ORCID Profile
0000-0003-0183-7761
Current Organisations
Alfred Health
,
Monash University
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Publisher: Wiley
Date: 27-11-2021
Abstract: A supraglottic airway device (SAD) may be utilised for rescue re‐oxygenation following a failed attempt at endotracheal intubation with direct or video laryngoscopy. However, the choice of subsequent method to secure a definitive airway is not clearly established. The aim of the present study was to compare two techniques for securing a definitive airway via the in‐situ SAD. A randomised controlled trial was undertaken. The population studied was emergency physicians (EPs) attending a cadaveric airway course. The intervention was intubation through a SAD using a retrograde intubation technique (RIT). The comparison was intubation through a SAD guided by a flexible airway scope (FAS). The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000995875). Four EPs completed intubations using both methods on four cadavers for a total of 32 experiments. The mean time to intubation was 18.2 s (standard deviation 8.8) in the FAS group compared with 52.9 s (standard deviation 11.7) in the RIT group a difference of 34.7 s (95% confidence interval 27.1–42.3, P 0.001). All intubations were completed within 2 min and there were no equipment failures or evidence of airway trauma. Successful tracheal intubation of cadavers by EPs is achievable, without iatrogenic airway trauma, via a SAD using either a FAS or RIT, but was 35 s quicker with the FAS.
Publisher: Wiley
Date: 09-1993
Publisher: Sri Lanka Journals Online (JOL)
Date: 14-11-2017
Publisher: Sri Lanka Journals Online (JOL)
Date: 14-11-2017
Publisher: SAGE Publications
Date: 19-03-2010
Abstract: Knowledge of current epidemiology and spine trauma trends assists in public resource allocation, fine-tuning of primary prevention methods, and benchmarking purposes. Data on all patients with traumatic spine injuries admitted to the Alfred Hospital, Melbourne between May 1, 2009, and January 1, 2011, were collected from the Alfred Trauma Registry, Alfred Health medical database, and Victorian Orthopaedic Trauma Outcomes Registry. Epidemiological trends were analyzed as a general cohort, with comparison cohorts of nonsurvivors versus survivors and elderly versus nonelderly. Linear regression analysis was utilized to demonstrate trends with statistical significance. There were 965 patients with traumatic spine injuries with 2,333 spine trauma levels. The general cohort showed a trimodal age distribution, male-to-female ratio of 2:2, motor vehicle accidents as the primary spine trauma mechanism, 47.7% patients with severe polytrauma as graded using the Injury Severity Score (ISS), 17.3% with traumatic brain injury (TBI), the majority of patients with one spine injury level, 7% neurological deficit rate, 12.8% spine trauma operative rate, and 5.2% mortality rate. Variables with statistical significance trending toward mortality were the elderly, motor vehicle occupants, severe ISS, TBI, C1–2 dissociations, and American Spinal Injury Association (ASIA) A, B, and C neurological grades. Variables with statistical significance trending toward the elderly were females low falls one spine injury level type 2 odontoid fractures subaxial cervical spine distraction injuries ASIA A, B, and C neurological grades and patients without neurological deficits. Of the general cohort, 50.3% of spine trauma survivors were discharged home, and 48.1% were discharged to rehabilitation facilities. This study provides baseline spine trauma epidemiological data. The trimodal age distribution of patients with traumatic spine injuries calls for further studies and intervention targeted toward the 46- to 55-year age group as this group represents the main providers of financial and social security. The study's unique feature of delineating variables with statistical significance trending toward both mortality and the elderly also provides useful data to guide future research studies, benchmarking, public health policy, and efficient resource allocation for the management of spine trauma.
Publisher: Japanese Circulation Society
Date: 2014
Publisher: Wiley
Date: 08-2017
DOI: 10.1111/JEBM.12256
Abstract: This systematic review aimed to determine the effect of prehospital notification systems for major trauma patients on overall (<30 days) and early (<24 hours) mortality, hospital reception, and trauma team presence (or equivalent) on arrival, time to critical interventions, and length of hospital stay. Experimental and observational studies of prehospital notification compared with no notification or another type of notification in major trauma patients requiring emergency transport were included. Risk of bias was assessed using the Cochrane ACROBAT-NRSI tool. A narrative synthesis was conducted and evidence quality rated using the GRADE criteria. Three observational studies of 72,423 major trauma patients were included. All were conducted in high-income countries in hospitals with established trauma services, with two studies undertaking retrospective analysis of registry data. Two studies reported overall mortality, one demonstrating a reduction in mortality (adjusted odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39 to 0.94, 72,073 participants) and the other demonstrating a nonsignificant change (OR 0.61, 95% CI 0.23 to 1.64, 81 participants). The quality of this evidence was rated as very low. Limited research on the topic constrains conclusive evidence on the effect of prehospital notification on patient-centered outcomes after severe trauma. Composite interventions that combine prehospital notification with effective actions on arrival to hospital such as trauma bay availability, trauma team presence, and early access to definitive management may provide more robust evidence towards benefits of early interventions during trauma reception and resuscitation.
Publisher: SAGE Publications
Date: 06-11-2013
Abstract: Retrospective review on clinical-quality trauma registry prospective data. To identify early predictors of suboptimal health status in polytrauma patients with spine injuries. A retrospective review on a prospective cohort was performed on spine-injured polytrauma patients with successful discharge from May 2009 to January 2011. The Short Form 12-Questionnaire Health Survey (SF-12) was used in the health status assessment of these patients. Univariate and multivariate logistic regression models were applied to investigate the effects of the Injury Severity Score, age, blood sugar level, vital signs, brain trauma severity, comorbidities, coagulation profile, spine trauma-related neurologic status, and spine injury characteristics of the patients. The SF-12 had a 52.3% completion rate from 915 patients. The patients who completed the SF-12 were younger, and there were fewer patients with severe spinal cord injuries (American Spinal Injury Association classifications A, B, and C). Other comparison parameters were satisfactorily matched. Multivariate logistic regression revealed five early predictive factors with statistical significance ( p ≤ 0.05). They were (1) tachycardia (odds ratio [OR] = 1.88 confidence interval [CI] = 1.11 to 3.19), (2) hyperglycemia (OR = 2.65 CI = 1.51 to 4.65), (3) multiple chronic comorbidities (OR = 2.98 CI = 1.68 to 5.26), and (4) thoracic spine injuries (OR = 1.54 CI = 1.01 to 2.37). There were no independent early predictive factors identified for suboptimal mental health-related qualify of life outcomes. Early independent risk factors predictive of suboptimal physical health status identified in a level 1 trauma center in polytrauma patients with spine injuries were tachycardia, hyperglycemia, multiple chronic medical comorbidities, and thoracic spine injuries. Early spine trauma risk factors were shown not to predict suboptimal mental health status outcomes.
Publisher: Elsevier BV
Date: 05-2008
DOI: 10.1016/J.INJURY.2007.10.021
Abstract: To characterise patients who were admitted to the ward following Emergency Department (ED) management for thoracic injury yet went on to require Intensive Care Unit (ICU) admission. To identify risk factors for failed ward management. All patients admitted to the ward following chest trauma from 2002 to 2006 were identified from the Alfred Hospital trauma database. Patients who went on to require ICU admission were compared to those admitted to and discharged from the ward without requiring ICU. Possible predictors of ICU admission were analysed. There were 764 patients during the study period who were admitted to the ward following chest trauma. Of these, 70 patients went on to require Intensive Care admission. Patients requiring ICU admission spent a significantly longer time in hospital and required significantly more rehabilitation. Multivariate analysis using stepwise logistic regression confirmed intercostal catheter (ICC) insertion and higher injury severity scores as significant independent variables associated with ICU admission. Associated abdominal injury, along with multiple rib fractures and flail were also predictive of failed ward management. This study demonstrated that intercostal catheter insertion (tube thoracostomy) was an independent risk factor for deterioration following admission along with multiple rib fractures and certain associated injuries. This should be considered when admitting patients to the ward.
Publisher: Elsevier BV
Date: 08-2011
DOI: 10.1016/J.BURNS.2011.01.021
Abstract: To improve the accuracy of blood loss estimation during extensive escharectomy and auto-microskin grafting on extremities in adult male major burn patients. All adult male major burn patients admitted to our center who underwent extensive escharectomy and auto-microskin graft on extremities for more than 10% TBSA during the period 1 January 2008 to 31 December 2009 were involved in this study. The blood loss during the operation was estimated by the surgeons or calculated according to the changes in hemoglobin levels. The average burn and escharectomy areas for the 64 burn patients included in the study were 74.16 ± 16.96% and 30.27 ± 15.63% TBSA respectively. The auto-microskin donor area was 3.81% TBSA. The volumes of intra-operative calculated and estimated blood losses and transfused blood during the operation were 0.47 ml/cm2, 0.13 ml/cm2 and 0.20 ml/cm2 surgical area 77.29 ml, 20.51 ml and 32.83 ml per 1% TBSA), respectively. Within two weeks after injury surgical blood loss appeared to be greater the later the operation was carried out. Within the first week after injury the mean proportional blood loss was increased with area excised. In this study the average calculated blood loss for the operation of extensive escharectomy and microskin graft in adult male major burn patient was 0.47 ml/cm2 (77.29 ml per 1% TBSA). This result will help us to predict expected blood loss more accurately.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2010
Publisher: Wiley
Date: 27-10-2008
Publisher: Wiley
Date: 15-09-2021
Abstract: Moderate to severe traumatic brain injury (TBI) contributes to a significant burden across Australia. However, the data required to inform targeted equitable system‐level improvements in emergency TBI care do not exist. The incidence and determinants of outcomes following moderate to severe TBI in Australia remain unknown. The variation in the impact of moderate to severe TBI, according to patient demographics and injury mechanism, is poorly defined. The Australian Traumatic Brain Injury National Data Project will lead to a clear understanding, across Australia and pre‐specified subgroups (including Aboriginal and Torres Strait Islander peoples), of the incidence, determinants and impact of priority outcomes following moderate to severe TBI, including survival to discharge home. Furthermore, this project will establish a set of national clinical quality indicators for patients experiencing a moderate to severe TBI. The Australian Traumatic Brain Injury National Data Project will inform where to target emergency care system‐wide improvements. Without baseline data, efforts are wasted.
Publisher: Elsevier BV
Date: 04-2017
DOI: 10.1016/J.JOCN.2016.12.009
Abstract: Prediction of post-concussive syndrome after apparent mild traumatic brain injury (TBI) and subsequent cognitive recovery remains challenging, with substantial limitations of current methods of cognitive testing. This pilot study aimed to determine if levels of micro ribonucleic acids (RNAs) circulating in plasma are altered following TBI, and if changes to levels of such biomarkers over time could assist in determination of prognosis after TBI. Patients were enrolled after TBI on presentation to the Emergency Department and allocated to three groups: A - TBI (physical trauma to the head), witnessed loss of consciousness, amnesia, GCS=15, a normal CT Brain and a recorded first pass after post-traumatic amnesia (PTA) scale B TBI, witnessed LOC, amnesia, GCS=15, a normal CT brain and a PTA scale test fail and: C - TBI and initial GCS <13 on arrival to the ED. Venous blood was collected at three time points (arrival, day 5 and day 30). Isolation of cell-free total RNA was then assayed using a custom miRNA PCR array. Two micro-RNAs, mir142-3p and mir423-3p demonstrated potential clinical utility differentiating patients after mild head injury into those at greater risk of developing amnesia and therefore, post-concussive syndromes. In addition, these miRNA demonstrated a decrease in expression over time, possibly indicative of brain healing after the injury. Further evaluation of these identified miRNA markers with larger patient cohorts, correlation with clinical symptoms and analysis over longer time periods are essential next steps in developing objective markers of severity of TBI.
Publisher: Wiley
Date: 11-07-2010
DOI: 10.1111/J.1742-6723.2010.01303.X
Abstract: A low case incidence and variable skill level prompted the development of a credentialing programme and specific surgical training in resuscitative thoracotomy for emergency physicians at The Alfred, a Level 1 Adult Victorian Major Trauma Service. A review of the incidence of traumatic pericardial t onade and the objectives of resuscitative thoracotomy were undertaken. A training programme involving pre-reading of a 17 page teaching manual, a 40 min didactic lecture and a 2 h surgical skills station using anaesthetized pigs were developed. The specific indication for resuscitative thoracotomy for this programme is ultrasound demonstrated cardiac t onade secondary to blunt or penetrating truncal trauma in a haemodynamically unstable patient with a systolic blood pressure of less than 70 mmHg despite pleural decompression and intravenous volume replacement. Cardiac electrical activity must be present. The primary aims of resuscitative thoracotomy taught are release of cardiac t onade, control of haemorrhage and access for internal cardiac massage. Emergency physicians working in high-volume Trauma Centres are expected to diagnose cardiac t onade and on occasion decompress the pericardium. Specific training in the procedure should be undertaken.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2012
Publisher: JMIR Publications Inc.
Date: 29-03-2020
Abstract: elemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation. ur objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care. his systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies–of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently. ut of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes. he information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented.
Publisher: No publisher found
Date: 2007
Publisher: Wiley
Date: 14-06-2017
Abstract: A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography (FAST), early computed tomography scanning with contrast angiography, angio-embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi-faceted change over a 12-year period. A retrospective cohort study was conducted comparing patients presenting with serious pelvic injury in 2002 to those presenting in 2013. The primary exposure and comparator variables were the year of presentation and the primary outcome variable was mortality at hospital discharge. Potential confounders were evaluated using multivariable logistic regression analysis. There were 1213 patients with a serious pelvic injury (Abbreviated Injury Scale ≥3), increasing from 51 in 2002 to 156 in 2013. Demographics, injury severity and presenting clinical characteristics were similar between the two time periods. There was a statistically significant difference in mortality from 20% in 2002 to 7.7% in 2013 (P = 0.02). The association between the primary exposure variable of being injured in 2013 and mortality remained statistically significant (adjusted odds ratio 0.10 95% confidence interval: 0.02-0.60) when adjusted for potential clinically important confounders. Multi-faceted interventions directed at the spectrum of trauma resuscitation from pre-hospital care to definitive surgical management were associated with significant reduction in mortality of patients with severe pelvic injury from 2002 to 2013. This demonstrates the effectiveness of an integrated, inclusive trauma system in achieving improved outcomes.
Publisher: Wiley
Date: 10-2005
DOI: 10.1111/J.1742-6723.2005.00775.X
Abstract: Objective: Application of the Trauma and Injury Severity Score (TRISS) to a trauma population identifies patients with ‘unexpected survival’. This study used TRISS analysis to identify ‘unexpected survivors’ suffering major thoracic trauma, who survived to hospital discharge. Further analysis determined prehospital interventions that appeared to contribute to ‘unexpected survival’. Methods: The present study was a single‐centre, retrospective case review with comparative statistical analysis. Patients were identified from the Alfred Trauma Registry between 1 July 2002 and 30 June 2003. Results: There were 336 adult trauma patients treated at The Alfred Trauma Centre with an Injury Severity Score (major trauma) and at least one thoracic Anatomical Injury Score of 3 (severe) or greater. Of the eligible patients, 322/336 (95.8%, 95%[confidence interval] CI 95.1–96.5%) had complete data available for analysis. The study population mortality was 42/322 (13.0%, 95% CI 12.3–13.7%). There were 20 ‘unexpected survivors’ (5.9%) and 5 (1.5%) ‘unexpected deaths’ on TRISS analysis. Chest decompression and/or endotracheal intubation prehospital was performed on 16/20 ‘unexpected survivors’. GCS for ‘unexpected survivors’ and ‘expected deaths’ (3.8 vs 3.5, P = 0.27) was not a predictor of survival. Respiratory rate per minute (16.2 vs 8.8, P = 0.01) and systolic blood pressure – mmHg (98 vs 80, P = 0.03) were significantly greater in the ‘unexpected survivors’ group compared with the ‘expected death’ group. Conclusion: For patients sustaining severe thoracic blunt trauma, prehospital intubation and chest decompression appear to be associated with unexpected survival. A low GCS at scene is not predictive of ‘unexpected survival’ or ‘expected death’.
