Animal-related injury in an urban New Zealand population

The contribution of animals to injury in urban populations is not well described. We reviewed our trauma admissions for animal-related injury to identify animals involved, risk factors and patterns of injury. Eight thousand nine hundred and fifty-four patients were admitted for trauma during the study period. One hundred and sixty-seven injuries were due to animals (1.9%). Horses were involved in 86% and dogs in 10% of injuries. Most horse riders were injured in falls. Factors associated with increased risk included being young, female and riding for leisure. Body regions most commonly injured were the head and both upper and lower extremities. Patterns of injury were identified. Horse-related injury is a significant source of traumatic injury in an identifiable at-risk subgroup of our urban population. High rates of head injury and low rates of helmet use suggest a more effective strategy to encourage use of protective headgear is needed. Further efforts aimed at injury prevention must include an improvement in skill and knowledge of horsemanship, particularly in the at-risk group of young female amateur riders. Mechanistic patterns of injury and body-region markers identified in this study may assist early recognition of severe and occult injuries in these patients.

Co-morbidities in trauma patients: common and significant

INTRODUCTION

Trauma is a heterogeneous 'disease' that affects all age groups with varying degrees of severity. While injury severity, time to definitive care, and the quality of care in trauma patients have been quantified, it has been much more difficult to quantify pre-existing health status or 'host factors' in trauma patients and relate them to trauma outcome. Numerous studies have attempted this task, but none have succeeded in producing a simple system to quantify co-morbidities. As a prelude to developing a simple Abbreviated injury scale (AIS)-like score, the incidence of major and minor co-morbidities (and outcomes) in a cohort of admitted trauma patients > or =40 years of age were evaluated.

METHODS

A prospective review of the Auckland Trauma Registry of trauma patients age > or =40 years that were admitted to Auckland Hospital between 1 January 2003 and 3 March 2003 was performed. Among the data collected were the patient's co-morbidities. The co-morbidities were divided into major and minor co-morbidities: major co-morbidities were defined by criteria found in the APACHE 2 PIC system, whereas minor co-morbidities were all the other co-morbidities not included in the APACHE 2 PIC system.

RESULTS

A total of 105 patients were included. There were 57 males and 48 females in this study. Overall, 71% of the population had pre-existing co-morbid conditions, with 23% having a major co-morbid condition. Major trauma [injury severity score (ISS) of 15] was seen to decrease as age increases. The mortality rate in this group of patients was 4.7%.

DISCUSSION

Co-morbidities were surprisingly common in trauma patients. Trauma outcome in patients with co-morbidities is difficult to predict and is not well addressed by any of the existing injury scales. The possibility of developing single 'AIS-like' co-morbidity score merits ongoing evaluation. The prevalence of co-morbidities in trauma patients > or =40 years of age suggests that the influence of co-morbidity on outcome should be considered in a much greater cohort than is currently the case.

Transfer function index: is it a reliable method for vein graft surveillance?

INTRODUCTION

Duplex ultrasound scanning is currently the best available non-invasive method for vein graft surveillance. However, it is expensive and its results are highly operator dependent. The aim of the present study is to compare, another non-invasive method of graft surveillance, the transfer function index (TFI), with duplex ultrasound scanning in identifying significant stenoses in infrainguinal saphenous vein bypass grafts.

METHODS

Initially a retrospective pilot study was carried out between 1 January and 30 June 2002. Patients were identified from the vascular surgical operation database. The ultrasound report and TFI result of each patient were reviewed. Then a prospective comparative study was carried out between 1 July and 31 December 2002. Duplex ultrasound and TFI studies were undertaken at the 3 month interval. Comparisons were made between the accuracy and predictive value of ultrasound versus TFI in assessing significant graft stenosis.

RESULTS

In the present retrospective study TFI measurement was significantly lower in the at-risk grafts than in the normal grafts (P = 0.001). In the prospective group TFI was again found to be significantly lower in the at-risk group (mean TFI 0.86) than in the normal group (mean TFI 1.064, P = 0.001). The sensitivity and specificity of the TFI were 92% and 97%, respectively. The accuracy of TFI was calculated to be 98%.

