of road traffic accidents increased dramatically which is a major threat for the national health system. Reliable data on the magnitude of traffic accidents as well as the current management of victims is missing. Our multistep international cooperation project aims to (1) identify local needs and knowledge related to trauma management, to (2) assess basic behavioural patterns and attitudes of road users in order to (3) establish a school-based educational programme and trauma courses for doctors.Methods and resultsAs part of a European Union co-financed cooperation, two European and one Vietnamese university set up three action lines (Trauma and Emergency Courses, school-based education programs, public awareness campaigns). Specific contents of the activities were derived from a literature search, a questionnaire pilot-study and by panel consensus technique. After adjustment to local capabilities (equipment, infrastructure, etc.) these were implemented within a professional network of hospitals, schools, public and media institutions.The literature research and questionnaire results from 1 000 young road users indicates that for pedestrian and two-wheelers accidents, low compliance with traffic regulations and high prevalence of risk-taking behaviour dominate Vietnam's road traffic environment. A school-based educational program (4 hrs/month) was set up using teachers who were trained on road safety issues. Also, major parts of the public awareness campaigns (i.e. broadcasts, media conferences) reflected these topics. From panel discussions and Delphi-technique, diagnosis and early treatment of severe head trauma and internal haemorrhage were identified as topics of highest interest for doctors therefore representing key topics of the Trauma and Emergency Courses. Conclusion: Knowledge on behaviour and attitudes of road users in Vietnam as well as on local infrastructure and effective networks is essential to establish sustainable and effective countermeasures. Our approach might serve as guideline for future small scale projects as it proved to be feasible, cost-effective but provided scientific base for immediate on spot activities.

Red blood cell transfusion within the first 24 hours of admission is associated with increased mortality in the pediatric trauma population: a retrospective cohort study

Taylor J Stone, Paul J Riesenman and Anthony G Charles — 2008-10-20

Background: Allogeneic red blood cell transfusion is associated with increased morbidity and mortality in adult trauma patients. Although studies have suggested that the adoption of a more restrictive transfusion strategy may be safely applied to critically ill adult and all-cause critically ill pediatric patients, recent developments in our understanding of the negative consequences of red blood cell transfusion have focused almost entirely on adult populations, while the applicability of these findings to the pediatric population remains poorly defined. The object of this study was to evaluate the effect of red blood cell transfusion within the first 24 hours following admission on mortality in pediatric trauma patients treated at our institution. Results: Age, race, and mechanism of injury did not differ between transfused and non-transfused groups, although there were significantly more female patients in the transfusion group (51 vs. 37%; p < 0.01). Shock index (pulse/systolic blood pressure), injury severity score, and new injury severity score were all significantly higher in the transfused group (1.21 vs. 0.96, 26 vs. 10, and 33 vs. 13 respectively; all p ≤ 0.01). Patients who received a red blood cell transfusion experienced a higher mortality compared to the non-transfused group (29% vs. 3%; p < 0.001). When attempting to control for injury severity, goodness-of-fit analysis revealed a poor fit for the statistical model preventing reliable conclusions about the contribution of red blood cell transfusion as an independent predictor of mortality. Conclusion: Red blood cell transfusion within the first 24 hours following admission is associated with an increase in mortality in pediatric trauma patients. The potential contribution of red blood cell transfusion as an independent predictor of hospital mortality could not be assessed from our single-institution trauma registry. A review of state-wide or national trauma databases may be necessary to obtain adequate statistical confidence.

Evaluation of the safety of high-frequency chest wall oscillation (HFCWO) therapy in blunt thoracic trauma patients