Publisher: Elsevier BV
Date: 2010
DOI: 10.1016/J.INJURY.2009.09.029
Abstract: Recent retrospective studies have found high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratios during trauma resuscitation to be associated with improved mortality. Whilst this association may be related to a mortality bias present in these studies, there has been an overall tendency towards a 1:1 FFP:PRBC ratio in massive transfusion guidelines worldwide. The aim of this study was to retrospectively review the administration of FFP in patients undergoing massive transfusion during trauma resuscitation, to add to the evidence base for massive transfusion guidelines. Multi-trauma patients who were administered blood transfusions of 5units or more of packed red blood cells (PRBCs) in the first 4h were included in this study. Mortality was the primary endpoint with length of hospital stay, ICU hours and mechanically ventilated hours secondary endpoints. There were 331 patients included in this study with a median Injury Severity Score (ISS) of 36 (25-50) and a mortality of 29.9%. There was little change in the ratio of FFP:PRBC transfused per patient from 2005 to 2008. A low FFP:PRBC ratio in the first 4h of resuscitation, older age, low initial GCS and coagulopathy on presentation were significant independent factors associated with mortality. When deaths in the first 24h were excluded, the FFP:PRBC ratio had no association with mortality. This study has shown increased initial survival in association with higher FFP:PRBC ratios during massive transfusion in a population with a high proportion of blunt injuries. The association is difficult to interpret because of an inherent survival bias. The optimal ratio of FFP:PRBC during massive transfusion may be different to 1:1 and further prospective research is required. There is now an increasing need for well designed randomised controlled trials to determine the best FFP:PRBC ratio for the resuscitation of blunt multi-trauma patients.
Publisher: No publisher found
Date: 03-06-2005
Publisher: BMJ
Date: 10-08-2010
Abstract: Clinical handover between paramedics and the trauma team is undertaken in a time-pressured environment. Paramedics are often required to handover complex problems to a multitude of staff. There is evidence that information loss occurs at this transition. The aims of this project were to (1) develop a minimum dataset to assist paramedics provide handover (2) identify attributes of effective and ineffective handover (3) determine the feasibility of advanced data transmission and (4) identify how to best display data in trauma bays. Qualitative study of paramedics and trauma team members. A thematic analysis was undertaken using grounded theory. Ten paramedics and 17 trauma team members were interviewed. A minimum dataset modified on an existing template was developed to include fields required by the trauma team to inform immediate treatment. Respondents stated that an effective handover was one which was delivered succinctly and in a structured manner, and contained only vital data necessary to direct immediate treatment. Advanced transmission of data to the receiving hospital was widely supported. While computers carried by paramedics were capable of exporting data to the receiving hospital, barriers such as time constraints, workflow issues and infection control issues impeded the ability to do this in the current environment. There is support for the adoption and further evaluation of a handover template. It can provide valuable structure to the face-to-face handover, and experience from other specialties suggests it can reduce information loss. Strategies to enable information to be transmitted in advance of the patients' arrival must address concerns voiced by paramedics.
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.INJURY.2013.01.010
Abstract: The use of intravenous oxygen carriers (packed red blood cells (PRBC), whole blood and synthetic haemoglobins (HBOCs) for selected pre-hospital trauma resuscitation cases has been reported, despite a lack of validated clinical indications. The aim of this study was to retrospectively identify a sub-group of adult major trauma patients most likely to benefit from pre-hospital oxygen carrier administration and determine the predictive relationship between pre-hospital shock index (SI) [pulse rate/systolic blood pressure] and haemorrhagic shock, blood transfusion and mortality. A retrospective review of adult major trauma patients recorded in The Alfred Trauma Registry was conducted. Patients were included if they received at least 1L of pre-hospital crystalloid and spent over 30 min in transit. The association of shock index and transfusion was determined. Patients were further sub-grouped by mode of transport to determine the population of trauma patients who could be included into prospective studies of intravenous oxygen carriers. There were 1149 patients included of whom 311 (21.9%) received an acute blood transfusion. The SI correlated well with transfusion practice. A SI ≥ 1.0, calculated after at least 1L of crystalloid transfusion, identified patients with a high specificity (93.5% 95% CI: 91.8-94.8) for receiving a blood transfusion within 4h of hospital arrival. While patients transported by helicopter had higher injury severity and blood transfusion requirement, there were no difference in physiological variables and outcomes when compared to patients transported by road car. A shock index ≥ 1.0 is an easily calculated variable that may identify patients for inclusion into trials for pre-hospital oxygen carriers. Shocked patients have high mortality rates whether transported by road car or by helicopter. The efficacy of pre-hospital intravenous oxygen carriers should be trialled using a shock index ≥ 1.0 despite fluid resuscitation as the clinical trigger for administration.
Publisher: Elsevier BV
Date: 2009
Publisher: SAGE Publications
Date: 07-02-2021
Abstract: The ability to evaluate the degree of healing of a fractured bone is an integral part of orthopaedic clinical care. The conventional assessment techniques including X-ray and computed tomography are qualitative assessments, where their accuracy is dependent on the surgeon’s experience. Although there has been a significant research devoted to accurately define fracture healing, development of more efficient diagnostic tools for an accurate diagnosis of non-unions is still a very subjective area. This article investigates the potential use of the dynamic response to assess the healing of a fractured femur treated with an intramedullary nail. While compared to the conventional method, the dynamic technique is highly advantageous, as it is non-radiative and non-invasive. The experimental work presented utilises an osteotomised composite femur specimen fixated with an intramedullary nail. The test specimen was tightly enclosed by dense and soft modelling clay to simulate the d ing effect resulting from mass loading of soft tissues. A long curing adhesive epoxy is applied to the osteotomised region, and the curing of the epoxy is used to simulate the fracture healing process. The results provided evidence indicating that the magnitude and phase of the cross-spectrum, and the coherence function acquired at different healing times from the two-sensor measurement strategy can be used to derive a healing index to quantify the state of healing of the fixated femur. The findings suggest the possible viability of vibrational dynamic technique for healing assessment and, furthermore, its development will yield an assessment technique that complements existing clinical diagnostic tools.
Publisher: BMJ
Date: 12-08-2014
DOI: 10.1136/INJURYPREV-2014-041336
Abstract: Traumatic injury is a leading contributor to the overall global burden of disease. However, there is a worldwide shortage of population data to inform understanding of non-fatal injury burden. An improved understanding of the pattern of recovery following trauma is needed to better estimate the burden of injury, guide provision of rehabilitation services and care to injured people, and inform guidelines for the monitoring and evaluation of disability outcomes. To provide a comprehensive overview of patient outcomes and experiences in the first 5 years after serious injury. This is a population-based, nested prospective cohort study using quantitative data methods, supplemented by a qualitative study of a seriously injured participant s le. All 2547 paediatric and adult major trauma patients captured by the Victorian State Trauma Registry with a date of injury from 1 July 2011 to 30 June 2012 who survived to hospital discharge and did not opt-off from the registry. To analyse the quantitative data and identify factors that predict poor or good outcome, whether there is change over time, differences in rates of recovery and change between key participant subgroups, multilevel mixed effects regression models will be fitted. To analyse the qualitative data, thematic analysis will be used to identify important themes and the relationships between themes. The results of this project have the potential to inform clinical decisions and public health policy, which can reduce the burden of non-fatal injury and improve the lives of people living with the consequences of severe injury.
Publisher: Wiley
Date: 26-10-2016
DOI: 10.1111/ANS.13725
Publisher: MDPI AG
Date: 30-08-2019
Abstract: Background and Objectives: Major trauma centres manage severely injured patients using multi-disciplinary teams but the evidence-base that targeted Trauma Team Training (TTT) improves patients’ outcomes is unclear. This systematic review aimed to identify the association between the implementation of TTT programs and patient outcomes. Materials and Methods: We searched OVID Medline, PubMed and The Cochrane Library (CENTRAL) from the date of the database commencement until 10 of April 2019 for a combination of Medical Subject Headings (MeSH) terms and keywords relating to TTT and clinical outcomes. Reference lists of appraised studies were also screened for relevant articles. We extracted data on the study setting, type and details about the learners, as well as clinical outcomes of mortality and/or time to critical interventions. A meta-analysis of the association between TTT and mortality was conducted using a random effects model. Results: The search yielded 1136 unique records and abstracts, of which 18 full texts were reviewed. Nine studies met final inclusion, of which seven were included in a meta-analysis of the primary outcome. There were no randomised controlled trials. TTT was not associated with mortality (Pooled overall odds ratio (OR) 0.83 95% Confidence Interval 0.64–1.09). TTT was associated with improvements in time to operating theatre and time to first computerized tomography (CT) scanning. Conclusions: Despite few publications related to TTT, its introduction was associated with improvements in time to critical interventions. Whether such improvements can translate to improvements in patient outcomes remains unknown. Further research focusing on the translation of standardised trauma team reception “actions” into TTT is required to assess the association between TTT and patient outcome.
Publisher: Elsevier BV
Date: 11-2005
DOI: 10.1016/J.INJURY.2005.05.011
Abstract: The incidence of major trauma and associated fatalities in the State of Victoria, Australia, have declined over 20 years following the successful implementation of strategies to modify environmental and behavioural factors that contribute to motor vehicle injuries. However, several system deficiencies in the management of major trauma patients had remained unresolved. To investigate these shortfalls the State Government of Victoria established a task force in 1997 to review trauma and emergency services. The task force adopted the principle of "the right patient to the right hospital in the shortest time" and in 2000 began to deploy an integrated State Trauma System. Implementation of such a system required the designation of specific hospitals of various levels to care for trauma patients the concentration of trauma expertise at these centres integration and coordination between the service providers development of agreed triage and transfer protocols and improved education, training and research programs. A statewide major trauma database was established to enable system monitoring and facilitate further enhancements. The Victorian experience with the development of an integrated trauma system should aid in the development of similar systems nationally and internationally and is described in this paper.
Publisher: Oxford University Press (OUP)
Date: 23-12-2016
DOI: 10.1136/POSTGRADMEDJ-2016-134491
Abstract: CT of the brain (CTB) is one of the most common radiological investigations performed in the emergency department (ED). Emergency clinicians rely upon this imaging modality to aid diagnosis and guide management. However, their capacity to accurately interpret CTB is unclear. This systematic review aims to determine this capacity and identify the potential need for interventions directed towards improving the ability of emergency clinicians in this important area. A systematic review of the literature was conducted without date restrictions. We searched MEDLINE, EMBASE and Cochrane databases and studies reporting the primary outcome of concordance of CTB interpretation between a non-radiologist and a radiology specialist were identified. Studies were assessed for heterogeneity and a subgroup analysis of pooled data based on medical specialty was carried out to specifically identify the concordance of ED clinicians. The quality of evidence was assessed using the GRADE criteria. There were 21 studies included in this review. Among the included studies, 12 reported on the concordance of emergency clinicians, 5 reported on radiology trainees and 4 on surgeons. Clinical and statistical heterogeneity between studies was high (I2=97.8%, p& .01). The concordance in the emergency subgroup was the lowest among all subgroups with a range of 0.63–0.95 and a clinically significant error rate ranging from 0.02 to 0.24. Heterogeneity and the presence of bias limit our confidence in these findings. However, the variance in the interpretation of CTB between emergency clinicians and radiologists suggests that interventions towards improving accuracy may be useful.
Publisher: Wiley
Date: 24-05-2018
Publisher: Wiley
Date: 2006
DOI: 10.1111/J.1445-2197.2006.03641.X
Abstract: Background: The Parkland formula is established as the ‘gold standard’ for initial fluid resuscitation for major burns. The purpose of this study was to review our fluid resuscitation practice for major burns to determine whether anecdotal observations of significant variations from the Parkland formula were wide spread and whether any difference could be used as a basis for a revision of fluid resuscitation in major burns. Methods: A retrospective review of 127 presentations to The Alfred Burns Unit with total body surface area (TBSA) affected ≥15% was conducted. A retrospective review of the resuscitation data from these patients was compared with the Parkland formula as well as other studies. Results: A total of 49 patients with complete data on fluid administration and uncomplicated burns were included in the analysis. Significantly larger volumes of fluid (5.58 mL/kg per %TBSA) were given to these patients in the first 24 h than predicted by the Parkland formula. Mean arterial pressure, pulse rate and urine output were at satisfactory levels. Clinically evident complications from fluid administration were minimal. Mortality was similar to that in other centres. Conclusion: Fluid resuscitation volumes significantly higher than those predicted by the Parkland formula were given, without adverse consequences. This retrospective review supports a prospective, multicentre, randomized, controlled study comparing this study with the Parkland formula, resulting in a better guide to initial fluid resuscitation in major burns.
Publisher: BMJ
Date: 23-07-2012
Abstract: Injured patients presenting with hypothermia, acidosis and coagulopathy have been identified at high risk of death. This study aimed to describe the presentation, management and outcome of major trauma patients presenting with the 'triad of death' and identify ways to improve survival. A retrospective, explicit chart review was undertaken on patients presenting to a level I adult major trauma centre with the 'triad of death'. These patients presented directly from the scene, were coagulopathic (international normalised ratio (INR) >1.5), hypothermic (temperature <35°C) and acidotic (pH <7.2) on arrival. There were 90 patients over an 8-year period, with an overall mortality of 47.8%. No significant differences were observed among demographics and injury severity scores between survivors and non-survivors. Extremes of systolic blood pressure and heart rate, a high activated partial thromboplastin time activated partial thromboplastin time, low fibrinogen counts, pH, bicarbonate, base excess and haemoglobin were present among survivors. There were no survivors in our cohort with an initial INR greater than 3.2. Survivors received significantly lower volumes of packed red blood cells. There has been little change in mortality over time in this subgroup of major trauma patients. While the presence of the triad alone does not determine futility, there were no survivors over 8 years with extreme coagulopathy with concurrent hypothermia and acidosis.
Publisher: BMJ
Date: 07-2017
Publisher: Wiley
Date: 11-2014
DOI: 10.5694/MJA13.00235
Abstract: To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC). Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011. Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality. There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1% P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77 95% CI, 1.10-2.87). The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.
Publisher: Wiley
Date: 21-01-2018
Abstract: The Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y.) Program at The Alfred uses vivid clinical reality to build resilience and prevent injury by following a trauma patient's journey through hospital. The present study aims to analyse the effect of P.A.R.T.Y. on safety perceptions of driving after alcohol, seat belt use and risk-taking activities. Pre-programme, immediately post-programme and 3-5 months post-programme surveys with questions focused on the programme aims were distributed to all consented participants. There were 2502 participants during the study period and 1315 (53%) responses were received. The mean age was 16.2 (SD 0.8) years, 724 (56%) were women and 892 (68%) possessed a learner's permit for driving. Pre-programme, 1130 (86%) participants reported 'definitely not' likely to drive after drinking alcohol, that improved to 1231 (94%) immediately post-programme and 1215 (93%) at 3-5 months post-programme (P < 0.01). Designating a safe driver after drinking was reported by 1275 (97%) pre-programme, 1295 (98%) immediately post-programme and 1286 (98.2%) 3-5 months post-programme (P = 0.02). The perception of sustaining 'definite' injury after a motor vehicle crash without a seat belt increased from 780 (60%) pre-programme to 1051 (80%) immediately post-programme and 886 (69%) 3-5 months post-programme (P < 0.01). The possibility of sustaining 'definite' injury after risk-taking activities was reported by 158 (12%) pre-programme, 467 (36%) post-programme and 306 (23%) 3-5 months post-programme (P < 0.01). The P.A.R.T.Y. Program at The Alfred engaged substantial numbers of youths and achieved significant improvements among key outcome measures. Objectives were sustained at 3-5 months post-programme, but demonstrated decay, highlighting the importance of continual reinforcement.
Publisher: No publisher found
Date: 2007
Publisher: Wiley
Date: 22-07-2007
DOI: 10.1111/J.1742-6723.2007.00958.X
Abstract: To determine the drug use in injured Victorian drivers involved in motor vehicle collisions and subsequently transported to a major adult trauma centre in Victoria. A blood s le was obtained from patients who had been taken to The Alfred Emergency & Trauma Centre (Prahran, Vic., Australia) following a motor vehicle collision. This was performed at the same time and under the same law as compulsory blood screening in Victoria (Section 56 of the Road Safety Act). Four hundred and thirty-six specimens were analysed. Blood stored in vacutainer tubes containing preservative were screened for drugs using enzyme-linked immunosorbent assay and gas chromatography-mass spectometry analysis. Medically administered drugs were excluded from the results. Four hundred and thirty-six specimens were analysed. Metabolites of cannabis were the most commonly found drug (46.7%), the active form of cannabis (Delta9-tetrahydrocannabinol) was found in 33 specimens (7.6%). The next most prevalent drugs were benzodiazepines (15.6%), opiates (11%), hetamines (4.1%) and methadone (3%). Cocaine was detected in 1.4% of cases. Of the motor vehicle collisions 66% involved males and females of 15-44 years old and Delta9-tetrahydrocannabinol was almost exclusively found in this age group. In motor vehicle collisions involving older drivers there was an increasing use of benzodiazepines. In women >65 years old 30% were positive for benzodiazepines. Drug usage found in this group of injured drivers was disturbingly high. The introduction of further initiatives to decrease the prevalence of drug use in motor vehicle drivers is required.