CONCLUSION

TFI is an accurate non-invasive method of vascular graft surveillance. TFI can be carried out in the vascular clinic and is quick and inexpensive. Normally TFI could replace duplex ultrasound surveillance, with ultrasound being reserved for those with an abnormal TFI.

Trauma care systems in New Zealand

Trauma in New Zealand is modest in extent in relation to many other areas of the world. Trauma care is delivered in the context of an ad hoc trauma system which nevertheless seems to function reasonably well. Current funding strictures in the short term seem likely to prevent formal adoption of a trauma system which would have the prospect of providing information determining the real quality of trauma care in New Zealand.

Driver sleepiness and risk of serious injury to car occupants: population based case control study

OBJECTIVES

To estimate the contribution of driver sleepiness to the causes of car crash injuries.

DESIGN

Population based case control study.

SETTING

Auckland region of New Zealand, April 1998 to July 1999.

PARTICIPANTS

571 car drivers involved in crashes where at least one occupant was admitted to hospital or killed ("injury crash"); 588 car drivers recruited while driving on public roads (controls), representative of all time spent driving in the study region during the study period.

MAIN OUTCOME MEASURES

Relative risk for injury crash associated with driver characteristics related to sleep, and the population attributable risk for driver sleepiness.

RESULTS

There was a strong association between measures of acute sleepiness and the risk of an injury crash. After adjustment for major confounders significantly increased risk was associated with drivers who identified themselves as sleepy (Stanford sleepiness score 4-7 v 1-3; odds ratio 8.2, 95% confidence interval 3.4 to 19.7); with drivers who reported five hours or less of sleep in the previous 24 hours compared with more than five hours (2.7, 1.4 to 5.4); and with driving between 2 am and 5 am compared with other times of day (5.6, 1.4 to 22.7). No increase in risk was associated with measures of chronic sleepiness. The population attributable risk for driving with one or more of the acute sleepiness risk factors was 19% (15% to 25%).

CONCLUSIONS

Acute sleepiness in car drivers significantly increases the risk of a crash in which a car occupant is injured or killed. Reductions in road traffic injuries may be achieved if fewer people drive when they are sleepy or have been deprived of sleep or drive between 2 am and 5 am.

Ruptured abdominal aortic aneurysms: clinical presentation in Auckland 1993-1997

BACKGROUND

Rupture of an abdominal aortic aneurysm (RAAA) carries a reported mortality rate in the range of 32-95%. Survival requires prompt diagnosis and surgical management. The presenting features, however, are varied, often insidious and potentially misleading with Osler noting nearly 100 years ago that a correct premortem diagnosis was achieved in only 33% of cases. The present study aims to review our present accuracy in diagnosing this condition and outline demographic and presenting features of patients with RAAA.

METHODS

A review was undertaken of hospital and Coroner's files of all patients residing in the Auckland Coronial region who had RAAA between 1 January 1993 and 31 December 1997.

RESULTS

Three hundred and twenty-nine cases of RAAA were identified, and they occurred most commonly in the 8th decade. The male:female ratio was 3:1 and at least 73% of patients were Caucasian. The overall mortality was 71%. Nearly half underwent surgery and the hospital averaged mortality rate was 46%. No patient survived without surgery. Classic presenting features of RAAA were absent in many cases. Abdominal pain, back pain and a palpable mass occurred in only 49%, 36% and 18% of patients, respectively. Other common presenting symptoms included vomiting, general malaise and pelvic or hip pain. Forty-three patients (16%) were initially misdiagnosed.

CONCLUSIONS

Although our ability to correctly diagnose a RAAA has improved since Osler's time, the initial misdiagnosis rate of 16% leaves no room for complacency. Ruptured abdominal aortic aneurysms must be included in the differential diagnosis of any patient over the age of 55 years who presents with shock, even if the pain is non-specific or atypical.

Trauma and co-morbidity--a pilot study

AIMS

To study the adult trauma patient population at the Auckland Hospital in order to determine the age distribution of trauma, the prevalence and importance of co-morbid conditions and any effect of the latter on the length of stay in the hospital.