2008-10-06

Background: Airway clearance is frequently needed by patients suffering from blunt chest wall trauma. High Frequency Chest Wall Oscillation (HFCWO) has been shown to be effective in helping to clear secretions from the lungs of patients with cystic fibrosis, bronchiectasis, asthma, primary ciliary dyskinesia, emphysema, COPD, and many others. Chest wall trauma patients are at increased risk for development of pulmonary complications related to airway clearance. These patients frequently have chest tubes, drains, catheters, etc. which could become dislodged during HFCWO. This prospective observational study was conducted to determine if HFCWO treatment, as provided by The Vest™ Airway Clearance System (Hill-Rom, Saint Paul, MN), was safe and well tolerated by these patients. Methods: Twenty-five blunt thoracic trauma patients were entered into the study. These patients were consented. Each patient was prescribed 2, 15 minute HFCWO treatments per day using The Vest® Airway Clearance System (Hill-Rom, Inc., St Paul, MN). The Vest® system was set to a frequency of 10–12 Hz and a pressure of 2–3 (arbitrary unit). Physiological parameters were measured before, during, and after treatment. Patients were free to refuse or terminate a treatment early for any reason. Results: No chest tubes, lines, drains or catheters were dislodged as a result of treatment. One patient with flail chest had a chest tube placed after one treatment due to increasing serous effusion. No treatments were missed and continued without further incident. Post treatment survey showed 76% experienced mild or no pain and more productive cough. Thirty days after discharge there were no deaths or hospital re-admissions. Conclusion: This study suggests that HFCWO treatment is safe for trauma patients with lung and chest wall injuries. These findings support further work to demonstrate the airway clearance benefits of HFCWO treatment.

The BHU bicentric bipolar prosthesis in fracture neck femur in active elderly

Anil K Rai, Rakesh Agarwal, Saurabh Singh and Ratnav Ratan — 2008-09-25

Background: 55 BHU bicentric bipolar hemiarthroplasties were reviewed after a mean follow up of 4 years (range 1–5 years). Patients with displaced subcapital fractures were selected for operation on the basis of good mobility before the fracture. Object of the study was to see the efficacy of BHU bipolar prostheses and functional outcome. Results: There were no incidences of dislocation. Modified Harris hip scoring system scoring system was used which included sitting crosslegged and squatting in view of the sociocultural needs of the patients of Indian subcontinent. Modified Harris hip scoring system 89% had a good or excellent result and 94% had no or only occasional pain. Majority of the patients returned to their prefracture activity. Conclusion: Thus at follow up of 4 year the BHU bicentric bipolar prosthesis has been shown to be a good option for intracapsular fractures of neck femur with encouraging results.

Outcomes of Ilizarov ring fixation in recalcitrant infected tibial non-unions – a prospective study

2008-07-23

Background: Infected non-union of long bones is a problem in the developing countries. Persistent infection, deformity, shortening, bone loss, joint stiffness and disability complicate the non-union. Secondary procedures are often required for correction of bone defects and deformity. Ilizarov method addresses all the above problems simultaneously and offers a panacea for infected non-unions. The stability of the fixation and provision for bone transport allows bridging of bone defects, limb lengthening, early weight bearing ambulation and joint mobilisation.Aim of the studyTo know the suitability of this procedure in recalcitrant infected tibial non-unions in the Indian population and the influence of socio-economic factors in the functional outcome.Method of studyThis was a 3-year prospective study in 22 consecutive patients with an average follow up of 13 months following fracture union. The results were analysed using the ASAMI scoring system. Results: Of 22 patients in the study, 13 patients who underwent external bone transport, had an average bone gap of 4 cms [2–11 cms] with an average duration of fixation of 9.3 months [6.5–13 months]. There were 4 excellent, 3 good, 4 fair and 2 poor bony results and 1 excellent, 3 good, 6 fair and 2 poor results. 1 patient was lost for follow up at final functional analysis. 9 patients who underwent internal bone transport had an average bone gap of 5.4 cms [1.5–9 cms] with an average duration of fixation of 8.5 months [4–11 months]. There were 3 good 4 fair and 2 poor bony results and 1 good, 3 fair, and 2 poor functional results. Good to excellent results were witnessed in well-motivated patients with adequate social and financial support. Patients with fair to poor results preferred amputation to limb salvage despite the fact that they retained their limbs. Conclusion: Treatment of infected non-unions of Tibia with Ilizarov ring fixation is effective but for optimal results the treatment needs to be individualised by the treating surgeon with due consideration of the socio-economic factors.