Publisher: SAGE Publications
Date: 06-2012
Abstract: The establishment of a spine trauma registry collecting both spine column and spinal cord data should improve the evidential basis for clinical decisions. This is a report on the pilot of a spine trauma registry including development of a minimum dataset. A minimum dataset consisting of 56 data items was created using the modified Delphi technique. A pilot study was performed on 104 consecutive spine trauma patients recruited by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data analysis and collection methodology were reviewed to determine its feasibility. Minimum dataset collection aided by a dataset dictionary was uncomplicated (average of 5 minutes per patient). Data analysis revealed three significant findings: (1) a peak in the 40 to 60 years age group (2) premorbid functional independence in the majority of patients and (3) significant proportion being on antiplatelet or anticoagulation medications. Of the 141 traumatic spine fractures, the thoracolumbar segment was the most frequent site of injury. Most were neurologically intact (89%). Our study group had satisfactory 6-month patient-reported outcomes. The minimum dataset had high completion rates, was practical and feasible to collect. This pilot study is the basis for the development of a spine trauma registry at the Level 1 trauma center.
Publisher: Wiley
Date: 25-02-2017
Abstract: Multiply injured patients represent a particularly demanding subgroup of trauma patients as they require urgent simultaneous clinical assessments using physical examination, ultrasound and invasive monitoring together with critical management, including tracheal intubation, thoracostomies and central venous access. Concurrent access to multiple body regions is essential to facilitate the concept of 'horizontal' resuscitation. The current positioning of trauma patient, with arms adducted, restricts this approach. Instead, the therapeutic cruciform positioning, with arms abducted at 90°, allows planning and performing of multiple life-saving interventions simultaneously. This positioning also provides a practical surgical field with improved sterility and procedural access.
Publisher: Wiley
Date: 17-11-2021
Publisher: Wiley
Date: 26-05-2022
Abstract: The present study aimed to determine the difference in force required to puncture simulated pleura comparing Kelly cl s to fine artery forceps. The treatment of symptomatic traumatic pneumothorax and haemothorax involves puncture of the parietal pleura to allow decompression. This is usually performed using Kelly cl s or fine artery forceps. Over‐puncture pulmonary injury risk increases with the force used. An experienced single operator performed puncturing of simulated parietal pleura on a thoracic mannequin while wearing a force sensor under gloves. The force imparted at the device tip onto the parietal pleura was estimated by subtracting the force required to hold the device from the total force. Outcome variables were the total maximum force and force imparted by the device. There were 11 simulated procedures completed, seven using Kelly cl s and four using fine artery forceps. After subtracting the force required to hold the chosen forceps, the median value of pleural puncture force using Kelly cl s was 52.91 N (IQR 36.68–63.56) and 10.70 N (IQR 7.64–26.56) using fine artery forceps ( P = 0.006). A significantly increased force was required to puncture simulated parietal pleura using Kelly cl s compared to fine artery forceps. This higher puncture force will be associated with increased instrument acceleration at the time of pleural puncture, which may result in an increased risk of injury to the underlying lung. Based on these data, clinicians may reduce the risk of pulmonary injury by using fine artery forceps rather than Kelly cl s when performing pleural decompression.
Publisher: Wiley
Date: 29-01-2021
Abstract: Rib fractures are not only painful but are associated with morbidity and mortality, especially in older patients. The serratus anterior plane block (SAPB) is a plane block distant from major neurovascular bundles and may provide anaesthesia to a substantial area of the hemithorax. This pilot study was designed to assess if the SAPB can be safely and efficiently incorporated to the trauma reception workflow of an adult, level 1 trauma centre. A convenience s le of 20 adult patients with at least two or more unilateral rib fractures received a SAPB performed by an emergency physician in addition to their standard analgesic regime. Time to perform the procedure, the number of attempts and complications were recorded as feasibility measures. Secondary outcome was the safety of the block. Numerical pain scores at pre‐determined time points over 4 h, the diagnosis of hospital‐acquired pneumonia, hospital length of stay and mortality at hospital discharge were collected to provide pilot data on effectiveness. The median time to perform the procedure was 5.5 (interquartile range 4.6–10) mins with a range of 2–10.5 min. Most (16 80%) SAPBs were completed in a single attempt. There were no documented complications. Median pain scores reduced from 6.5 (6–8) and were maintained at 3 (2–5) at 4 h after the SAPB. The present study demonstrated the feasibility of ultrasound‐guided SAPB among patients with multiple rib fractures in the ED. No complications were observed. Further prospective evaluation of analgesic effects in a larger cohort is indicated.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2016
Publisher: Elsevier BV
Date: 03-2011
DOI: 10.1016/J.BURNS.2010.03.004
Abstract: This study presents fungi and their characteristics identified from burn patients at a major Chinese burn centre. All burns patients admitted to our Burn Research Institute from 2003 to 2006 inclusive were included in this study. Once fungal infection was suspected clinically, s les including wound tissue, blood, urine, stool and sputum were harvested for the culture of yeast. The sensitivities of the identified yeast were determined and the positive s les and cases were analysed. Out of a total of 3909 cases, 467 patients were clinically suspected of fungal infection, of which 1970 s les were taken for yeast culture. A total of 38 s les and 36 patients tested positive. The three most positive s les were urine, blood and catheter. Candida tropicalis was identified as the most common yeast type (42.1%), followed by Candida albicans (31.6%), Candida famata (T. Famata) (10.5%) and Candida glabrata (T. Glabrata) (7.9%). Except for C. galbrata, most of the yeast strains found in the study were sensitive to the routine antimycotic agents. There were eight deaths in the 36 positive patients. As much as 83.3% of the positive cases suffered burns of more than 50% total body surface area (TBSA) and half of the positive cases were greater than 80% TBSA. A total of 78.95% of the positive s les were taken from patients after 2 weeks post-burn injury. A profile of the fungi isolated from burn patients in a major Chinese burn centre is presented.
Publisher: Elsevier BV
Date: 05-2006
DOI: 10.1016/J.INJURY.2005.11.011
Abstract: The use of guidelines regarding the termination or withholding of cardiopulmonary resuscitation (CPR) in traumatic cardiac arrest patients remains controversial. This study aimed to describe the outcomes for victims of penetrating and blunt trauma who received prehospital CPR. We conducted a retrospective review of a statewide major trauma registry using data from 2001 to 2004. Subjects suffered penetrating or blunt trauma, received CPR in the field by paramedics and were transported to hospital. Demographics, vital signs, injury severity, prehospital time, length of stay and mortality data were collected and analysed. Eighty-nine patients met inclusion criteria. Eighty percent of these were blunt trauma victims, with a mortality rate of 97%, while penetrating trauma patients had a mortality rate of 89%. The overall mortality rate was 95%. Sixty-six percent of patients had a length of stay of less than 1 day. Four patients survived to discharge, of which two were penetrating and two were blunt injuries. Hypoxia and electrical injury were probable associated causes of two cardiac arrests seen in survivors of blunt injury. While only a small number of penetrating and blunt trauma patients receiving CPR survived to discharge, this therapy is not always futile. Prehospital emergency personnel need to be aware of possible hypoxic and electrical causes for cardiac arrest appearing in combination with traumatic injuries.
Publisher: Elsevier BV
Date: 06-2010
DOI: 10.1016/J.BURNS.2009.07.008
Abstract: This study aims to review the changes in management of inhalation injury and the associated reduction in mortality over the past 2 decades. The records of burn patients with inhalation injury hospitalised in our institute from 1986 to 2005 were retrospectively analysed. The incidence of inhalation injury and the associated mortality were analysed. Meanwhile, the relationship of inhalation injury with age, total burn area, tracheostomy intubation and mechanical ventilation were studied. The incidence of inhalation injury was 8.01% in the total 10 608 hospitalised burn patients during the 20 years surveyed. Inhalation injury was always associated with large-sized burn and was more common in adults. The incidence of tracheostomy and mechanical ventilation increased from 39.46 and 30.28% in the period from 1986 to 1995 to 70.12 and 39.74% from 1996 to 2005, respectively. The overall mortality of inhalation-injured burn patients was 15.88% compared with 0.82% of the non-inhalation group. The mortality of the burn patients with inhalation injury dropped from 25.29% during the first 10 years to 11.71% during the second decade (p<0.01). Mortality secondary to inhalation injury as the lead cause decreased from 14.56 to 6.29% (p<0.01). The care of inhalation injury has made significant progress over the past 2 decades. The early diagnosis of inhalation injury, early airway control and pulmonary function assistance with mechanical ventilation contribute to the reduction of mortality.
Publisher: SAGE Publications
Date: 2019
Abstract: This paper aims to evaluate the effects of mass loading on the healing assessment of an internally fixated femur by vibrational means. The presence of soft tissue surrounding a femur increases d ing and mass of a system, and hence affects the vibrational response of a mechanical structure by obscuring the coherent modes. This may compromise vibration-based monitoring strategies in identifying modes associated with fracture healing. This paper presents a series of experimental works to address this issue. Two osteotomised composite femurs were internally fixated using a plate-screw system and an intramedullary nail. Soft tissue is approximated by surrounding an artificial Sawbone femur with modelling clay. The femur is excited by an instrumented impact hammer and instrumented with two accelerometers to record bending and torsion modes between 0 and 600 Hz. A 30-min epoxy was applied to simulate the healing of the fractured femur in the osteotomised region. The resonant frequencies and its modes are monitored while union is being formed and a healing index is calculated at various times to quantify the degree of healing. The results demonstrate that the effect of modelling clay compressed the natural modes along the frequency axis. It is observed that frequency bandwidth in the vicinity of 150 Hz and 500 Hz is sensitive to the state of healing of the fixated femurs, which is due to the increase in stiffness of the osteotomised region. These findings were used to formulate the healing index which assists in identifying the initial, later and complete healing stages in conjunction with the index derivative. In this study, a two-sensor measurement strategy to quantify fixated femur healing is investigated. It is shown that the mass loading effect did not affect this vibrational analysis method ability to assess the state of healing, and both coherent bending and twisting modes associated with healing were easily identified. The proposed healing index, its derivative, and the cross-spectra are a viable tool for quantitative healing assessment.
Publisher: Wiley
Date: 12-06-2023
Abstract: Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries. A retrospective review was conducted of patients with blunt‐TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non‐survivor and survivor groups were collected to examine factors associated with delayed diagnosis. A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made h in 126 (81.3%), and h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty‐eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural‐effusions/elevated‐hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted. The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower‐chest/upper‐abdomen, a high degree of clinical suspicion should be held and follow‐up CXRs/CTs arranged.
Publisher: Wiley
Date: 22-12-2020
Abstract: This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients. Patients aged 18-60 years, transported directly from scene with exsanguinating, sub-diaphragmatic haemorrhage and hypovolaemic shock (systolic BP 1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment. Despite considerable training and resource allocation to ensure 24-h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14-month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit.
Publisher: Wiley
Date: 28-12-2017
Publisher: Wiley
Date: 08-2006
DOI: 10.1111/J.1445-2197.2006.03841.X
Abstract: The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision-making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point-of-care computer technology linked to real-time decision-making and trauma team coordination may achieve error reduction through standardized decision-making and a corresponding reduction in preventable mortality and morbidity.
Publisher: BMJ
Date: 17-06-2020
DOI: 10.1136/EMERMED-2019-208935
Abstract: Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI. This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period. There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p .001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81) hypotension 8.3% vs 7.0% (p=0.62) any complication 27.4% vs 23.6% (p=0.35)). This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.
Publisher: Elsevier BV
Date: 06-2012
DOI: 10.1016/J.ANNEMERGMED.2011.11.012
Abstract: We assess the efficacy of intravenous ketamine compared with intravenous morphine in reducing pain in adults with significant out-of-hospital traumatic pain. This study was an out-of-hospital, prospective, randomized, controlled, open-label study. Patients with trauma and a verbal pain score of greater than 5 after 5 mg intravenous morphine were eligible for enrollment. Patients allocated to the ketamine group received a bolus of 10 or 20 mg, followed by 10 mg every 3 minutes thereafter. Patients allocated to the morphine alone group received 5 mg intravenously every 5 minutes until pain free. Pain scores were measured at baseline and at hospital arrival. A total of 135 patients were enrolled between December 2007 and July 2010. There were no differences between the groups at baseline. After the initial 5-mg dose of intravenous morphine, patients allocated to ketamine received a mean of 40.6 mg (SD 25 mg) of ketamine. Patients allocated to morphine alone received a mean of 14.4 mg (SD 9.4 mg) of morphine. The mean pain score change was -5.6 (95% confidence interval [CI] -6.2 to -5.0) in the ketamine group compared with -3.2 (95% CI -3.7 to -2.7) in the morphine group. The difference in mean pain score change was -2.4 (95% CI -3.2 to -1.6) points. The intravenous morphine group had 9 of 65 (14% 95% CI 6% to 25%) adverse effects reported (most commonly nausea [6/65 9%]) compared with 27 of 70 (39% 95% CI 27% to 51%) in the ketamine group (most commonly disorientation [8/70 11%]). Intravenous morphine plus ketamine for out-of-hospital adult trauma patients provides analgesia superior to that of intravenous morphine alone but was associated with an increase in the rate of minor adverse effects.
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.INJURY.2010.08.007
Abstract: During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury. A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted. There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0-82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4-100.0) for urethral trauma. Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.
Publisher: Wiley
Date: 08-04-2014
Abstract: Early diagnosis of haemorrhagic shock (HS) might be difficult because of compensatory mechanisms. Clinical scoring systems aimed at predicting transfusion needs might assist in early identification of patients with HS. The Shock Index (SI) - defined as heart rate ided by systolic BP - has been proposed as a simple tool to identify patients with HS. This systematic review discusses the SI's utility post-trauma in predicting critical bleeding (CB). We searched the databases MEDLINE, Embase, CINAHL, Cochrane Library, Scopus and PubMed from their commencement to 1 September 2013. Studies that described an association with SI and CB, defined as at least 4 units of packed red blood cells (pRBC) or whole blood within 24 h, were included. Of the 351 located articles identified by the initial search strategy, five met inclusion criteria. One study pertained to the pre-hospital setting, one to the military, two to the in-hospital setting, and one included analysis of both pre-hospital and in-hospital values. The majority of papers assessed predictive properties of the SI in ≥10 units pRBC in the first 24 h. The most frequently suggested optimal SI cut-off was ≥0.9. An association between higher SI and bleeding was demonstrated in all studies. The SI is a readily available tool and may be useful in predicting CB on arrival to hospital. The evaluation of improved utility of the SI by performing and recording at earlier time-points, including the pre-hospital phase, is indicated.
Publisher: Springer Science and Business Media LLC
Date: 11-07-2014
Publisher: Wiley
Date: 15-04-2012
DOI: 10.1111/J.1537-2995.2012.03648.X
Abstract: Critically bleeding trauma patients require coordinated and efficient decision-making processes to ensure optimal management of their massive transfusion (MT) requirements. Human factors (HFs) is a discipline that investigates factors influencing work processes from the organizational, group, and in idual levels. Given the complexity of trauma resuscitation, implementing any intervention for decision support in MT is challenging and may benefit from a HFs-assisted approach. A systematic review was performed to identify reports of the introduction of any type of decision support for the provision of MT in critically bleeding adult trauma patients. Crucial contributions reported to influence design and uptake of the intervention were categorized into four HFs categories (environment, human, machine, and task). Extracted information was supplemented by surveying the contact authors. Evidence of clinical practice changes resulting from the intervention was also considered. We identified nine studies that had reported an intervention implementing new practice guidelines or a MT protocol. All were before-and-after comparative cohort studies and used historical controls as the preintervention cohort. Based on the identified reports, this review provides a HFs-assisted approach to aid clinicians and policy makers with the implementation of decision support for MT in the trauma care setting.
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 07-2013
DOI: 10.3171/2013.4.SPINE12876
Abstract: The treatment of morbidly obese in iduals with spine trauma presents unique challenges to spine surgeons and trauma staff. This study aims to increase awareness of current limitations in the surgical management of spine trauma in morbidly obese in iduals, and to illustrate practical solutions. Six morbidly obese patients were treated surgically for spine trauma over a 2-year period at a single trauma center in Australia. All patients were involved in high-speed motor vehicle accidents and had multisystem injuries. All weighed in excess of 265 pounds (120 kg) with a body mass index ≥ 40 (range 47.8–67.1). Cases were selected according to the considerable challenges they presented in all aspects of their management. Best medical and surgical care may be compromised and outcome adversely affected in morbidly obese patients with spine trauma. The time taken to perform all aspects of care is usually extended, often by many hours. Customized orthotics may be required. Imaging quality is often compromised and patients may not fit into scanners. Surgical challenges include patient positioning, surgical access, confirmation of the anatomical level, and obtaining adequate instrument length. Postoperative nursing care, wound healing, and venous thromboembolism prophylaxis are also significant issues. Management pathways and hospital guidelines should be developed to optimize the treatment of morbidly obese patients, but innovative solutions may be required for in idual cases.
Publisher: MDPI AG
Date: 22-01-2019
DOI: 10.3390/S19030454
Abstract: Quantitative and reliable monitoring of osseointegration will help further evaluate the integrity of the orthopaedic construct to promote novel prosthesis design and allow early mobilisation. Quantitative assessment of the degree or the lack of osseointegration is important for the clinical management with the introduction of prosthetic implants to utees. Acousto-ultrasonic wave propagation has been used in structural health monitoring as well as human health monitoring but so far has not extended to osseointegrated implants or prostheses. This paper presents an ultrasonic guided wave approach to assess the osseointegration of a novel implant. This study explores the potential of integrating structural health monitoring concepts into a new osseointegrated implant. The aim is to demonstrate the extension of acousto-ultrasonic techniques, which have been widely reported for the structural health monitoring of engineering structures, to assess the state of osseointegration of a bone and implant. To illustrate this potential, this paper will report on the experimental findings which investigated the unification of an aluminium implant and bone-like geometry surrogate. The core of the test specimen is filled with silicone and wrapped with plasticine to simulate the highly d ed cancellous bone and soft tissue, respectively. To simulate the osseointegration process, a 2-h adhesive epoxy is used to bond the surrogate implant and a bone-like structure. A series of piezoelectric elements are bonded onto the surrogate implant to serve as actuators and sensors. The actuating piezoelectric element on an extramedullary strut is excited with a 1 MHz pulse signal. The reception of the ultrasonic wave by the sensing elements located on the adjacent and furthest struts is used to assess the integration of this implant to the parent bone structure. The study shows an Osseointegration Index can be formulated by using engineering and acousto-ultrasonic methods to measure the unification of a bone and implant. This also highlights a potential quantitative evaluation technique regardless of bone-implant geometry and soft tissue d ing.
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.RESUSCITATION.2011.04.007
Abstract: The inability to accurately predict acute traumatic coagulopathy (ATC) has been a key factor in the low level of evidence guiding its management. The aim of this study was to develop a tool to accurately identify patients with ATC using pre-hospital variables without the use of pathology or radiological testing. Retrospective data from the trauma registry on major trauma patients were used to identify variables independently associated with coagulopathy. These variables were clinically evaluated to develop a scoring system to predict ATC, which was prospectively validated in the same setting. There were 1680 major trauma patients in the derivation dataset, with 151 patients being coagulopathic. Pre-hospital variables independently associated with ATC were entrapment (OR 1.85 95% CI: 1.12-3.06), temperature (OR 0.60 95% CI: 0.60-0.72), systolic blood pressure (OR 0.99 95% CI: 0.98-0.99), abdominal or pelvic content injury (OR 2.0 95% CI: 1.27-3.12) and pre-hospital chest decompression (OR 4.99 2.77-8.99). The COAST score was developed, scoring points for entrapment, temperature <35°C, systolic blood pressure < 100 mm Hg, abdominal or pelvic content injury and chest decompression. Prospectively validated using 1225 major trauma patients, a COAST score of ≥ 3 had a specificity of 96.4% with a sensitivity of 60.0%, with an area under the receiver operating characteristic curve of 0.83 (0.78-0.88). The COAST score accurately identified a group of patients with ATC using pre-hospital observations. This predictive tool can be used to select patients for inclusion into prospective studies examining management options for ATC. Mortality in these patients is high, potentially improving feasibility of outcome studies.
Publisher: JMIR Publications Inc.
Date: 11-12-2017
Abstract: lthough many mHealth interventions have shown efficacy in research, few have been effectively implemented and sustained in real-world health system settings. Despite this programmatic gap, there is limited conclusive evidence identifying the factors that affect the implementation and successful integration of mHealth into a health system. he aim of this study is to examine the in idual, organizational, and external level factors associated with the effective implementation of WelTel, an mHealth intervention designed to support outpatient medication adherence and engagement in care in Africa and North America. e will adopt the Consolidated Framework for Implementation Research (CFIR) constructs for evaluation of mHealth implementation including a scoring and monitoring system. We will apply the adapted tool to identify facilitators and barriers to implementation of the WelTel mHealth intervention in order to determine how the technology platform is perceived, diffused, adapted, and used by different mHealth project teams and health system actors in Africa and North America. We will use a mixed-methods approach to quantitatively test whether the factors identified in the CFIR framework are associated with the successful uptake of the mHealth intervention toward implementation goals. We will triangulate these data through interviews and focus group discussion with project stakeholders, exploring factors associated with successful implementation and sustainment of these interventions. he development of the customized CFIR is finalized and currently is in pilot testing. The initial results of the use of the tool in those 13 implementations will be available in 2019. Continuous conference and peer- reviewed publications will be published in the coming years. he results of this study will provide an in-depth understanding of in idual, organizational, and external level factors that influence the successful implementation of mHealth in different health systems and geographic contexts over time. Via the tool’s unique scoring system connected to qualitative descriptors, these data will inform the most critical implementation targets and contribute to the tailoring of strategies that will assist the health system in overcoming barriers to implementation, and ultimately, improve treatment adherence and engagement in care. R1-10.2196/9633
Publisher: Public Library of Science (PLoS)
Date: 05-07-2017
Publisher: Wiley
Date: 21-12-2017
Abstract: Cervical spine traumatic epidural haematomas (CSTEH) can cause potentially devastating neurological deficits if not promptly identified. Study aims were to determine the incidence, characteristics and outcomes for patients with CSTEH. A retrospective study was performed at a tertiary hospital with an adult Level 1 Trauma Centre on all consecutive patients diagnosed with CSTEH over a 4 year period. Medical record review was undertaken for all patients with the diagnoses of CSTEH to identify patient characteristics including age, mechanism of injury and co-morbid conditions. Additional data was extracted regarding radiology interpretation, surgical interventions, thromboembolic chemoprophylaxis use, discharge disposition and neurological outcomes. A total of 27 888 patients were admitted with traumatic injuries between 1 July 2010 and 30 June 2014, of which 1916 patients sustained cervical spine injuries. The incidence of CSTEH was 0.6% among all trauma patients and 9.1% among patients with any cervical spine injury. Of those with CSTEH, 89 patients (50.9%) had neurological deficits consistent with the anatomical location of the epidural haematoma. Magnetic resonance imaging diagnosed CSTEH in 132 patients (75.4%), of whom 23 patients (13.1%) had normal computed tomography cervical spine imaging. Among the patients diagnosed with CSTEH, 13 (7.4%) died and 78 (44.6%) required cervical spine surgical decompressions. This study shows a high incidence of CSTEH among trauma patients. CSTEH is associated with significant morbidity and mortality. High clinical vigilance is required to allow the request and acquisition of urgent magnetic resonance imaging to diagnose CSTEH as the entity is often not evident on initial cervical spine computed tomography investigations.
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.INJURY.2013.06.010
Abstract: An audit of ambulance service clinical records from 2001 to 2002 in Melbourne, Australia revealed 10 patients with tension pneumothorax on arrival at hospital which had been undetected or untreated by paramedics. The clinical practice guideline for paramedic recognition of tension pneumothorax was subsequently changed to emphasise heightened clinical suspicion of a tension pneumothorax in the setting of chest trauma, especially when patients were managed with positive pressure ventilation. This study was undertaken to determine whether the number of undetected or untreated tension pneumothoraces had decreased after the new clinical practice guideline and associated education program if there were unintended consequences arising from earlier paramedic intervention and what effect, if any, this change had on subsequent hospital treatment. Retrospective case note review of all patients requiring intercostal catheter (ICC) insertion at The Alfred Hospital, Melbourne, Australia, using records from Ambulance Victoria, the Alfred Trauma Registry and the National Coronial Information System. In 2001-2002 paramedics treated 22 patients with suspected tension pneumothorax before transport to the Alfred Hospital. In 2006-2007 this number had increased to 81. There was a decrease from ten to four in the number of unrecognised or untreated tension pneumothoraces between the two time periods. No unintended or adverse consequences of prehospital needle decompression could be found. However, there was an increase in the number of patients who had prehospital needle decompression that needed further treatment for tension pneumothorax on arrival at hospital. This need for further treatment was associated with use of shorter cannulas and unilateral needle decompression by paramedics. A small change in clinical practice guidelines, supported by an education and audit program, led to a reduction in unrecognised untreated tension pneumothoraces by paramedics without an increase in complications. Paramedics should be aware that a shorter cannula may fail to reach the pleural space and that both sides of the chest may require decompression.
Publisher: Wiley
Date: 10-2011
DOI: 10.1111/J.1742-6723.2011.01459.X
Abstract: Injury is a major global health problem. India suffers more deaths from vehicle collisions than any other country. Since 2004 The Alfred Hospital in Melbourne, Australia has established strong linkages with Christian Medical College (CMC) in Ludhiana, the Punjab, India and Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka, supporting trauma care capacity-building. In response to the demand for a systematic approach to trauma care in India and Sri Lanka, The Alfred Trauma Team Training Program was developed, funded by the Australian Agency for International Development, The Alfred and its participating staff, CMC and THK. The aim of the programme was to enhance the understanding and skill in reception and resuscitation of critically injured patients in a cohort of providers of emergency care. Participants were selected from nine sites: CMC, five government hospitals across the Punjab, Delhi, THK and Teaching Hospital Peradeniya in Kandy, Sri Lanka. The programme was conducted at CMC, with follow-up visits to THK and Teaching Hospital Peradeniya, and focused on team-based scenarios. The faculty included emergency clinicians from The Alfred. Participants showed improvement in the knowledge and skills of trauma reception and resuscitation. Observed programme challenges included the variety of health systems from which the participants were sourced. The Trauma Team Training Program allowed Australian emergency clinicians to impart some skills towards improving the level of trauma reception and resuscitation by 26 participants from nine sites. The team-based systematic approach to the delivery of emergency trauma care was valued by the participants.
Publisher: Wiley
Date: 12-1994
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.INJURY.2015.03.021
Abstract: This article proposes a counter-argument to standard Advanced Trauma Life Support (ATLS) training--which advocates bladder catheterisation to be performed as an adjunct to the primary survey and resuscitation for early decompression of the bladder and urine output monitoring. We argue the case for delaying bladder catheterisation until after definitive truncal Computed Tomography (CT) imaging. To reduce pelvic volume and associated bleeding, our trauma team delay catheter insertion until after the initial CT scan. The benefits of a full bladder also include improved views on initial Focussed Assessment with Sonography in Trauma (FAST) scan and improved interpretation of injuries on CT. Our urinary catheter related infection rates anecdotally decreased when insertion was delayed and consequently performed in a more controlled, non-resuscitation setting following CT. Adult blunt multitrauma patients with pelvic ring fractures are at risk of significant haemorrhage. Venous, arterial and medullary injuries with associated bleeding may be potentiated by an increased pelvic volume with ring disruption, as well as a reduced pressure effect from retroperitoneal and intra-pelvic organs on bleeding sites. Various techniques are used to reduce intra-pelvic bleeding. For shocked patients who have sustained major pelvic injuries with no other signs of urinary tract trauma and minimal urine in the bladder on initial FAST scan, we advocate careful, aseptic Foley catheter insertion followed by bladder insufflation with 500-600 mL of Normal Saline (NS) and subsequent catheter cl ing to t onade pelvic bleeding.
Publisher: Wiley
Date: 19-12-2018
Abstract: Trauma and other disease registries have been used to improve patient care and outcomes at the system level. Paradoxically, registries have had little role in informing the care of any in idual patient while that care is being determined and delivered. The lack of timeliness of useful data is a major barrier to the value of registries in improving in idual patient care real-time. What do trauma and emergency care providers require from their trauma registries to inform real-time patient-tailored improvements in trauma care? Research is urgently needed to improve the usefulness of disease registries, and to develop innovative processes and applications using patient data to inform patient care real-time, thereby improving patient outcomes.
Publisher: Wiley
Date: 12-2006
Publisher: Elsevier BV
Date: 09-2014
DOI: 10.1016/J.INJURY.2014.01.016
Abstract: Older age and blood transfusion have both been independently associated with higher mortality post trauma and the combination is expected to be associated with catastrophic outcomes. Among patients who received a massive transfusion post trauma, we aimed to investigate mortality at hospital discharge of patients ≥65 years old and explore variables associated with poor outcomes. A retrospective review of registry data on all major trauma patients presenting to a level I trauma centre between 2006 and 2011 was conducted. Mortality at hospital discharge among patients ≥65 years old was compared to the younger cohort. A multivariable logistic regression model was constructed to determine independent risk-factors for mortality among older patients. There were 51 (16.4%) patients of age ≥65 years who received a massive transfusion. There were 20 (39.2%) deaths, a proportion significantly higher than 55 (21.1%) deaths among younger patients (p<0.01). Pre-hospital GCS, the presence of acute traumatic coagulopathy and higher systolic blood pressure on presentation were independently associated with higher mortality. Age and volume of red cells transfused were not significantly associated with higher mortality. Survival to hospital discharge was demonstrated in elderly patients receiving massive transfusions post trauma, even in the presence of multiple risk factors for mortality. Restrictive resuscitation or transfusion on the basis of age alone cannot be supported. Early aggressive resuscitation of elderly trauma patients along specific guidelines directed at the geriatric population is justified and may further improve outcomes.
Publisher: Wiley
Date: 04-2008
DOI: 10.1111/J.1742-6723.2008.01071.X
Abstract: In response to the Indian Ocean tsunami of December 2004, the Health for the South Project was developed for Sri Lanka. The capacity-building component of this project involves the provision of trauma and emergency care training to the staff of Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka. A principal objective of this training for THK is an increased capacity to respond to future disasters in the south of Sri Lanka. Key elements of the capacity-building programme include the on-site emergency care training by teams of Australian emergency physicians and emergency nurses, working alongside the staff of the Emergency Treatment Unit in THK. It is expected that the programme will continue for at least 2 years, during which time a new Emergency and Trauma Centre will be constructed.
Publisher: AMPCo
Date: 09-2017
DOI: 10.5694/MJA17.00015
Abstract: To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury. A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007-2015.Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type. There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00 95% CI, 0.99-1.01 P = 0.70), motorcyclists (IRR, 0.99 95% CI, 0.97-1.01 P = 0.45) or pedestrians (IRR, 1.00 95% CI, 0.97-1.02 P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08 95% CI 1.05-1.10 P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007-2015, although the cost per patient declined for all road user groups. As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.
Publisher: Wiley
Date: 03-08-2022
DOI: 10.5694/MJA2.51674
Abstract: Traumatic brain injury (TBI) is the largest contributor to death and disability in people who have experienced physical trauma. There are no national data on outcomes for people with moderate to severe TBI in Australia. To determine the incidence and key determinants of outcomes for patients with moderate to severe TBI, both for Australia and for selected population subgroups, including Aboriginal and Torres Strait Islander Australians. The Australian Traumatic Brain Injury National Data (ATBIND) project will analyse Australia New Zealand Trauma Registry (ATR) data and National Coronial Information Service (NCIS) deaths data. The ATR documents the demographic characteristics, injury event description and severity, processes of care, and outcomes for people with major injury, including TBI, assessed and managed at the 27 major trauma services in Australia. We will include data for people with moderate to severe TBI (Abbreviated Injury Scale [AIS] (head) score higher than 2) who had Injury Severity Scores [ISS] higher than 12 or who died in hospital. People will also be included if they died before reaching a major trauma service and the coronial report details were consistent with moderate to severe TBI. The primary research outcome will be survival to discharge. Secondary outcomes will be hospital discharge destination, hospital length of stay, ventilator-free days, and health service cost. The Alfred Ethics Committee approved ATR data extraction (project reference number 670/21). Further ethics approval has been sought from the NCIS and multiple Aboriginal health research ethics committees. The ATBIND project will conform with Indigenous data sovereignty principles. Our findings will be disseminated by project partners with the aim of informing improvements in equitable system-level care for all people in Australia with moderate to severe TBI. Not applicable.
Publisher: Elsevier BV
Date: 12-2012
DOI: 10.1016/J.INJURY.2011.08.032
Abstract: The aim of this study was to establish the profile and outcomes of paediatric major trauma care (PTMC) within an integrated inclusive regionalised trauma system. Prospectively collected data from July 2001 to June 2009 from the Victorian State Trauma Registry of patients aged 2) was the most frequent injury (n=950, 58%). Surgery was required in 39% (n=637) of all cases 437 patients in the 10-17 year old group and 200 patients in the 0-9 year old group the mortality was 6.6%. There were 530 patients (32.4%) ventilated in ICU these had a median ISS (IQR) of 25 (17-34) and mortality of 7.4%. Improvements in risk-adjusted mortality have occurred as the years have progressed [adjusted OR 95% CI: 0.87 (0.76, 0.99)] and being treated at a Level 1 trauma centre was associated with lower adjusted odds of mortality [adjusted OR 95% CI: 0.27 (0.11, 0.68)]. The establishment of this integrated inclusive regionalised trauma system has been associated with progressively improving risk-adjusted mortality. The relatively low volume of major trauma requiring surgery in the 0-9 year old age group is notable, creating a challenging environment for maintaining skills and institutional preparedness.
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.INJURY.2014.03.002
Abstract: Intercostal catheter (ICC) insertion is the standard pleural decompression and drainage technique for blunt and penetrating traumatic injury. Potentially high complication rates are associated with the procedure, with the literature quoting over 20% in some cases (1-4). Empyema in particular is a serious complication. Risk adverse industries such as the airline industry and military services regularly employ checklists to standardise performance and decrease human errors. The use of checklists in medical practice is exemplified by introduction of the WHO Surgical Safety checklist. The Alfred Hospital in Melbourne, Australia is an Adult Level 1 Trauma Centre. In August 2009 The Alfred Trauma Service introduced an evidence-based checklist system for the insertion of ICCs, combined with standardised formal training for resident medical staff, in an attempt to minimise the incidence of ICC related empyema. Between January 2003 and July 2009 the incidence of empyema was 1.44% (29 in 2009 insertions). This decreased to 0.57% between August 2009 and December 2011 (6 in 1060 insertions) when the measures described above were introduced [p=0.038 Fisher's exact test, 2-tailed]. Quality control checklists - such as the ICC checklist described - are a sensible and functional means to standardise practice, to decrease procedural error and to reduce complication rates during trauma resuscitation.
Publisher: Wiley
Date: 11-02-2020
Publisher: Wiley
Date: 19-12-2020
Abstract: This retrospective observational study aimed to compare the impact of the Prevent Alcohol and Risk‐Related Trauma Youth (P.A.R.T.Y.) Program when delivered as In‐hospital or Outreach models to rural and regional students. The study population were consented participants from regional areas between 2013 and 2017 who completed pre‐programme, immediately post‐programme and 3–5 months post‐programme surveys. Responses from the metropolitan In‐hospital programme participants and regional Outreach programme participants were analysed within groups across the three time points. The primary outcome variable was a change in self‐reported perception of driving after drinking alcohol. Secondary outcome variables were designating a safe driver after drinking, perception of risk of injury if not wearing a seatbelt, risks of injury if undertaking physical risk‐taking activities and likelihood of the programme changing perceptions. There were 1314 participants invited to participate and 547 (42%) sets of complete surveys were received, of whom 296 (54%) were Outreach participants. Pre‐programme, a significantly lower proportion of Outreach participants reported ‘definitely not’ to driving after drinking (84% vs 91%), and perceived a ‘definite’ likelihood of sustaining injury if not wearing a seatbelt (57% vs 66%). Outreach participants displayed improvements in likelihood to drive after drinking alcohol immediately post‐programme and on follow up ( P = 0.028). Responses to all other secondary outcome measures demonstrated some improvement. Although demographically similar, baseline perceptions toward alcohol, risk‐taking and injury differed between groups. Improvements in perception were demonstrated across both models. These findings support P.A.R.T.Y. as an injury prevention initiative for regional youth.
Publisher: Wiley
Date: 23-03-2018
DOI: 10.1111/ANS.14479
Abstract: The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. Retrospective comparison of adult primary admissions (Glasgow Coma Scale 2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79% P = 0.7 and age: 34 (18-88) versus 33 (18-85) P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8) P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75) P = 0.09), prehospital hypotension (15.4% versus 11.7% P = 0.5) and desaturation (14.6% versus 17.5% P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6) P = 0.04) and more often successful PETI (85% versus 22% P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3% P = 0.34 OR = 0.84 95% CI: 0.38-1.86 P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58 95% CI: 1.30-1.92 P < 0.05). Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay.
Publisher: Elsevier BV
Date: 04-2016
DOI: 10.1016/J.IJID.2016.02.002
Abstract: Clinical reasoning utilizing certain symptoms and scores has not proven to be a reliable decision-making tool to determine whether or not to suspect a group A Streptococcus (GAS) infection in the patient presenting with a sore throat. Culture as the so-called 'gold standard' is impracticable because it takes 1 to 2 days (and even longer in remote locations) for a result, and thus treatment decisions will be made without the result available. Rapid diagnostic antigen tests have demonstrated sufficient sensitivities and specificities in detecting GAS antigens to identify GAS throat infections. Throat swab s les were collected from patients attending the Mount Isa Hospital emergency department for a sore throat these s les were compared to swab s les collected from healthy controls who did not have a sore throat. Both groups were aged 3-15 years. All swab s les were analyzed with a point-of-care test (Alere Test Pack +Plus with OBC Strep A). The etiologic predictive value (EPV) of the throat swab was calculated. The 95% confidence interval for positive EPV was 88-100% and for negative EPV was 97-99%, depending on assumptions made. This study demonstrates that the point-of-care test Alere Test Pack +Plus Strep A has a high positive predictive value and is able to rule in GAS infection as long as the proportion of carriers is low. Also the negative predictive value for ruling out GAS as the etiologic agent is very high irrespective of the carrier rate. Hence, this test is always useful to rule out GAS infection.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2019
Publisher: MDPI AG
Date: 06-09-2022
DOI: 10.3390/S22186727
Abstract: Osseointegration implant has attracted significant attention as an alternative treatment for transfemoral utees. It has been shown to improve patients’ sitting and walking comfort and control of the artificial limb, compared to the conventional socket device. However, the patients treated with osseointegration implants require a long rehabilitation period to establish sufficient femur–implant connection, allowing the full body weight on the prosthesis stem. Hence, a robust assessment method on the osseointegration process is essential to shorten the rehabilitation period and identify the degree of osseointegration prior to the connection of an artificial limb. This paper investigates the capability of a vibration-related index (E-index) on detecting the degree of simulated osseointegration process with three lengths of the residual femur (152, 190 and 228 mm). The adhesive epoxy with a setting time of 5 min was applied at the femur–implant interface to represent the stiffness change during the osseointegration process. The cross-spectrum and colormap of the normalised magnitude demonstrated significant changes during the cure time, showing that application of these plots could improve the accuracy of the currently available diagnostic techniques. Furthermore, the E-index exhibited a clear trend with a noticeable average increase of 53% against the cure time for all three residual length conditions. These findings highlight that the E-index can be employed as a quantitative justification to assess the degree of osseointegration process without selecting and tracing the resonant frequency based on the geometry of the residual femur.
Publisher: Springer Science and Business Media LLC
Date: 09-10-2021
Publisher: Elsevier BV
Date: 05-2017
DOI: 10.1016/J.INJURY.2017.02.025
Abstract: The aim of this study was to evaluate the incidence and severity of blunt cardiac injury (BCI) as determined by cardiac magnetic resonance imaging (CMR), and to compare this to currently used diagnostic methods in severely injured patients. We conducted a prospective, pilot cohort study of 42 major trauma patients from July 2013 to Jan 2015. The cohort underwent CMR within 7 days, enrolling 21 patients with evidence of chest injury and an elevated Troponin I compared to 21 patients without chest injury who acted as controls. Major adverse cardiac events (MACE) including ventricular arrhythmia, unexplained hypotension requiring inotropes, or a requirement for cardiac surgery were recorded. 6/21 (28%) patients with chest injuries had abnormal CMR scans, while all 21 control patients had normal scans. CMR abnormalities included myocardial oedema, regional wall motion abnormalities, and myocardial haemorrhage. The left ventricle was the commonest site of injury (5/6), followed by the right ventricle (2/6) and tricuspid valve (1/6). MACE occurred in 5 patients. Sensitivity and specificity values for CMR at predicting MACE were 60% (15-95) and 81% (54-96), which compared favourably with other tests. In this pilot trial, CMR was found to give detailed anatomic information of myocardial injury in patients with suspected BCI, and may have a role in the diagnosis and management of patients with suspected BCI.
Publisher: BMJ
Date: 13-07-2013
DOI: 10.1136/EMERMED-2013-202862
Abstract: Improved early pain control may affect the longer-term prevalence of persistent pain. In a previous randomised, controlled trial, we found that the administration of ketamine on hospital arrival decreased pain scores to a greater extent than morphine alone in patients with prehospital traumatic pain. In this follow-up study, we sought to determine the prevalence of persistent pain and whether there were differences in patients who received ketamine or morphine. This study was a long-term follow-up study of the prehospital, prospective, randomised, controlled, open-label study comparing ketamine with morphine in patients with trauma and a verbal pain score of >5 after 5 mg intravenous morphine. Patients were followed-up by telephone 6-12 months after enrollment, and a questionnaire including the SF-36 (V.2) health-related quality of life survey and the Verbal Numerical Rating Scale for pain was administered. A total of 97/135 (72%) patients were able to be followed-up 6-12 months after enrollment between July 2008 and July 2010. Overall, 44/97 (45%) participants reported persistent pain related to their injury, with 3/97 (3%) reporting persistent severe pain. The prevalence of persistent pain was the same between study groups (22/50 (44%) for the ketamine group vs 22/47 (46%) for the morphine group). There was no difference in the SF-36 scores between study arms. There is a high incidence of persistent pain after traumatic injury, even in patients with relatively minor severity of injury. Although decreased pain scores at hospital arrival are achieved with ketamine compared with morphine, this difference does not affect the prevalence of persistent pain or health-related quality of life 6 months after injury. Further larger studies are required to confirm this finding. Australian and New Zealand Clinical Trials Registry (ACTRN12607000441415).
Publisher: Springer Science and Business Media LLC
Date: 04-11-2020
DOI: 10.1186/S13012-020-01057-0
Abstract: The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T 3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators ( n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action (ii) Fidelity to the protocols : reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence) and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. Despite initial high ‘buy-in’ from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2005
DOI: 10.1097/01.TA.0000169807.96533.F2
Abstract: There is no consensus on the most appropriate method of cervical spine assessment in unconscious trauma patients. Passive flexion-extension imaging is one option for further investigating unconscious patients whose plain cervical radiographs are normal. This study examines the usefulness of this passive imaging in investigating for occult cervical injury. All unconscious patients admitted to The Alfred Trauma Intensive Care Unit over 1 year (January 1-December 31, 1998), who could not be clinically assessed within 48 hours in regard to their cervical spine, were identified. Results of passive flexion-extension radiography were compared with final injury status and clinical outcome as determined by retrospective review of the imaging reports, radiographic films, and case notes. One hundred twenty-three patients with normal three-view plain radiographs proceeded to passive functional investigation. These were false-negative in four of the seven patients with cervical spine injuries at presentation. No patients suffered any adverse neurologic events from their delayed diagnoses or from the flexion-extension procedure. Passive flexion-extension imaging has inadequate sensitivity for detecting occult cervical spine injuries. Although no patients suffered adverse neurologic complications, the potential for devastating consequences from missed cervical injury has resulted in the removal of passive flexion-extension imaging from the screening protocol.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2013
Publisher: Wiley
Date: 11-2004
Publisher: Wiley
Date: 13-05-2019
Publisher: Wiley
Date: 21-06-2020
Publisher: Elsevier BV
Date: 05-2015
DOI: 10.1016/J.INJURY.2014.12.009
Abstract: Detecting occult bleeding can be challenging and may delay resuscitation. The Shock Index (SI) defined as heart rate ided by systolic blood pressure has attracted attention. Prediction models using combinations of pre-hospital SI (phSI) and the trauma centre SI (tcSI) values may be effective in identifying patients requiring massive blood transfusions (MT). To explore whether combinations of the phSI and the tcSI augment MT prediction. The scores were retrospectively developed using all major trauma patients that presented to The Alfred Hospital between 2006 and 2012. The first PH and TC observations were used. To avoid exclusion of the 'sickest' patients, the SI was imputed to 2 where SBP was missing, but HR was present. We developed 4 models. (i) 'Dichotomised', defined as positive when both phSI and tcSI were ≥1. (ii) 'Formulaic', defined by logistic regression analysis. (iii) 'Combination', defined pragmatically based on the logistic regression. (iv) 'Trending', defined as: tcSI minus phSI. There were 6990 major trauma patients and 360 (5.2%) received MT. There were 1371 cases with either phSI or tcSI missing and were thus excluded from the analysis. The 'Dichotomised' had higher positive predictive value than the tcSI with a further 5 per 100 patients identified. The 'Formulaic' model, defined as: log Odds (MT)=2.16×tcSI+0.89×phSI-5.42, and the 'Combination' model, defined as: phSI×0.5+tcSI, performed equally (AUROC 0.83 versus 0.83, χ(2)=0.86, p=0.35). The 'Formulaic' performed marginally, but statistically significantly, more accurate than the tcSI alone (AUROC 0.83 versus 0.82, χ(2)=6.89, p<0.01). An 'Upward Trending' SI was observed in 1758 patients, revealing a 4.6-fold univariate association with MT (OR 4.55 95%CI 2.64-7.83), and an AUROC of 0.79 (95%CI 0.74-0.83). The 'Downward Trending' SI was protective against MT (OR 0.44 95%CI 0.34-0.57). The initial pre-hospital SI is associated with MT. However, this relationship did not clinically augment MT decision when combined with the in-hospital SI. The simplicity of the SI makes it a favourable option to explore further. Computer-assisted technology in data capturing, analysis and prognostication presents avenues for further research.
Publisher: Mary Ann Liebert Inc
Date: 06-2011
Abstract: The question as to whether mild traumatic brain injury (mTBI) results in persisting sequelae over and above those experienced by in iduals sustaining general trauma remains controversial. This prospective study aimed to document outcomes 1 week and 3 months post-injury following mTBI assessed in the emergency department (ED) of a major adult trauma center. One hundred and twenty-three patients presenting with uncomplicated mTBI and 100 matched trauma controls completed measures of post-concussive symptoms and cognitive performance (Immediate Post-Concussion Assessment and Cognitive Testing battery ImPACT) and pre-injury health-related quality of life (SF-36) in the ED. These measures together with measures of psychiatric status (the Mini-International Neuropsychiatric Interview [MINI]) pre- and post-injury, the Hospital Anxiety and Depression Scale, Visual Analogue Scale for Pain, Functional Assessment Questionnaire, and PTSD Checklist-Specific, were re-administered at follow-up. Participants with mTBI showed significantly more severe post-concussive symptoms in the ED and at 1 week post-injury. They performed more poorly than controls on the Visual Memory subtest of the ImPACT at 1 week and 3 months post-injury. Both the mTBI and control groups recovered well physically, and most were employed 3 months post-injury. There were no significant group differences in psychiatric function. However, the group with mild TBI was more likely to report ongoing memory and concentration problems in daily activities. Further investigation of factors associated with these ongoing problems is warranted.
Publisher: BMJ
Date: 22-08-2013
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.INJURY.2014.06.014
Abstract: Rib fractures are a common injury presenting to major trauma centres and community hospitals. Aside from the acute impact of rib fracture injury, longer-term morbidity of pain, disability and deformity have been described. Despite this, the mainstay of management for the vast majority of rib fracture injuries remains supportive only with analgesia and where required respiratory support. This study aimed to document the long-term quality of life in a cohort of major trauma patients with rib fracture injury over 24 months. Retrospective review (July 2006-July 2011) of 397 major trauma patients admitted to The Alfred Hospital with rib fractures and not treated with operative rib fixation. The main outcome measures were quality of life over 24 months post injury assessed using the Glasgow Outcome Scale Extended and SF12 health assessment forms and a pain questionnaire. Assessment over 24 months of major trauma patients with multiple rib fractures demonstrated significantly lower quality of life compared with published Australian norms at all time points measured. Return to work rates were poor with only 71% of those who were working prior to their accident, returning to any work. This study demonstrates a significant reduction in quality of life for rib fracture patients requiring admission to hospital, which does not return to the level of Australian norms for at least two years.
Publisher: Elsevier BV
Date: 12-2013
DOI: 10.1016/J.INJURY.2013.04.009
Abstract: There is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people. To identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures. We identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence. Sixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation. Geriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues.
Publisher: American Medical Association (AMA)
Date: 02-2011
DOI: 10.1001/ARCHSURG.2010.333
Abstract: This project tested the hypothesis that computer-aided decision support during the first 30 minutes of trauma resuscitation reduces management errors. Ours was a prospective, open, randomized, controlled interventional study that evaluated the effect of real-time, computer-prompted, evidence-based decision and action algorithms on error occurrence during initial resuscitation between January 24, 2006, and February 25, 2008. A level I adult trauma center. Severely injured adults. The primary outcome variable was the error rate per patient treated as demonstrated by deviation from trauma care algorithms. Computer-assisted video audit was used to assess adherence to the algorithms. A total of 1171 patients were recruited into 3 groups: 300 into a baseline control group, 436 into a concurrent control group, and 435 into the study group. There was a reduction in error rate per patient from the baseline control group to the study group (2.53 to 2.13, P = .004) and from the control group to the study group (2.30 to 2.13, P = .04). The difference in error rate per patient from the baseline control group to the concurrent control group was not statistically different (2.53 to 2.30, P = .21). A critical decision was required every 72 seconds, and error-free resuscitations were increased from 16.0% to 21.8% (P = .049) during the first 30 minutes of resuscitation. Morbidity from shock management (P = .03), blood use (P < .001), and aspiration pneumonia (P = .046) were decreased. Computer-aided, real-time decision support resulted in improved protocol compliance and reduced errors and morbidity. Trial Registration clinicaltrials.gov Identifier: NCT00164034.
Publisher: Wiley
Date: 04-2014
Abstract: Following findings of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, tranexamic acid (TxA) use post trauma is becoming widespread. However, issues of generalisability, applicability and predictability beyond the context of study sites remain unresolved. Internal and external validity of the CRASH-2 trial are currently lacking and therefore incorporation of TxA into routine trauma resuscitation guidelines appears premature. The Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH)-Trauma study is a National Health and Medical Research Council-funded randomised controlled trial of early administration of TxA in severely injured patients likely to have acute traumatic coagulopathy. The study population chosen has high mortality and morbidity and is potentially most likely to benefit from TxA's known mechanisms of action. This and further trials involving appropriate s le populations are required before evidence based guidelines on TxA use during trauma resuscitation can be developed.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2013
Publisher: Wiley
Date: 04-2007
DOI: 10.1111/J.1742-6723.2007.00948.X
Abstract: To identify potentially preventable prehospital deaths following traumatic cardiac arrest. Deaths following prehospital traumatic cardiac arrest during 2003 were reviewed in the state of Victoria, Australia. Possible survival with optimal bystander first-aid and shorter ambulance response times were identified. Injury Severity Scores (ISS) were calculated. Victims with an ISS <50 and signs of life were reviewed for potentially preventable factors contributing to death including signs of airway obstruction, excessive bleeding and/or delayed ambulance response times. We reviewed 112 cases that had full ambulance care records, hospital records and autopsy details in Victoria 2003. Most deaths involved road trauma and 55 victims had an ISS 10 min might have contributed to five deaths with an ISS <25. Five (4.5%) potentially preventable prehospital trauma deaths were identified. Three deaths potentially involved airway obstruction and two involved excessive bleeding. There is a case for increased awareness of the need for bystander first-aid at scene following major trauma.
Publisher: Elsevier BV
Date: 09-2012
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.INJURY.2017.08.024
Abstract: Pulmonary thromboembolism (PTE) is a dangerous complication of traumatic injury, with varied risk profiles and treatment options. This review aims to describe reported incidence and variables associated with PTE among severely injured patients. Searches were conducted using PubMed, Cochrane and MEDLINE. Relevant studies were identified by two independent reviewers based on predetermined inclusion criteria. Incidence of PTE was the primary outcome measure. Variables associated with PTE was the secondary outcome measure. The Newcastle-Ottawa Scale was used to assess quality of included studies. There were eight studies that satisfied inclusion criteria. The diagnosed incidence of PTE in these populations ranged from 0.35 to 24%. The most common variables associated with PTE were pelvic or lower limb injury, chest injury, higher total Injury Severity Score, male sex and age. Variables that were less commonly associated with PTE were previous warfarin use, head injury, high serum lactate, soft tissue injury, more than one operation, more than three days on a ventilator, presence of a subclavian central venous catheter, need for a blood transfusion, systolic blood pressure <90mmHg, abdominal injury, presence of a deep venous thrombosis, inferior vena cava filter placement and isolated liver spleen or spinal injuries. The reported incidence of PTE after major trauma is variable and dependent on inclusion criteria, diagnostic criteria and study design. Identified variables differed to those reported for venous thromboembolism in other populations. It is difficult to predict populations at risk of clinically significant PTE following injury using available evidence. Further studies linked to patient-specific variables will assist in more precise risk-stratification and interventions.
Publisher: MDPI AG
Date: 19-02-2019
DOI: 10.3390/S19040857
Abstract: The lack of a quantitative method to adequately assess fractured bone healing that has undergone fixation limits prognostic capabilities on patients’ optimal return to work. This paper addresses the use of vibrational analysis to monitor the state of healing of a plate-screw fixated femur and supplement the current clinical radiographic assessment. This experimental study involves an osteotomised composite femur specimen enclosed by modelling clay to simulate the d ing effect of overlying soft tissues. Epoxy adhesives are applied to the fractured region and to simulate the healing process. With the instrumentation described, the cross-spectrum and coherence are obtained and analysed in the frequency domain over a period of time. The results suggest that it is crucial to analyse the cross-spectrum and proposed healing index to quantitatively assess the stages of healing. The results also show that the mass loading effect due to modelling clay did not influence the proposed healing assessment technique. The findings indicate a potential non-intrusive technique to evaluate the healing of fractured femur by utilising the vibrational responses.
Publisher: Wiley
Date: 11-12-2020
Publisher: Elsevier BV
Date: 12-2009
DOI: 10.1016/J.BURNS.2009.02.020
Abstract: Fluid resuscitation is one of the critical treatments for the major burn patient in the early phases after injury. We evaluated the practice of fluid resuscitation for severely burned patients with the Third Military Medical University (TMMU) protocol, which is most widely used in many regions of China. Patients with major burns (>30% total body surface area (TBSA)) presenting to Southwest Hospital, Third Military Medical University, between January 2005 and October 2007, were included in this study. Fluid resuscitation was initiated by the TMMU protocol. A total of 71 patients were (46 adults and 25 children) included in this study. All patients survived the first 48 h after injury smoothly and none developed abdominal compartment syndrome or other recognised complications associated with fluid resuscitation. The average quantity of fluid infused was 3.3-61.33% more than that calculated based on the TMMU protocol in both adult and paediatric groups. The average urine output during the first 24h after injury was about 1.2 ml per kg body weight per hour in the two groups, but reached 1.2 ml and 1.7 ml during the second 24h in adult and pediatric groups, respectively. This study indicates that the TMMU protocol for fluid resuscitation is a feasible option for burn patients. In idualised resuscitation - guided by the physiological response to fluid administration - is still important as in other protocols.
Publisher: Elsevier BV
Date: 2012
DOI: 10.1016/J.INJURY.2010.10.015
Abstract: Acute traumatic coagulopathy is observed in 10-25% of patients post major trauma and its management forms an integral part of haemostatic resuscitation. The identification and treatment of this coagulopathy is difficult and there is uncertainty regarding optimal therapeutic guidelines during the early phases of trauma resuscitation. This study aimed to examine the association between acute coagulopathy and early deaths post major trauma. A retrospective review of data over a 5 year period was performed to determine the associations between variables considered to contribute to mortality for adult major trauma patients (Injury Severity Score (ISS)>15) receiving blood transfusions as part of their initial resuscitation. Early death, defined as death in ED, or death in the operating theatre (OT), Intensive Care Unit (ICU) or wards within 24 h of admission was the primary end-point. Patients with non-survivable head injury on initial imaging were excluded. Univariate associations were calculated and multivariable logistic regression analysis was used to determine independent associations with mortality. There were 772 patients included in this study with a median ISS of 29 (19-41), with 91.7% blunt trauma. All-cause in-hospital mortality was 17.5%, while 77 (9.7%) patients died early. Increasing age (OR 1.04), a GCS of 3-8 (OR 5.05), and the presence of acute coagulopathy (OR 8.77) were significant independent variables associated with early death. Acute traumatic coagulopathy, independent of injury severity, transfusion practice or other physiological markers for haemorrhage, was associated with early death in major trauma patients requiring a blood transfusion. Early recognition and management of coagulopathy, independent of massive transfusion guidelines, may improve outcome from trauma resuscitation. Further studies are required for the early recognition of acute traumatic coagulopathy to enable the development of an evidence base for management.
Publisher: Wiley
Date: 08-11-2022
Abstract: Haemorrhagic shock after trauma is a leading cause of death worldwide, particularly in young in iduals. Despite advances in trauma systems and resuscitation strategies, mortality from haemorrhagic shock has not declined over the previous two decades. A proportion of shocked trauma patients may experience a deficiency of cortisol relative to the severity of their injury. The benefit of exogenous steroid administration in patients suffering haemorrhagic shock as a result of injury is unclear. A systematic review of four databases (Ovid Medline, Ovid Embase, Cochrane, Scopus) was undertaken. Inclusion and exclusion criteria were pre‐determined and two reviewers independently screened the articles with disagreements arbitrated by a third reviewer. The primary outcome variable was 28‐day mortality. Quality of studies were assessed using the Cochrane‐risk‐of‐bias (RoB 2) tool. Of the 2919 studies yielded by the search strategy, 1274 duplicates were removed and 1645 screened on title and abstract. After the full text of 33 studies were assessed, two articles were included. Both studies were over 30 years old with small numbers of participants and with primary outcomes not including mortality. Of the data available, no statistically significant difference in mortality was detected. Hospital length of stay, reversal of shock or adverse events were not reported. Both studies were at risk of bias. There are no high quality or recent studies in the English literature investigating the use of steroids for haemorrhagic shocked trauma patients. PROSPERO: CRD42021239656.
Publisher: Springer Science and Business Media LLC
Date: 18-10-2016
Publisher: Elsevier BV
Date: 2015
Publisher: Elsevier BV
Date: 09-2021
Publisher: JMIR Publications Inc.
Date: 08-12-2020
DOI: 10.2196/18959
Abstract: Telemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation. Our objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care. This systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies–of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently. Out of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes. The information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented.
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1016/J.AUCC.2017.06.003
Abstract: Traumatic brain injury (TBI) is a significant public health issue. Assessing pupil reactivity is a crucial aspect of its management and the pupillometer has been shown to be a more objective tool compared to the standard penlight. Its use, however, is not widespread. To investigate the paucity in uptake, we examined the frequency of use of pupillometers (NeurOptics An online cross-sectional survey. Surveys were distributed five months after the introduction of pupillometers (in May 2015) to ICU doctors and nurses working in a quaternary referral centre providing state services for trauma. The survey included sections on: questions on demographics and experience, methods of conventional pupillary assessment in patients with TBI, experience of using the pupillometer, and questions on barriers to its use. Responses were collated as discrete variables and summarised using counts and proportions. Comparisons among proportions were undertaken using the chi-squared test and reported with 95% confidence intervals. A total of 79 responses were recorded, predominantly 94.9% (n=75) from nursing staff. A total of 50 (63.3%) responders were using the pupillometers, with a mean frequency-of-use rating of 4.67 out of 10 and a mean user-friendliness rating of 6.28 out of 10. There was no association between frequency of use and user-friendliness (p=0.36). The main identified barriers to its use included a lack of education with regards to its use, a perceived lack of clinical significance, a lack of standardisation of documenting findings, and difficulties with access to disposable patient shields (Smartguards). There was good adoption of the technology in the early phases of ICU implementation with user-friendliness rated favourably. In this paper we identify barriers to use and discuss possible solutions to increase clinical utility.
Publisher: Elsevier BV
Date: 05-2011
Publisher: Elsevier BV
Date: 2012
Publisher: Elsevier BV
Date: 09-2007
DOI: 10.1016/J.INJURY.2007.03.021
Abstract: To review the massive transfusion practice at a Level I adult Trauma Centre during initial trauma reception and resuscitation. All trauma patients presenting to The Alfred Emergency & Trauma Centre and receiving a transfusion of five units or more of packed red blood cells within 4h of presentation over a 26-month period were included in this study. Patient demographics, clinical characteristics, injuries, surgical management and volume of blood transfused were analysed with mortality as the primary endpoint. Initial clinical features and injuries predictive of massive transfusion were also analysed. There were 119 patients who received a transfusion of five units or more of packed red blood cells (PRBCs) within 4h of presentation. The median Injury Severity Score of this group of patients was 34.0 (IQR 26-48) and mortality was 27.7%. The median number of packed red blood cell transfused was 8.0 (IQR 6-14) in the 1st 4h. Initial clinical features and injuries independently associated with a larger volume of blood transfused were initial hypotension, fractures of the pelvis, kidney injuries, initial acidaemia, and thrombocytopaenia. The Injury Severity Score, initial coagulopathy measured by APTT and the presence of head injuries were the independent predictors of mortality. The volume of blood transfused during trauma resuscitation was not found to be an independent predictor of mortality. Prospective studies into transfusion practice and clinical features of patients during the trauma resuscitation phase requiring massive transfusion are needed to establish evidence-based guidelines for massive transfusion.
Publisher: Wiley
Date: 08-1999
Publisher: JMIR Publications Inc.
Date: 03-07-2018
DOI: 10.2196/RESPROT.9633
Publisher: Springer Science and Business Media LLC
Date: 17-07-2017
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 10-05-2017
Abstract: Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the ‘safe zone’ of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation.
Publisher: Hamad bin Khalifa University Press (HBKU Press)
Date: 10-05-2017
Abstract: Background: Cardiac injury is uncommon, but it is important to diagnose, in order to prevent subsequent complications. Extended focused assessment with sonography in trauma (eFAST) allows rapid evaluation of the pericardium and thorax. The objective of this study was to describe cardiac injuries presenting to a major trauma centre and the diagnostic performance of eFAST in detecting haemopericardium as well as broader cardiac injuries. Methods: Data of patients with severe injuries and diagnosed cardiac injuries (Injury Severity Score and AIS 2008 codes for cardiac injuries) were extracted from The Alfred Trauma Registry over a four-year period from July 2010 to June 2014. The initial eFAST results were compared to those of the final diagnosis, which were determined after analysing imaging results and intraoperative findings. Results: Thirty patients who were identified with cardiac injuries met the inclusion criteria. Among these, 22 patients sustained injuries under the scope of eFAST, of which a positive eFAST scan in the pericardium was reported in 13 (59%) patients, while nine (41%) patients had a negative scan. This resulted in a sensitivity of 59% (95% CI: 36.7%–78.5%). The sensitivity of detecting any cardiac injuries was lower at 43.3% (95% CI: 26.0–62.3). Conclusions: The low sensitivities of eFAST for detecting cardiac injuries and haemopericardium demonstrate that a negative result cannot be used in isolation to exclude cardiac injuries. A high index of suspicion for cardiac injury remains essential. Adjunct diagnostic modalities are indicated for the diagnosis of cardiac injury following major trauma.
Publisher: Wiley
Date: 31-07-2023
DOI: 10.5694/MJA2.52055
Abstract: To describe the frequency of hospitalisation and in‐hospital death following moderate to severe traumatic brain injury (TBI) in Australia, both overall and by patient demographic characteristics and the nature and severity of the injury. Cross‐sectional study analysis of Australia New Zealand Trauma Registry data. People with moderate to severe TBI (Abbreviated Injury Score [head] greater than 2) who were admitted to or died in one of the twenty‐three major Australian trauma services that contributed data to the ATR throughout the study period, 1 July 2015 – 30 June 2020. Primary outcome: number of hospitalisations with moderate to severe TBI secondary outcome: number of deaths in hospital following moderate to severe TBI. During 2015–20, 16 350 people were hospitalised with moderate to severe TBI (mean, 3270 per year), of whom 2437 died in hospital (14.9% mean, 487 per year). The mean age at admission was 50.5 years (standard deviation [SD], 26.1 years), and 11 644 patients were male (71.2%) the mean age of people who died in hospital was 60.4 years (SD, 25.2 years), and 1686 deaths were of male patients (69.2%). The overall number of hospitalisations did not change during 2015–20 (per year: incidence rate ratio [IRR], 1.00 95% confidence interval [CI], 0.99–1.02) and death (IRR, 1.00 95% CI, 0.97–1.03). Injury prevention and trauma care interventions for people with moderate to severe TBI in Australia reduced neither the incidence of the condition nor the associated in‐hospital mortality during 2015–20. More effective care strategies are required to reduce the burden of TBI, particularly among younger men.
Publisher: Wiley
Date: 02-06-2021
Abstract: In response to COVID‐19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first‐attempt success (FAS) associated with ED intubation. An analysis of prospectively collected registry data of all ED intubations over a 3‐year period at an Australian Major Trauma Centre. During the first 6 months of the COVID‐19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with ‘sign‐off’ for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre‐drawn medications. There were 783 patients, 136 in the COVID‐19 era and 647 in the pre‐COVID‐19 comparator group. The rate of hypoxia was higher during the COVID‐19 era compared to pre‐COVID‐19 (18.4% vs 9.6%, P 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID‐19 vs 22.6% pre‐COVID‐19, P 0.001). Other adverse events were similar before and during COVID‐19 (hypotension 12.5% vs 7.9%, P = 0.082 bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID‐19 (95.6% vs 82.5%, P 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P 0.001) and rocuronium (86.8% vs 52.1%, P 0.001). This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist.
Publisher: BMJ
Date: 14-12-2022
DOI: 10.1136/EMERMED-2021-211280
Abstract: This study explored the perspectives and behaviours of emergency physicians (EPs), regularly involved in resuscitation, to identify the sources and effects of any stress experienced during a resuscitation as well as the strategies employed to deal with these stressors. This was a two-centre sequential exploratory mixed-methods study of EPs consisting of a focus group, exploring the human factors related to resuscitation, and an anonymous survey. Between April and June 2020, the online survey was distributed to all EPs working at Australia’s largest two major trauma centres, both in Melbourne, and investigated sources of stress during resuscitation, impact of stress on performance, mitigation strategies used, impact of the COVID-19 pandemic on stress and stress management training received. Associations with gender and years of clinical practice were also examined. 7 EPs took part in the focus group and 82 responses to the online survey were received (81% response rate). The most common sources of stress reported were resuscitation of an ‘unwell young paediatric patient’ (81%, 95% CI 70.6 to 87.6) or ‘unwell pregnant patient’ (71%, 95% CI 60.1 to 79.5) and ‘conflict with a team member’ (71%, 95% CI 60.1 to 79.5). The most frequently reported strategies to mitigate stress were ‘verbalising a plan to the team’ (84%, 95% CI 74.7 to 90.5), ‘implementing a standardised/structured approach’ (73%, 95% CI 62.7 to 81.6) and ‘asking for help’ (57%, 95% CI 46.5 to 67.5). 79% (95% CI 69.3 to 86.6) of EPs reported that they would like additional training on stress management. Junior EPs more frequently reported the use of ‘mental rehearsal’ to mitigate stress during a resuscitation (62% vs 22% p .01) while female EPs reported ‘asking for help’ as a mitigator of stress more frequently than male EPs (79% vs 47% p=0.01). Stress is commonly experienced by EPs during resuscitation and can impact decision-making and procedural performance. This study identifies the most common sources of stress during a resuscitation as well as the strategies that EPs use to mitigate the effects of stress on their performance. These findings may contribute to the development of tailored stress management training for critical care clinicians.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.INJURY.2017.08.056
Abstract: Computed tomography of the brain (CTB) has a fundamental role in the diagnosis and management of traumatic brain injury (TBI). There may be substantial discordance between initial CTB interpretation by emergency clinicians and the final radiology report. This study aimed to assess the utility of a structured reporting template in improving the accuracy of CTB interpretation by emergency clinicians. A prospective pre- and post-intervention cohort study was undertaken using a study population of emergency medicine trainees. The CTB reporting template was created with consultation from radiology, emergency medicine and trauma specialists. Participants reported on a set of randomly selected trauma CTBs first without, and then with, the reporting template. Each case was independently assessed for concordance with the radiology report by two blinded assessors (including a radiologist) and the proportion of concordant reports in each phase calculated. There were 26 participants recruited to the study who reported on a total of 320 CTBs. In the pre-intervention phase, 121 (76%) cases were concordant with the radiology report compared to 147 (92%) post-intervention (p<0.01). The AUROC was 0.84 (95% CI: 0.78-0.89) pre-intervention and improved to 0.94 (95% CI: 0.88-0.99) with the intervention (p=0.01). A higher level of baseline accuracy was observed in advanced trainees (78%) compared to basic trainees (72%), but both improved to a similar level of 92% with the use of the CTB reporting template. There was a marked reduction in false negative errors, with increased identification of critical diagnoses such as cerebral herniation and diffuse axonal injury. The use of the CTB reporting template significantly increased the accuracy of emergency medicine trainees and reduced the number of missed critical diagnoses. Reporting templates may represent an effective strategy to improve CTB interpretation and enhance the initial care of head injured patients.
Publisher: Wiley
Date: 06-2004
Publisher: Informa UK Limited
Date: 25-08-2015
DOI: 10.3109/02688697.2014.950632
Abstract: Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with poor outcomes. Among patients with iTBI, we aimed to select an appropriate definition of ATC, outline the incidence of ATC and examine clinical variables associated with ATC. A retrospective review of The Alfred Trauma Registry was conducted and patients with iTBI (head AIS [Abbreviated Injury Score] ≥ 3 and all other body regions AIS < 3) were selected for analysis. The association of the international normalised ratio (INR) on arrival at hospital with the mortality on hospital discharge was explored, to select an appropriate clinical horizon to define ATC. The incidence of ATC was calculated using this definition. Injury and clinical variables measurable pre-hospital and immediately on arrival at the hospital were analysed to determine independent associations with ATC. There were 1718 patients with iTBI included in the study. The overall mortality was 12%, but significantly greater when initial INR was measured at ≥ 1.3 (45.1% p 50 yrs, SI ≥ 1, or abnormal pupils, was 97.54% (95% CI: 96.6-98.2) specific for ATC. An abnormal initial INR in the setting of iTBI was associated with poor outcomes, regardless of magnitude. The incidence of ATC appears too low to recommend empiric pro-coagulant management for all patients with iTBI. The subgroup of patients older than 50 yrs., with shock or abnormal size of pupils, may be considered for interventional trials of early treatment against ATC.
Publisher: Elsevier BV
Date: 2010
DOI: 10.1016/J.INJURY.2009.06.020
Abstract: To comprehensively examine the inter-hospital transfer of major trauma patients-including the reason for transfer, duration, escorts, interventions and unexpected events. This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form. A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min. Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%). Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p<0.001). Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p<0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p<0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p<0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p=0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p=0.001). Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: Elsevier BV
Date: 10-2021
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.INJURY.2014.08.050
Abstract: Red blood cell (RBC) transfusion is often essential during trauma resuscitation but is associated with high cost and potential adverse outcomes. This study aimed to determine the incidence of potentially avoidable RBC transfusions (PAT) among adult major trauma patients. A retrospective review of data collected by Registry on patients presenting between Jan 2006 and Dec 2011 was conducted. Eligible patients received at least 1 unit of RBC in the first 24h following presentation to the Emergency Department (ED). Episodes of PAT were determined according to haemodynamic stability and post-transfusion haemoglobin levels. There were 621 patients included, of whom 224 (36.1% 95% CI: 32.3-40.0) received PAT. Of them, 132 (58.9%) were haemodynamically stable on arrival and did not require a surgical procedure. Patients with PAT had significantly lower injury severity scores (30 vs 34, p<0.01), higher presenting systolic blood pressure (129 vs 112mm Hg, p<0.01) and a lower frequency of a shock index ≥1 (24.1 vs 65.0%, p<0.01), compared to those without PAT. They also had a significantly lower mortality (13.4 vs 21.7%, p<0.01). PAT after trauma was common and often delivered to haemodynamically stable patients who did not require surgical procedures. Clinical decision pathways for trauma resuscitation should aim to limit PAT.
Publisher: Wiley
Date: 11-08-2023
Abstract: Haemorrhagic shock is a life‐threatening complication of trauma, but remains a preventable cause of death. Early recognition of retroperitoneal haemorrhage (RPH) is crucial in preventing deleterious outcomes including mortality. Injury to the 9–11th intercostal arteries (i.e. arteries of the lower thoracic region) are complicit in RPH. However, the associated injuries, implications and management of such bleeds remain poorly characterised. We performed a retrospective review of the medical records of patients diagnosed with RPH who presented to our level‐1 trauma centre (2009–2019). We described the associated injuries, management and outcomes relating to RPH of the lower thoracic region (the 9–11th intercostal arteries) from this cohort to identify potential predictors and evaluate the impact of early identification and management of non‐cavitary bleeds. Haemorrhage of the lower intercostal arteries (LIA) into the retroperitoneal space is associated with an increased number of posterior lower rib fractures and pneumothorax/haemothorax. A higher proportion of patients in the LIA group required massive transfusion, angioembolisation or surgical ligation when compared to other causes of RPH. The present study highlights the importance of injury patterns, particularly posterior lower rib fractures, as predictors for early recognition and management of RPH in the prevention of deleterious patient outcomes. RPH secondary to bleeding of the LIA may require early and aggressive management of haemorrhage through massive transfusion, and angioembolisation or surgical ligation when compared to RPH because of other causes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2012
Publisher: Wiley
Date: 04-2009
DOI: 10.1111/J.1742-6723.2009.01172.X
Abstract: In response to the Indian Ocean tsunami of 2004, the Health for the South project, Capacity-Building programme was implemented in Galle, Sri Lanka. The objectives of the Capacity-Building programme were to develop the emergency and trauma service capability at Teaching Hospital Karapitiya in Galle. Over 15 months, ED clinicians, from the Alfred Hospital and Royal Children's Hospital in Melbourne, provided training in the Emergency Treatment Unit of the main referral hospital for the south of Sri Lanka. This programme, completed in June 2008, significantly improved the hospital's ability to conduct trauma resuscitation, and to attain an increased level of disaster preparedness. In addition, valuable lessons were noted that will guide future initiatives in trauma care training in similar contexts.
Publisher: Wiley
Date: 06-1993
Publisher: Elsevier BV
Date: 12-2015
DOI: 10.1016/J.JOCN.2015.05.034
Abstract: This study aims to investigate an association between ethanol exposure and in-hospital mortality among patients with isolated traumatic brain injury (iTBI). Ethanol exposure is associated with a substantially increased risk of sustaining an iTBI. However, once an iTBI has been sustained, it is unclear whether ethanol exposure is neuroprotective or harmful. We conducted a retrospective review of patients who presented between 2006 and 2012 and were entered into the Alfred Hospital trauma registry. The patients who presented with iTBI, as defined by a head abbreviated injury scale (AIS) score ⩾3 and all other body regions with AIS<3, and who had ethanol levels recorded on admission, were eligible for inclusion. The association between ethanol exposure as a continuous variable, and in-hospital mortality, was explored using multivariable logistic regression analysis. There were 1688 patients with iTBI who met the inclusion criteria, 577 (34.2%) of whom tested positive for ethanol. Ethanol exposure was not significantly associated with a change in the in-hospital mortality rate (adjusted odds ratio 1.01 95% confidence interval 1.00-1.02 p=0.19). A substantial proportion of patients with iTBI were exposed to ethanol, but ethanol exposure was not independently associated with a change in mortality rate following iTBI. Any neuroprotection or harm from ethanol exposure was not conclusive, requiring further prospective trials.
Publisher: American Medical Association (AMA)
Date: 07-2017
Publisher: Wiley
Date: 27-02-2022
Abstract: The wide‐spread use of an initial ‘Glasgow Coma Scale (GCS) 8 or less’ to define and dichotomise ‘severe’ from ‘mild’ or ‘moderate’ traumatic brain injury (TBI) is an out‐dated research heuristic that has become an epidemiological convenience transfixing clinical care. Triaging based on GCS can delay the care of patients who have rapidly evolving injuries. Sole reliance on the initial GCS can therefore provide a false sense of security to caregivers and fail to provide timely care for patients presenting with GCS greater than 8. Nearly 50 years after the development of the GCS – and the resultant misplaced clinical and statistical definitions – TBI remains a heterogeneous entity, in which ‘best practice’ and ‘prognoses’ are poorly stratified by GCS alone. There is an urgent need for a paradigm shift towards more effective initial assessment of TBI.
Publisher: American Psychological Association (APA)
Date: 2012
DOI: 10.1037/A0027888
Abstract: There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury (mTBI). This study aimed to prospectively examine the influence of preinjury factors, injury-related factors, and postinjury factors on outcome following mTBI. Participants were 123 patients with mTBI and 100 trauma patient controls recruited and assessed in the emergency department and followed up 1 week and 3 months postinjury. Outcome was measured in terms of reported postconcussional symptoms. Measures included the ImPACT Post-Concussional Symptom Scale and cognitive concussion battery, including Attention, Verbal and Visual memory, Processing Speed and Reaction Time modules, pre- and postinjury SF-36 and MINI Psychiatric status ratings, VAS Pain Inventory, Hospital Anxiety and Depression Scale, PTSD Checklist-Specific, and Revised Social Readjustment Scale. Presence of mTBI predicted postconcussional symptoms 1 week postinjury, along with being female and premorbid psychiatric history, with elevated HADS anxiety a concurrent indicator. However, at 3 months, preinjury physical or psychiatric problems but not mTBI most strongly predicted continuing symptoms, with concurrent indicators including HADS anxiety, PTSD symptoms, other life stressors and pain. HADS anxiety and age predicted 3-month PCS in the mTBI group, whereas PTSD symptoms and other life stressors were most significant for the controls. Cognitive measures were not predictive of PCS at 1 week or 3 months. Given the evident influence of both premorbid and concurrent psychiatric problems, especially anxiety, on postinjury symptoms, managing the anxiety response in vulnerable in iduals with mTBI may be important to minimize ongoing sequelae.
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.JOCN.2015.11.024
Abstract: Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and is associated with poor outcomes. We aimed to evaluate the effectiveness of procoagulant agents administered to patients with ATC and iTBI during resuscitation, hypothesizing that timely normalization of coagulopathy may be associated with a decrease in mortality. A retrospective review of the Alfred Hospital trauma registry, Australia, was conducted and patients with iTBI (head Abbreviated Injury Score [AIS] ⩾3 and all other body AIS <3) and coagulopathy (international normalized ratio ⩾1.3) were selected for analysis. Data on procoagulant agents used (fresh frozen plasma, platelets, cryoprecipitate, prothrombin complex concentrates, tranexamic acid, vitamin K) were extracted. Among patients who had achieved normalization of INR or survived beyond 24hours and were not taking oral anticoagulants, the association of normalization of INR and death at hospital discharge was analyzed using multivariable logistic regression analysis. There were 157 patients with ATC of whom 68 (43.3%) received procoagulant products within 24hours of presentation. The median time to delivery of first products was 182.5 (interquartile range [IQR] 115-375) minutes, and following administration of coagulants, time to normalization of INR was 605 (IQR 274-1146) minutes. Normalization of INR was independently associated with significantly lower mortality (adjusted odds ratio 0.10 95% confidence interval 0.03-0.38). Normalization of INR was associated with improved mortality in patients with ATC in the setting of iTBI. As there was a substantial time lag between delivery of products and eventual normalization of coagulation, specific management of coagulopathy should be implemented as early as possible.
Publisher: Elsevier BV
Date: 09-2008
DOI: 10.1016/J.INJURY.2008.04.024
Abstract: Improvements in pre-hospital care and the development of integrated Trauma Systems have streamlined access for the severely injured to sophisticated, specialist Trauma Centre reception and resuscitation. We describe the initial care of a survivor of combined ruptures of the left ventricle and left atrium secondary to blunt injury. This case emphasises the contribution of such a Trauma System in achieving a favourable outcome for a severely injured trauma patient with injuries previously considered non-survivable.
Publisher: Elsevier BV
Date: 09-2010
Publisher: Wiley
Date: 03-03-2016
Abstract: History, clinical examination and throat culture may be inadequate to rule in or out the presence of group A streptococci (GAS) infection in patients with sore throat in a remote location. We correlated the diagnostic accuracy for guiding antibiotic prescription of clinical decision and physiological scoring systems to a rapid diagnostic point of care (POC) test result in paediatric patients presenting with sore throat. Prospective diagnostic accuracy study conducted between 30 June 2014 and 27 February 2015 in a remote Australian ED using a convenience s le. Among paediatric patients presenting with sore throat, the Centor criteria and clinical decision were documented. Simultaneously, patients without sore throat or respiratory tract infection were tested to determine the number of carriers. A throat swab on all patients was tested using a POC test (Alere TestPack +Plus Strep A with on board control), considered as reference standard to detect GAS infection. A total of 101 patients with sore throat were tested with 26 (25.7%) positive for GAS. One hundred and forty-seven patients without sore throat were tested with one positive POC test result (specificity 99% 95% CI 96-100). Positive predictive value for clinician decision-making for a positive GAS swab (bacterial infection) was 29% (95% CI 17-43), negative predictive value 78% (95% CI 63-88). Area under ROC for the Centor score was 0.70 (95% CI 0.58-0.81). Clinician judgement and Centor score are inadequate tools for clinical decision-making for children presenting with sore throat. Adjunctive POC testing provides sufficient accuracy to guide antibiotic prescription on first presentation.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2013
DOI: 10.1016/J.JAMCOLLSURG.2012.12.024
Abstract: Traumatic flail chest injury is a potentially life threatening condition traditionally treated with invasive mechanical ventilation to splint the chest wall. Longer-term sequelae of pain, deformity, and physical restriction are well described. This study investigated the impact of operative fixation in these patients. A prospective randomized study compared operative fixation of fractured ribs in the flail segment with current best practice mechanical ventilator management. In-hospital data, 3-month follow-up review, spirometry and CT, and 6-month quality of life (Short Form-36) questionnaire were collected. Patients in the operative fixation group had significantly shorter ICU stay (hours) postrandomization (285 hours [range 191 to 319 hours] for the surgical group vs 359 hours [range 270 to 581 hours] for the conservative group p = 0.03) and lesser requirement for noninvasive ventilation after extubation (3 hours [range 0 to 25 hours] in the surgical group vs 50 hours [range 17 to 102 hours] in the conservative group p = 0.01). No differences in spirometry at 3 months or quality of life at 6 months were noted. Operative fixation of fractured ribs reduces ventilation requirement and intensive care stay in a cohort of multitrauma patients with severe flail chest injury.
Publisher: Elsevier BV
Date: 10-2007
DOI: 10.1016/J.ANNEMERGMED.2007.06.487
Abstract: We illustrate how audio-video data records can improve emergency medical care, using airway management to show how such video data may help to identify unsafe acts, accident precursors, and latent and systems failures and to evaluate performance. This was a retrospective analysis of videos of real patient resuscitation in a trauma center. Participant care providers reviewing their own videos of tracheal intubation identified failures to use diagnostic equipment, fixation errors, and team and communication errors. Neutral expert observers noted team coordination failures and poor error recovery. Comparison with a consensus guideline for a tracheal intubation task/communication pathway showed that communications were unclear or not made, and key tasks were omitted by team members. Differences were detected between performance of tracheal intubation in elective and emergency circumstances. Revised practices ("3 Cs": clinical examination, communication, carbon dioxide) mitigated task performance and communication deficiencies. Video is complementary to traditional quality improvement methods for improving performance in airway management and emergency medical and trauma care, assessing standard operating procedures, and reviewing communications. Video data identify performance details not found in quality improvement approaches, including medical record review or recall by participant care providers. Weaknesses in using video for data include lengthy video review processes, poor audio, and the inability to adequately analyze events outside the field of view. Opportunities are to use video audit for quality improvement of other emergency tasks. Video buffering reduces personnel requirements for capture and simplifies data extraction. Medicolegal and confidentiality threats are significant.
Publisher: Wiley
Date: 31-10-2022
Abstract: The objectives of the present study were to report the proportion of older teenagers, including the subgroup operating a motor vehicle, presenting to an adult major trauma centre after injury with a positive blood alcohol concentration (BAC) over a 12‐year period. This was a registry‐based cohort study, including all patients aged 16–19 years presenting to an adult major trauma centre in Victoria, Australia from January 2008 to December 2019 and included in the trauma registry. A Poisson regression model was used to test for change in incidence of positive BAC associated trauma and summarised using incidence rate ratios (IRRs) and 95% confidence intervals (CIs). There were 1658 patients included for analysis and alcohol was detected in 368 (22.2% 95% CI 20.2–24.3). Most alcohol positive presentations were on weekend days ( n = 207 56.3%) and most were males ( n = 307). Over the 12‐year period, there was a reduction in the incidence of older teenagers presenting with a positive BAC (IRR 0.95 95% CI 0.93–0.98 P = 0.001). Among patients presenting after trauma in the setting of operating a motor vehicle ( n = 545), alcohol was detected in 80 (14.7%) with no significant change in incidence of positive BAC (IRR 0.95 95% CI 0.89–1.02 P = 0.17). A substantial proportion of older teenagers included in the registry had alcohol exposure prior to trauma. Despite a modest down‐trending incidence, the need for continuing preventive measures is emphasised. In particular, preventive efforts should be targeted at male, older teenagers undertaking drinking activities on weekend days and driving motor vehicles.
Publisher: Elsevier BV
Date: 2017
Publisher: Springer Science and Business Media LLC
Date: 17-10-2014
DOI: 10.1007/S00068-013-0341-Z
Abstract: Pancreatic enzymes are routinely measured during reception of trauma patients to assess for pancreatic injury despite conflicting evidence on their utility. The aim of this study was to investigate the utility of routine initial serum lipase measurement for the diagnosis of acute pancreatic trauma. Lipase measurements were introduced as part of the trauma pathology panel and requested on all patients who presented to an adult major trauma service and met trauma call-out criteria. Clinical records of these patients were extracted from the trauma registry and retrospectively reviewed. The performance of an initial serum lipase level measured on presentation to detect pancreatic trauma was determined. There were 2,580 patients included in the study, with 17 patients diagnosed with pancreatic trauma. An elevated lipase was recorded in 390 patients. Statistically significant associations were observed for elevated lipase in patients with pancreatic trauma, head injury, acute alcohol ingestion and massive blood transfusion. As a test for pancreatic trauma, an abnormal serum lipase result had a specificity of 85.3 % (95 % CI 83.8-86.6), sensitivity of 76.5 % (95 % CI 49.8-92.2), positive predictive value of 3.3 % (95 % CI 1.8-5.8) and negative predictive value of 99.8 % (95 % CI 99.4-99.9). Higher cut-offs of serum lipase did not result in better performance. A normal serum lipase result can be a useful adjunct to exclude pancreatic injury. A positive lipase result, regardless of the cut-off used, was not reliably associated with pancreatic trauma, and should not be used to guide further assessment.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2016
Publisher: Elsevier BV
Date: 05-2010
DOI: 10.1016/J.INJURY.2009.07.065
Abstract: The aim of effective clinical handover is seamless transfer of information between care providers. Handover between paramedics and the trauma team provides challenges in ensuring that information loss does not occur. Handover is often time-pressured and paramedics' clinical notes are often delayed in reaching the trauma team. Documentation by trauma team members must be accurate. This study evaluated information loss and discordance as patients were transferred from the scene of an incident to the Trauma Centre. Twenty-five trauma patients presenting by ambulance to a tertiary Emergency and Trauma Centre were randomly selected. Audiotaped (pre-hospital) and videotaped (in-hospital) handover was compared with written documentation. In the pre-hospital setting 171/228 (75%) of data items handed over by paramedics to the trauma team were documented and in the in-hospital handover 335/498 (67%) of information was documented. Information least likely to be documented by trauma team members (1) in the pre-hospital setting related to treatment provided and (2) in the in-hospital setting related to signs and symptoms. While 79% of information was subsequently documented by paramedics, 9% (n=59) of information was not documented either by trauma team members or paramedics and constitutes information loss. Information handed over was not congruent with documentation on seven occasions. Discrepancies included a patient's allergy status and sites of injury (n=2). Demographic details were most likely to be documented but not handed over by paramedics. By documenting where deficits in handover occur we can identify points of vulnerability and strategies to capture this information.
Publisher: Wiley
Date: 09-2022
Abstract: Inconsistency in the structure and function of team‐based major trauma reception and resuscitation is common. A standardised trauma team training programme was initiated to improve quality and consistency among trauma teams across a large, mature trauma system. The aim of this manuscript is to outline the programme and report on the initial perception of participants. The Alfred Trauma Team Reception and Resuscitation Training (TTRRT) programme commenced in March 2019. Participants included critical care and surgical craft group members commonly involved in trauma teams. Training was site‐specific and included rural, urban and tertiary referral centres. The programme consisted of prescribed pre‐learning, didactic lectures, skill stations and simulated team‐based scenarios. Participant perceptions of the programme were collected before and after the programme for analysis. The TTRRT was delivered to 252 participants and 120 responses were received. Significant improvement in participant‐reported confidence was identified across all key topic areas. There was also a significant increase in both confidence and clinical exposure to trauma team leadership roles after participation in the programme (from 53 [44.2%] to 74 [61.7% P = 0.007]). This finding was independent of clinician experience. A team‐based trauma reception and resuscitation education programme, introduced in a large, mature trauma system led to positive participant‐reported outcomes in clinical confidence and real‐life team leadership participation. Wider implementation combined with longitudinal data collection will facilitate correlation with patient and staff‐centred outcomes.
Publisher: Wiley
Date: 14-09-2010
Publisher: Wiley
Date: 13-05-2020
Publisher: Wiley
Date: 28-07-2018
Abstract: Regionalised civilian trauma systems improve patient outcomes, but may deskill clinicians outside major trauma services (MTSs). We aimed to characterise experience and confidence in trauma management among emergency physicians working in MTS to those working elsewhere. Emergency physicians working within the Victorian State Trauma System were surveyed about their pre- and post-fellowship training experience, their estimated hours per fortnight in different centres, the frequency of performance/supervision of critical emergency skills and their confidence in a range of trauma skills. The 138 respondents analysed represented 33% of active Victorian FACEMs. The cohort were mostly males (69.6%), younger than 50 (75.4%) and were generally (69.6%) six or more years post-fellowship. FACEMs working in a MTS were more likely to have been a trauma registrar prior to fellowship (13.3% vs 3.7%, P = 0.046). MTS clinicians performed more, supervised more and were more confident in trauma team leading, traumatic airway management and rapid infusion catheter and multi-access catheters. Confidence in trauma team leading was only associated with exposure to performance or supervision of trauma team leading. Performance of trauma team leading was more common in clinicians at a MTS (odds ratio 3.19, 95% CI 1.00-10.20, P = 0.05). Exposure to major trauma is associated with time spent working in a MTS and exposure is associated with confidence. A mature inclusive trauma system must ensure clinicians across the system gain the experience or training to provide trauma care that will result in similar outcomes for patients regardless of initial presenting hospital.
Publisher: BMJ
Date: 09-06-2016
DOI: 10.1136/EMERMED-2015-205450
Abstract: During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries. A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) 12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012. Log roll examination findings, as documented in the medical record, were compared with CT reports. Out of the 624 screened records, 222 (35.6%) were excluded as the log roll or CT/MRI had not been performed. There were a total of 2028 major trauma presentations to the Alfred Hospital Emergency and Trauma Centre during the study period. Excluded cases comprised 147 patients who did not have a documented log roll, and 75 patients who did not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a thoracolumbar fracture, and the sensitivity of log roll examination was found to be 27.5%, with a specificity of 91%. The negative likelihood ratio for abnormalities on log roll was low (0.8). Examination of the back in unconscious trauma patients could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans. The low sensitivity and poor negative likelihood ratio suggest that a normal log roll examination does not accurately predict the absence of bony injury to the thoracolumbar spine.
Publisher: Elsevier BV
Date: 11-2011
DOI: 10.1016/J.BURNS.2011.04.009
Abstract: The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg)×%TBSA burnt=mls in the first 2 h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration. A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period. There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22-0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04-0.26) mL/kg/%TBSA administered in the prior period (p=0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24 h, the volume of fluid administered in patients when The Alfred formula was used was 4.9±1.6 mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8±2.2 mL/%TBSA/kg (p=0.802). The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current 'gold standard'.
Publisher: Wiley
Date: 12-2003
Publisher: Wiley
Date: 04-10-2017
Abstract: To determine the proportion of non-motorised road users involved in road traffic crashes that presents to hospital intoxicated. We undertook a retrospective cohort study using data collected from the Alfred Trauma Registry. All patients presenting to an adult major trauma centre in Victoria, Australia from July 2009 to June 2014 who were involved in a road traffic crash as a non-motorised road user - pedestrians, pedal-cyclists, non-motorised scooter users, horse riders - were included. Patients who had a blood alcohol measurement were included, and intoxication was defined as a blood alcohol concentration ≥0.05 g/100 mL. There were 1323 patients included for analysis with data on presenting blood alcohol concentration. Alcohol was detected in 248 (18.7% 95% CI: 16.7-20.9) patients, whereas 211 (15.9% 95% CI: 14.1-18.0) were intoxicated. Among all included pedestrians, 161 (24.7%) were intoxicated among all included pedal-cyclists, 47 (7.3%) were intoxicated. Intoxicated patients were significantly younger, and a higher proportion were males and more likely to present after hours and on public holidays (P < 0.01). Survival to hospital discharge and inpatient rehabilitation requirements were similar among intoxicated and non-intoxicated patients. Intoxication was common among non-motorised road users, and the proportion of intoxicated patients in this subgroup appears unchanged over time despite public awareness programmes. The true burden of intoxication in non-motorised road users remains unknown because of a lack of routine testing. Legislation directed at testing for intoxication of non-motorised users and introduction of penalties should be considered to improve safety of all road users.
Publisher: Wiley
Date: 09-05-2018
Abstract: The Australian health system is generally well prepared for mass casualty events. Fortunately, there have been very few terrorist attacks and these have involved low numbers of casualties compared with events overseas. Nevertheless, Australian health professionals need to be prepared to treat mass casualties with blast and ballistic trauma. The US military and its allies including Australia have had extensive experience with mass casualty management in the Middle East and Afghanistan wars for more than a decade. To define their experience, they developed the Tactical Combat Casualty Care Guidelines that have saved many lives. It is now prudent to incorporate this knowledge and experience into civilian practice in Australia.
Publisher: Elsevier BV
Date: 2008
DOI: 10.1016/J.INJURY.2007.07.021
Abstract: This review examines pleural decompression and drainage during initial hospital adult trauma reception and resuscitation, when it is indicated for haemodynamically unstable patients with signs of pneumothorax or haemothorax. The relevant historical background, techniques, complications and current controversies are highlighted. Key findings of this review are that: 1. Needle thoracocentesis is an unreliable means of decompressing the chest of an unstable patient and should only be used as a technique of last resort. 2. Blunt dissection and digital decompression through the pleura is the essential first step for pleural decompression, as decompression of the pleural space is a primary goal during reception of the haemodynamically unstable patient with a haemothorax or pneumothorax. Drainage and insertion of a chest tube is a secondary priority. 3. Techniques to prevent tube thoracostomy (TT) complications include aseptic technique, avoidance of trocars, digital exploration of the insertion site and guidance of the tube posteriorly and superiorly during insertion. 4. Whenever possible, blunt thoracic trauma patients should undergo definitive CT imaging after TT to check for appropriate tube position.
Publisher: Elsevier BV
Date: 03-2011
DOI: 10.1016/J.RESUSCITATION.2010.10.016
Abstract: Serious sequelae have been associated with injured patients who are hypothermic (<35°C) including coagulopathy, acidosis, decreased myocardial contractility and risk of mortality. Establish the incidence of accidental hypothermia in major trauma patients and identify causative factors. Prospective identification and subsequent review of 732 medical records of major trauma patients presenting to an Adult Major Trauma Centre was undertaken between January and December 2008. Multivariate analysis was performed using logistic regression. Significant and clinically relevant variables from univariate analysis were entered into multivariate models to evaluate determinants for hypothermia and for death. Goodness of fit was determined with the use of the Hosmer-Lemeshow statistic. Overall mortality was 9.15%. The incidence of hypothermia was 13.25%. The mortality of patients with hypothermia was 29.9% with a threefold independent risk of death: OR (CI 95%) 3.44 (1.48-7.99), P = 0.04. Independent determinants for hypothermia were pre-hospital intubation: OR (CI 95%) 5.18 (2.77-9.71), P < 0.001, Injury Severity Score (ISS): 1.04 (1.01-1.06), P = 0.01, Arrival Systolic Blood Pressure (ASBP) 35 °C.
No related grants have been discovered for Mark Fitzgerald.