METHODS

Data were collected on 78 consecutive patients admitted to the Auckland Hospital under the Trauma team between December 1999 and January 2000. Data were collected by interviewing the patient, as well as reviewing patient's medical notes and the Trauma Registry.

RESULTS

The prevalence of co-morbidities was 14.7%. No co-morbidity was found below the age of 40 years, but the prevalence of co-morbidity increased with age. The average length of stay for patients with no comorbidities and an Injury Severity Score (ISS) >15 was 19 days while for those with co-morbidities was 24.5 days--an increase of 29%.

CONCLUSION

This pilot study has found that a significant number of trauma patients being admitted to Auckland Hospital have a pre-existing co-morbid condition that may alter their length of stay. It is an important issue that warrants further investigation, in order to devise a more accurate prognostic scoring system.

Blunt traumatic small bowel rupture: are children different?

BACKGROUND

In order to identify differences between children and adults with small bowel rupture (SBR) and to determine if a single diagnostic approach could be taught to paediatric and adult surgeons, a review of the experience at a children's and an adults' hospital was performed.

METHODS

Using the hospital patient database 17 children were identified with SBR over a 13.6-year period, and clinical records were available for review for 14. Using a trauma registry 16 adults were identified with SBR over a 4.7-year period and clinical records were reviewed in all 16.

RESULTS

The population incidence was 0.48/100000 per annum in children and 0.58/100000 per annum in adults. Motor vehicle crash was a less common mechanism of injury in children (35.7%) than in adults (75%). The time from injury to presentation (presentation interval) was significantly longer in children than in adults, even after excluding child abuse cases (median 2.9 h vs 65 min, respectively). The injury severity score was lower in children (median: 10) than in adults (median: 16.5). Peritoneal signs on follow-up examination were documented in 54.6% of children and in 90.9% of adults in whom follow-up examination was performed. Clinical findings on admission, findings on computed tomography, indications for operation and outcome were similar in children and adults.

CONCLUSION

Children differed from adults in aetiology, longer presentation interval and fewer associated injuries. Similarities in diagnostic parameters suggest that a single diagnostic approach could be taught for children and adults provided that the limitations of physical examination in small children are recognized.

Pelvic fracture pattern predicts pelvic arterial haemorrhage

BACKGROUND

The association between pelvic fracture pattern and the need for pelvic arterial embolization remains controversial. To address this issue, a study of the experience at Auckland Hospital was undertaken.

METHODS

Review was undertaken of a trauma database, blood bank database, patient records and pelvic radiographs. Of the 364 pelvic fracture patients admitted over a 4-year period, 76 were transfused with 6 or more units of blood in the first 24 h and these constitute the study population.

RESULTS

Embolized patients were older (median age 42 vs 29.5 years; P < 0.05) and had a higher abbreviated injury score for the pelvic girdle (median 3 vs 2; P < 0.05) compared to non-embolized patients. Revised trauma score (median 7.69 vs 7.55), injury severity score (median 29 vs 30.5), morbidity (55 vs 39%) and mortality (45 vs 32.1%) rates did not differ significantly between embolized and non-embolized groups, respectively. The median blood transfusion requirement in the first 6 h from injury was 14 units in embolized and 8 units in non-embolized patients (P = 0.005). Embolization was required in 12 of 27 (44.4%) patients with fracture patterns indicative of major pelvic ligament disruption, whereas seven of 38 (18.4%) patients without these fracture patterns required embolization (P < 0.05).

CONCLUSIONS

The need for pelvic embolization correlated with fracture patterns that indicated major ligament disruption, although the relationship was not sufficiently strong to warrant change to current indications for pelvic angiography.

Trauma form documentation in major trauma

AIMS

To examine the impact of a standardised trauma form for documentation in cases of major trauma, a prospective study was undertaken.

METHODS

Records written by medical staff pertaining to the assessment and treatment of major trauma patients in the resuscitation room were scored against a panel of parameters derived from advanced trauma life support guidelines. Demographics, aetiology, trauma scores and outcome data were obtained from a trauma registry. Attitudes of medical staff involved in major trauma to the trauma form were assessed using a questionnaire.

RESULTS

The trauma form was used in 53 of 69 (76.8%) consecutive cases of major trauma seen over a three month period. No significant differences existed in demographics, aetiology, trauma scores or outcome between form and formless groups. In the form group, a median of 44 of 51 (86.3%) relevant information parameters were documented versus 32 of 51 (62.7%) in the formless group, p < 0.0001. A positive approach to the trauma form was indicated by the questionnaire results.

CONCLUSION

The use of a standardised form improves documentation in major trauma.

Adult splenic injuries: treatment patterns and predictive indicators

BACKGROUND

With the trend towards conservation in splenic trauma, the ability to identify a group of patients for whom we can safely offer conservative treatment becomes an important factor.

METHODS

Data were reviewed from the trauma register at the Auckland Hospital, Auckland, New Zealand, in an attempt to isolate any predictive factors that may allow more appropriate allocation of treatment modalities in the future. Methods of treatment were determined and the success or failure of conservative management noted. Differences in the demographics, Injury Severity Score (ISS) and computed tomographic (CT) findings were particularly sought.

RESULTS

Over a period of 111 weeks 48 patients were admitted with splenic injuries. Fifteen (31.2%) had immediate splenectomy, 27 (56.2%) were initially treated non-operatively and six (10.1%) died pre-operatively. Of the non-operative group eight (29.6%) failed this management at an average of 4.125 days into their hospital stay. No differences were found in age, mechanism, gender or ISS between the failed and successfully treated group. Using the Buntain classification of CT-graded splenic injury, 13 (87%) who had successful non-operative treatment had a grade II or III compared with six (86%) who failed this management being grade IV.

CONCLUSION

Although these results did not reach statistical significance, by coupling the trends seen together with other work, CT grading of splenic injury is a predictive indicator and does appear to have a role in the early allocation of patients to appropriate treatment plans.

The management of anterior abdominal stab wounds in Australasia

BACKGROUND

The low incidence of stab wounds in Australasia has led to a more operative approach for the management of anterior abdominal stab wounds. A survey of Australasian surgeons interested in trauma was undertaken to analyse current practice.

METHODS

Ninety-seven early management of severe trauma surgical instructors (known as ATLS in Australasia) were surveyed using a four-part, single-page questionnaire.

RESULTS

Sixty-five instructors completed the survey. Thirty-nine instructors stated that they would admit patients with stab wounds even if the wound appeared superficial or 'skin only'. For 14 surgeons the decision to perform a laparotomy was dependent on fascial penetration and for 17 the decision depended upon peritoneal penetration. Six felt that all but the most superficial wounds should have a laparotomy. Laparoscopy, diagnostic peritoneal lavage and other investigations were also thought to be helpful. Thirteen surgeons felt that the presence of peritonism or tenderness were the most important determinants. There was no hospital protocol for 44 respondents and there was a wide variation in individual approach to this problem. However, all agreed that peritonism and haemodynamic instability were indications for immediate laparotomy.

CONCLUSIONS

There is still a low threshold for laparotomy in Australasia and this approach is not without risks. However, the alternative of using serial observation should be regarded as an active form of management and protocols must be established to ensure regular repeat examinations by experienced personnel. The low incidence of abdominal stab wounds in Australasia makes this approach difficult. A safe approach for the Australasian situation is described.

Trauma data collection using a customised trauma registry: a New Zealand experience

AIM

To describe the process of selection and adaptation of a trauma registry and the initial experience with its use.

METHOD

The decision-making processes involved in selection of a data set and computer software are described. The problems associated with collection of data, recording and analysis are outlined.

RESULTS

In the 6 months from 1 January to 30 June 1995, 615 patients were entered on the Auckland Hospital trauma registry. 590 patients were discharged or transferred alive and 25 (4.1%) died in hospital. Median length of stay of survivors was 6 days (mean 9.03 days) with median ICU stay being 0 days (mean 0.81 days). A range of difficulties including data collection, recording and analysis were experienced.

CONCLUSION

Despite some teething problems, establishment of a trauma registry has proven to be an achievable task within the trauma service. Recording of data which allows assessment of the quality of care, resource use and outcome has been possible. Effectiveness of the trauma service has been enhanced by the availability of this data.

Exsanguinating upper extremity vascular injury: is an initial approach by clavicular resection adequate?

Clavicular resection has been recommended by some as an acceptable approach to the repair of subclavian and axillary vascular injuries. We believe this may not be the best approach in patients with severe trauma and exsanguinating injuries. During the last 5 years, we have treated 11 patients with trauma to the subclavian or axillary vessels, four of whom presented in shock from exsanguinating injuries. After initial fluid resuscitation, we operated on each patient by resecting the medial portion of the clavicle. Three of the four patients required further surgery or extension of the incision to control bleeding. In our experience, clavicular resection as a primary approach to exsanguinating injuries did not provide either adequate tamponade of bleeding or the exposure needed to repair injured vessels safely. Clavicular resection may be acceptable for hemodynamically-stable patients with minimal soft tissue damage and simple, right-sided vessel lacerations, but we cannot recommend it as an initial approach in patients with severe, exsanguinating injuries.

DRG reimbursement for trauma: the demise of the trauma center (the use of ISS grouping as an early predictor of total hospital cost)

All institutional reimbursement for inpatient care in the State of New Jersey is administered by the DRG methodology (Prospective Payment System). This system is essentially identical to federal Medicare. In 1983 our hospital was designated the Level I trauma center for southern New Jersey (population, 2.6 million). Prehospital triage guidelines based on anatomic injury were implemented, and, as a result, an annual 30% increase in severe trauma cases (ISS greater than 16) was realized. In late 1984 serious financial shortfalls were noticed, especially in the higher ISS cases. A 1-year study (1985) of all patients admitted through the Trauma Center to an intensive care unit was completed (523 patients; mean ISS, 15.16; ISS greater than 16, 37.8%). All patients were stratified to one of five ISS groups (A: ISS 1-8; B: ISS 9-15; C: ISS 16-24; D: ISS 25-40; E: ISS greater than 40). Average cost, reimbursement, ISS, LOS, and mortality were reviewed for the entire aggregate and each severity group. The system of ISS grouping was an accurate method of cost analysis, and prospectively, ISS grouping allowed prediction of length of stay and total hospital cost. In addition, these data allowed early fiscal management decisions and resource allocation. As a reimbursement system, DRG falls short of the cost of care for all ISS levels and groups. As severity of injury rose, costs increased in a linear manner, but reimbursement did not, resulting in a substantial financial loss. The net loss to the hospital in 1 year was $1.86 million.(ABSTRACT TRUNCATED AT 250 WORDS)

Saline-expanded group O uncrossmatched packed red blood cells as an initial resuscitation fluid in severe shock

Despite an excellent military experience with the use of the "universal donor" as an immediately available blood component, considerable reluctance to use uncrossmatched Group O packed cells (TOB) remains. In addition, problems continue with rapid blood acquisition in the emergency department. To study the safety of TOB used as an immediate resuscitation component, a 30-month prospective study of all patients arriving at a single trauma unit was undertaken. By protocol TOB (O-, female; O+, male) was delivered to the shock room prior to patient arrival and was expanded to 500 mL by adding 250 mL prewarmed saline (39.4 C) to the existing RBC unit. Transfusion was ordered on clinical signs of Class III or Class IV hemorrhage. Ninety-nine patients entered the protocol, receiving a total of 1,136 units of blood (11.5 units/patient). Four hundred ten units (4.1 units/patient) of uncrossmatched blood were administered on patient arrival--322 units of TOB and 88 units of type-specific blood (TSB). Seven patients (7.4%) had prior transfusions, and 14 (58%) women had prior pregnancies. Complications included disseminated intravascular coagulation, 12%; adult respiratory distress syndrome, 8%; and hepatitis, 1%. Forty-nine patients (49%) required massive transfusion (greater than 10 units/24 hr). All patients were followed clinically and by the blood bank for any signs of transfusion reactions or incompatibility throughout their hospital courses; none developed. There were no deaths related to transfusion incompatibility. We conclude that TOB used as an immediate resuscitative blood component is safe.(ABSTRACT TRUNCATED AT 250 WORDS)