The profile of head injuries and traumatic brain injury deaths in Kashmir

GH Yattoo and Amin Tabish — 2008-06-21

This study was conducted on patients of head injury admitted through Accident & Emergency Department of Sher-i-Kashmir Institute of Medical Sciences during the year 2004 to determine the number of head injury patients, nature of head injuries, condition at presentation, treatment given in hospital and the outcome of intervention. Traumatic brain injury (TBI) deaths were also studied retrospectively for a period of eight years (1996 to 2003).The traumatic brain injury deaths showed a steady increase in number from year 1996 to 2003 except for 1999 that showed decline in TBI deaths. TBI deaths were highest in age group of 21–30 years (18.8%), followed by 11–20 years age group (17.8%) and 31–40 years (14.3%). The TBI death was more common in males. Maximum number of traumatic brain injury deaths was from rural areas as compared to urban areas.To minimize the morbidity and mortality resulting from head injury there is a need for better maintenance of roads, improvement of road visibility and lighting, proper mechanical maintenance of automobile and other vehicles, rigid enforcement of traffic rules, compulsory wearing of crash helmets by motor cyclist and scooterists and shoulder belt in cars and imparting compulsory road safety education to school children from primary education level. Moreover, appropriate medical care facilities (including trauma centres) need to be established at district level, sub-divisional and block levels to provide prompt and quality care to head injury patients

MRI efficacy in diagnosing internal lesions of the knee: a retrospective analysis

2008-06-02

Background: Many surgeons tend to believe that MRI is an accurate, non invasive diagnostic method, enough to lead to decisions for conservative treatment and save a patient from unnecessary arthroscopy. We conducted a retrospective study to investigate the accuracy of the MRI of the knee for the detection of injuries of the meniscus, cruciate ligaments and articular cartilage, in comparison with the preoperative clinical examination and intraoperative findings. Between May 2005 and February 2006 102 patients after clinical examination were diagnosed with meniscal or cruciate injury and underwent definitive treatment with arthroscopy. 46 of these patients fulfilled the inclusion criteria. The accuracy, sensitivity, specificity, negative and positive predictive values of the MRI findings were correlated with the lesions identified during arthroscopy. The diagnostic performance of the initial clinical examination was also calculated for the meniscal and cruciate ligament injuries. Results: The accuracy for tears of the medial, lateral meniscus, anterior and posterior cruciate ligaments and articular cartilage was 81%, 77%, 86%, 98% and 60% respectively. The specificity was 69%, 88%, 89%, 98% and 73% respectively. The positive predictive value was 83%, 81%, 90%, 75% and 53% respectively. Finally, the clinical examination had significant lower reliability in the detection of these injuries. Conclusion: MRI is very helpful in diagnosing meniscal and cruciate ligament injuries. But in a countable percentage reports with false results and in chondral defects its importance is still vague. The arthroscopy still remains the gold standard for definitive diagnosis.

Investment in online self-evaluation tests: A theoretical approach

2008-04-15

Background: Large-scale traumatic events may burden any affected public health system with consequential charges. One major post-disaster, expense factor emerges form early psychological interventions and subsequent, posttraumatic mental health care. Due to the constant increase in mental health care costs, also post-disaster public mental health requires best possible, cost-effective care systems. Screening and monitoring the affected population might be one such area to optimize the charges. Methods: This paper analyzes the potential cost-effectiveness of monitoring a psychologically traumatized population and to motivate individuals at risk to seek early treatment. As basis for our model served Grossman's health production function, which was modified according to fundamental concepts of cost-benefit analyzes, to match the basic conditions of online monitoring strategies. We then introduce some fundamental concepts of cost-benefit analysis. Results: When performing cost-benefit analyses, policy makers have to consider both direct costs (caused by treatment) and indirect costs (due to non-productivity). Considering both costs sources we find that the use of Internet-based psychometric screening instruments may reduce the duration of future treatment, psychological burden and treatment costs. Conclusion: The identification of individuals at risk for PTSD following a disaster may help organizations prevent both the human and the economic costs of this disease. Consequently future research on mental health issues should put more emphasis on the importance of monitoring to detect early PTSD and focus the most effective resources within early treatment and morbidity prevention.

'Damage control orthopaedics' in patients with delayed referral to a tertiary care center: experience from a place where Composite Trauma Centers do not exist

2008-01-29

Background: Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted on 51 cases after reviewing their records and complete management one year after the trauma. Results: At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality. Conclusion: In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases.