CYCLISTS AND HELMETS – EFFECTIVE OR FALSE SENSE OF SECURITY
Vindya Abeysinghe, Sudhakar Rao
Cycling provided major benefits to individuals and communities through better health outcomes and benefits to the environment.
The safety of cyclists is paramount and injury prevention measures include changes to road rules and adherence to personal safety by cyclists. In 2014 there were 6642 hospitalisations due to cyclling injuries, of which 1051 were “high threat to life” injuries.
The use of helmets as primary prevention of traumatic brain injury is supported by the Royal Australasian College of Surgeons and the American College of Surgeons. Anti-helmet lobby groups continue to challenge the status quo. Contemporaneous and local data is vital in providing a sound scientific basis to the stand taken by health advocates.
Hypothesis: Cyclists without helmets have more serious intracranial injuries, and suffer with more radiological lesions on CT scan.
Method: Data is collected in a prospective manner into the Trauma Registry at Royal Perth Hospital. The data for all cyclists was extracted from this database and analysed for a period of ten years. Cyclists who died at the scene were not analysed. Comparisons between helmeted and non-helmeted populations were made for intracranial injuries, and for cervical spine injuries.
Results: Helmets reduce the severity of intracranial injuries and also reduce the number of intracranial lesions seen on CT scan
Helmets are a vital part of Primary Injury Prevention for Cyclists
Ref: BITRE 2014 report
OSSEOINTEGRATED IMPLANTS FOR TRANS FEMORAL AMPUTEES: RADIOGRAPHIC EVALUATION OF BONE REMODELING
Seamus Thomson1, 2, William Lu1, Munjed Al Muderis1, 3, 4
Osseointegration is a novel method to overcome persistent socket issues by anchoring a transcutaneous implant directly onto the skeletal residuum. Although similar technologies have been applied in hip and knee arthroplasty, none have examined the bone remodeling effects of osseointegrated implants. Stress shielding results in the reduction of bone density due to the implant removing the stress that is usually exerted on the bone and reduces implant stability. This paper quantifys the bone remodeling effect in two of the most common osseointegration implants.
This is a prospective study of 50 patients with trans-femoral amputations and a minimum two-year follow-up. The Integral Leg Prosthesis (ILP) and Osseointegrated Prosthetic Limb (OPL), with differences in tapering, coating and bone ingrowth regions were examined. The surrounding bone was defined using inverse Gruen zones and graded into 5 levels of growth or resorption.
Results obtained at 1 and 2 year follow-ups were compared to the 6-month follow-up values as a baseline. Significant bone growth near the proximal end was observed on patients with the ILP implant. This was accompanied by significant resorption towards the distal end indicating the occurrence of stress shielding. The OLP implant demonstrated much more uniform bone density throughout the length of the implant.
Overall, the patterns of bone remodeling after osseointegration showed similarities to those seen on hip stems with a press-fit design. Of the two osseointegration implants examined in this paper, the OLP implant exhibited less stress shielding effects and is expected to provide better long-term stability.
THE USE OF OSSEOINTEGRATED TITANIUM IMPLANTS TO TREAT TRANS-TIBIAL AMPUTEES
William Lu1, Munjed Al Muderis2, 3
Osseointegration has emerged as a novel approach to resolve persistent socket prosthetic issues by attaching the prosthetic limb directly onto the skeletal residuum. Until recently, this procedure has been performed mostly in trans-femoral amputee (TFA) patients. This paper represents the first pilot study to examine the results of performing osseointegration in the tibia. The objective of this study is to describe the reconstruction strategy and clinical management protocol used in the treatment of TTA patients with osseointegrated implants.
This is a prospective pilot study of 15 patients, aged 37-77 (mean 55.1) years at surgery, with minimum two-year follow-up. Selection criteria included age over 18 years, unilateral TTA patients who had socket-related problems. All patients received osseointegrated implants which were press-fit into the amputated limb. Principle outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation (Q-TFA), Short Form Health Survey 36 (SF-36), Six Minute Walk Test (6MWT), Timed Up and Go (TUG). Adverse events recorded included infection, revision surgery, fractures, and implant failures.
Comparisons were made using differences between the mean pre-operative and mean post-operative values for each outcome measure. Significant improvements for all outcome measures were observed. The occurrence levels of adverse events including the infection rate and revision rate were similar to trans-femoral osseointegration cases.
These preliminary results suggest that osseointegration surgery for trans-tibial amputees is a safe and effective alternative treatment for amputees experiencing socket-related discomfort. This protocol has the potential to expand the application of osseointegration to help patients who have below the knee amputations.
THE USE OF OSSEOINTEGRATED TITANIUM IMPLANTS TO TREAT BILATERAL AMPUTEES
Lovejoy Mudyara, William Lu, Munjed Al Muderis
Current socket prostheses remain problematic, resulting in more than 90% of patients with bilateral above-knee amputations being confined to a wheelchair. Osseointegration has been regarded as a novel approach to overcome persistent socket prosthetic issues, using a transcutaneous implant directly attached to the residual bone. A number of bilateral amputees have been treated with osseointegration in our center since July 2012. This paper reports the early clinical outcomes in this particular group of patients, including the results of functional and quality of life assessments, and safety of the procedure.
This is a prospective pilot study of 13 patients, consisting of 10 males and 3 females, with minimum two-year follow-up. Selection criteria included adult bilateral amputees who had socket-related problems reconstructed with osseointegration. Outcome measures included the Q-TFA, SF-36, Six Minute Walk Test (6MWT), Timed Up and Go (TUG), and K-levels. Adverse events were recorded including infection, revision surgery, fractures, and implant failures.
Comparisons were made using differences between the mean pre-operative and mean post-operative values for each outcome measure. Significant improvements in all validated outcome measures were observed. The occurrence levels of adverse events, including the infection rate and revision rate, were similar to other established trans-femoral osseointegration studies.
These preliminary results indicate that osseointegration surgery is a safe and effective alternative treatment for bilateral amputees experiencing socket-related discomfort. Compared to the suboptimal outcomes of socket prostheses, osseointegration currently provides one of the best chances for any bilateral amputee to walk again and regain the ability to perform daily activities.
OSSEOINTEGRATION FOR THE RECONSTRUCTION OF DEVASTATING MILITARY AND TERRORIST BLAST INJURIES
Kevin Tetsworth, William Lu, Munjed Al Muderis
Blast injuries from military operations often result in devastating injuries which are difficult to reconstruct and frequently results in amputations. These injuries are often bilateral and can be difficult to fit with socket prostheses due suboptimal residual conditions. Osseointegration provides a solution here by attaching a transcutaneous implant direct to the residual bone. This study describes our experiences performing osseointegrated limb reconstruction in this challenging patient cohort.
This is a case series of 10 patients who had blast injuries resulting in lower limb amputations. Clinical outcomes were obtained pre- and post-operatively from 10 to 30 months (mean 16 months). Outcome measures included the Q-TFA, SF-36, the 6MWT and the TUG test. Adverse events recorded included infection, revisions, fractures, and implant failures.
Compared to baseline values, all outcome measures improved at follow-up. The post-operative Q-TFA and SF-36 scores were both significantly higher than baseline. The 6MWT and the TUG also improved, with a 330% increase for the 6MWT and 39% reduction for the TUG. Three patients experienced minor infections which responded to oral antibiotics. Refashioning of the soft tissue residuum was performed on 1 patient electively. One peri-prosthetic fracture occurred due to increased activity,and was successfully stabilised without the need for implant revision.
These findings have important implications for the reconstruction of amputees who suffered through military blast injuries. Despite having tremendous difficulties using socket-mounted prostheses, functional levels of the patients greatly improved after osseointegrated reconstruction. This suggests that osseointegration may be considered a highly effective strategy for these patients.
NOT A NANNY STATE – THE ETHICAL JUSTIFICATION FOR INJURY PREVENTION PUBLIC HEALTH POLICIES
Public health is widely accepted as those collective or social actions necessary to assure the conditions that allow health to flourish. The desire to avoid a “nanny state” is rooted in the notion that public health policies unjustly infringe on individual liberties. Health care practitioners involved in trauma care should have a robust understanding of the ethical justifications for public health care policies that aim to reduce injury – in particular those concerned with injury prevention in children. In particular, I submit that where public health policy regarding injury prevention is responsive to the needs of the population concerned they can be seen to augment autonomy and personal freedom rather than their common interpretation as paternalistic overreach by a “nanny state”.
BLOOD ALCOHOL LEVEL IS NOT AFFECTED (DILUTED) BY LARGE VOLUME RESUSCITATION OR TRANSFUSION.
Megge Beacroft, Sudhakar Rao
Alcohol and other mind altering substances affect the clinical assessment of a patient’s neurological status, ability to report or respond to clinical assessments, and furthermore may contribute to disordered physiological responses to haemorrhage.
A predictable metabolic rate and excretion rate of alcohol is useful to clinicians in being able to decide when a patient may be sober enough for reliable assessment of symptoms of head injury in particular, and also of other minor injuries that may have otherwise been undiscovered in a state of inebriation.
There are known factors that contribute to slightly different rates of alcohol distribution and metabolism (Body mass, gender, chronic alcohol consumption). What is less well known is whether trauma and resuscitation with intravenous fluids, or massive exchange transfusion alters the Blood Alcohol levels.
Method: We retrospectively reviewed patients who were admitted to the trauma service with high blood alcohol levels to determine the rate of change in Blood Alcohol levels in patients who received with various amounts of intravenous resuscitation.
Conclusion: Large volume resuscitation does not affect the Blood Alcohol level in a trauma patient. A predictive graphical reference chart can be used to predict when a trauma patient is likely to be “sober” enough for assessment and discharge from hospital emergency rooms.
TRENDS IN PREHOSPITAL TRAUMA DEATHS IN VICTORIA
Ben Beck1, Karen Smith1, 2, 3, Eric Mercier1, 4, Peter Cameron1, 5
Introduction: The aim of this study was to provide an epidemiological overview of prehospital trauma deaths over a 7-year period.
Methods: We performed a retrospective review of prehospital trauma deaths over the period of 2008 to 2014 in Victoria, Australia. Data was extracted from the Victorian State Trauma Registry and the National Coronial Information System. Poisson regression was used to investigate temporal trends in incidence rates.
Results: Over the seven year study period, there were 5,793 prehospital trauma deaths in Victoria with an overall crude incidence of 14.9 deaths per 100,000 population, with an average of 828 prehospital trauma deaths per year. These trauma deaths were mostly male (76%), occurred in major cities (59%), and resulted from intentional self-harm events (50%), unintentional events (43%), assaults (4%) and other and unknown events (3%).
The incidence of prehospital trauma deaths declined 2% per year from 2008 to 2014 (incidence rate ratio (IRR) = 0.98; 95%CI:0.97,1.00; P=0.017). Overall, deaths from transport events declined 4% per year (IRR = 0.96; 95%CI:0.94,0.98; P=0.001) while the incidence of deaths resulting from hangings did not change over the study period (IRR = 1.01; 95%CI:0.99,1.04; P=0.234). As a result, the incidence of hangings in 2014 (5.0 per 100,000 population) was greater than of transport events (4.3 per 100,000 population).
Conclusions: While declines were observed in the incidence of all prehospital trauma deaths over the study period, many of these deaths are preventable and these data can be used to drive injury prevention strategies.
EARLY IN-REACH REHABILITATION FOR TRAUMA PATIENTS AT A MAJOR TRAUMA CENTRE – INITIAL EXPERIENCE
Teresa Boyle1, Sabina Bialkowski2, Kate Dale1, Don Campbell1, Martin Wullschleger1
Purpose: To present initial data and describe the model of care of a novel clinical acute rehabilitation intervention service with a focus on trauma patients. This service provides multidisciplinary rehabilitation management on acute wards prior to the conclusion of the acute episode of care. Principle aims of the service are to reduce overall length of stay; improve function at discharge from hospital; reduce deconditioning; and facilitate comprehensive discharge planning.
Methodology: A descriptive review of trauma patients that have utilised the in-reach Rehabilitation Response Team, (RRT) over a 24-month period, April 2016 to April 2018. Outcome scores including Functional Independence Measure (FIM), De Morton Mobility Index, Patient Specific Functional Scales as well as Injury Severity Score, Demographics and length of stay are measured.
The multidisciplinary team is supervised by a rehabilitation consultant and allied health team leader. Ongoing formal and informal audit of workflow and outcomes is undertaken to ensure the quality improvement of the service.
Results: Since hospital-wide RRT implementation, 86 Trauma patients (14 female, 72 male) with a mean age of 49 years have utilised the service over a 24-month period. Mean length of stay on the program was 10.1 days and overall FIM efficiency was 1.59. Other relevant outcome metrics, as well as referrer and patient feedback will also be presented. Challenges and positive achievements encountered throughout this process are reported.
Conclusion: We present the implementation of a novel in-reach rehabilitation service in the setting of acute trauma at the Gold Coast University Hospital.
CHARACTERISTICS AND OUTCOMES OF ADULT TRAUMA PATIENTS ATTENDED BY ST JOHN AMBULANCE PARAMEDICS IN METROPOLITAN PERTH.
Elizabeth Brown2, 1, Hideo Tohira2, 3, Paul Bailey2, 4, 1, Judith Finn2, 3, 5, 1
Objective: To describe the epidemiology of adult trauma in metropolitan Perth, Western Australia, treated by ambulance paramedics.
Methods: Using the St John Ambulance Western Australia (SJA-WA) database and WA death data, a retrospective cohort study of trauma patients aged ≥16 years attended by paramedics in metropolitan Perth between 2013 and 2016 was undertaken. Comparisons of age, sex, mechanism of injury and acuity level were made between patients who died prehospital (immediate deaths), on the day of injury (early deaths), within 30-days (late deaths) and those who survived longer than 30-days (survivors). Trauma incidence and 30-day mortality rates were also calculated and prehospital interventions reported.
Results: There were 97,724 cases included in the study. Of these 2,183 patients died within 30-days (n=2,183/97,724, 2.2%). Motor vehicle accidents were responsible for the most immediate and early deaths (n=98/203, 48.3% and n=72/156, 46.2% respectively). A statistically significant increase in trauma incidence was observed (from 1,466 to 1,623 per 100,000 population-year p=<0.001). Low acuity injuries accounted for the majority of transports (acuity levels 3 to 5 n=60,594/79,887, 75.8%) with high-acuity accounting for just 2.7% (n=2,176/79,997). Insertion of intravenous catheters occurred in more than 30% of cases (n=25,060/80,643, 31.1%) with the most frequently performed intervention being the analgesia administration (n=32,333/80,643, 40.1%). Endotracheal intubation and other advanced life support interventions were performed in less than 1% of patients.
Conclusions: The incidence of trauma increased over the study period. Most patients had low-acuity injuries, high-acuity trauma occurring only infrequently. This has implications for paramedic skill retention.
THE DEVELOPMENT OF A MAJOR TRAUMA RECOVERY COORDINATOR POSITION: A PILOT PROJECT
Sara Calthorpe2, 1, Lara A Kimmel2, 3, Mark Fitzgerald1, William Veitch3, Belinda Gabbe3
Background: Previous research involving Victorian Major Trauma Services (MTS) has described patient dissatisfaction with the discharge process and coordination of follow-up care. A two-year pilot Major Trauma Recovery Coordinators (MTReC) to the Alfred Trauma Service was established to improve the discharge planning and post-discharge care coordination of trauma patients.
Methods: The MTReC role was specifically designed to include meeting with patients whilst in-hospital, follow up phone calls following discharge at set timepoints, and providing a single point of contact for patients after leaving the hospital. A custom-built database was established to capture detail about patient/family contacts and MTReC actions.
Results: During the first 12 months, 550 major trauma patients were coordinated by the MTReC. Direct patient interaction was predominant, with 28% of cases coordinated via proxy. For inpatients, 84% of issues concerned patients not understanding their injuries and medical management (34%); care instructions (32%) and/or discharge plans (49%). Following discharge, issues related to outpatient appointments (45%) and concerns including poor understanding of care instructions, pain management and discharge processes were most common. The MTReC received over 300 unscheduled phone calls, relating to 183 different patients.
Summary: Establishing a MTReC service within trauma centres is feasible and provides a single point of contact for trauma patients throughout the continuum of care. The key requirement of the MTReC was the provision of injury education and advice, coordination of follow-up care, and ensuring timely and efficient access to specialist outpatient clinics. The MTReC pilot is being further evaluated using qualitative and quantitative methods.
MEASUREMENT OF MOBILITY AND PHYSICAL FUNCTION IN HOSPITALISED TRAUMA PATIENTS: A SYSTEMATIC REVIEW OF INSTRUMENTS AND THEIR MEASUREMENT PROPERTIES
Sara Calthorpe1, 2, Lara A Kimmel1, 3, Melissa J Webb1, Belinda Gabbe3, Anne E Holland1, 4
Background: As trauma systems mature and the mortality rate following trauma plateaus, it is important to measure patient morbidity of which mobility and physical function are key aspects. However the optimal instrument to measure this in the acute hospital setting remains unclear.
Methods: A systematic review to identify and describe mobility and physical function instruments scored by direct patient observation, used in adult trauma patients in an acute hospital setting was undertaken. Instruments that were condition, disease or joint specific were excluded. The COSMIN checklist was used to assess risk of bias where relevant. Clinimetric properties were reported where possible, including reliability, validity and responsiveness.
Results: 10,250 articles were identified with 35 eligible for final review, including six different instruments. None had been specifically designed for use in a trauma population. The Functional Independence Measure (FIM) was most commonly cited (n= 10 studies), with evidence for construct validity, responsiveness and minimal floor/ceiling effects (<3%). The modified Iowa Level of Assistance (mILOA, n= 2 studies) was reliable and responsive, but ceiling effect ranged from 26% to 37%. Little clinimetric data were available for other measures
Discussion: Evidence from a small number of studies supports the use of the FIM and mILOA to measure mobility and physical function in trauma patients in the acute hospital setting, however comprehensive clinimetric data is lacking. Future research should investigate the reliability and validity of commonly used measures in defined trauma populations to establish their usefulness in evaluating acute treatment effectiveness and predict longer-term outcomes.
EXPERIENCE OF BLUNT CARDIAC INJURY IN A MAJOR TRAUMA CENTRE: A RETROSPECTIVE ANALYSIS
David Cheng1, Christopher Merrett1, Rodney Judson1
Background: Blunt cardiac injury is an uncommon diagnosis however its importance remains, due to its high association with mortality. The definition of blunt cardiac injury remains very broad; ranging from mild cardiac contusion with minimal sequela to ventricular rupture with high mortality. Little has changed in diagnostic algorithms in the last 15 years and the appropriate approach to identify those with cardiac injury is largely unknown.
Methods: A single site retrospective cohort analysis was conducted of all major trauma patients seen at the Royal Melbourne Hospital, a level 1 trauma centre, from January 1997 to January 2018. Surgical outcomes and mortality statistics were identified and retrospective review of the diagnostic workup including both biochemical markers and radiology were analysed.
Results: A retrospective chart review identified 108 patients with a diagnosis of blunt cardiac injury over a 22 year period. Analysis of the utility of serum troponins, extended focussed assessment with sonography for trauma (eFAST) scans, transthoracic echocardiography and CT angiography was performed. There appears to be a high false negative rate associated with eFAST examinations. 30 patients were complicated by cardiac arrest requiring cardiopulmonary resuscitation, 11 patients developed a cardiac arrhythmia and 3 patients were complicated by acute myocardial infarction.
Conclusion: This study shows our experience of blunt cardiac injury over a 22-year period in a single major trauma centre. Blunt cardiac injury is still an uncommon diagnosis however its risk of mortality remains high and appropriate diagnostic algorithms to identify the correct pathology quickly remains important.
RETROSPECTIVE REVIEW OF TRAUMATIC THORACIC SPINE INJURIES: “ARE WE MISSING SOMETHING?”
Erasmia Christou1, Sana Nasim1, Sudhakar Rao1
Objective: A recent audit at a Level 1 Trauma Centre showed that bowel and thoracic spine were the most commonly missed blunt trauma injuries. The purpose of this study was to determine the incidence of thoracic spinal injuries, identify potential factors contributing to the failure of their recognition and the consequences of such; this may help guide us in suspecting and identifying future injuries.
Methods: A retrospective review of data from the trauma registry was conducted from 2003 to 2015, and analysed via the SPSS-V.22 program.
Results: 2760 patients with thoracic spine injuries were identified; 129 (4.7%) of these patients had a missed injury. The mean Injury Severity Score (ISS) was 17 +/- 12, whilst the main causative mechanism was motor vehicle crash followed by falls. Glasgow Coma Scale (GCS), age and level of injury did not have any statistical significance in contributing to missing an injury; ISS, mechanism and neurology all played roles. 44% of patients with a missed injury required bracing; none required surgery, nor did any die.
Conclusion: Thoracic spine injuries were missed in less than 5% of patients; contributing factors included ISS and mechanism of injury, but not level of injury or GCS. As the number of trauma admissions increased over the years, the incidence of thoracic spinal injuries also increased and identification of missed injuries was subsequently higher. We should therefore have a reasonable index of suspicion for thoracic spine injuries when we treat all high risk trauma patients from motor vehicle crashes and falls.
SUDDEN ENDING OF LIFE – PALLIATIVE AND PASTORAL CARE
Trauma response is heavily oriented to medical interventions but in spite of best efforts, positive restoration of functional life is sometimes not possible. Transition to comfort care and preparation for end of life then becomes an urgent practicality. Medical personnel may need to share space in order to facilitate palliative care, pastoral care and possibly organ donation colleagues. This change of emphasis in an acute setting has not always occurred smoothly or in ways that are most beneficial to the patient or the family members or to the other staff involved in caring for the critical patient.
At a time when end of life care, euthanasia and the right to self-determination with respect to dying are current topics of public controversy and Western Australia is preparing for parliamentary debate over possible changes to the law, it is timely to recognize that within the hospital setting, there are frequent situations that require urgent decisions regarding critical choices of care management. What level of treatment or withdrawal of treatment is appropriate? What is the best way to offer pain relief and comfort? If the patient is not able to assess the situation and make a conscious and informed choice, who will? Who is available? How will they be informed and supported as next of kin and other closely involved people juggle hopes of survival alongside realistic possibilities of severe disability or death? How can staff be supported whilst handling emotional situations that include caring for shocked, angry or grieving relatives and friends?
ASSESSMENT OF THE IMPACTS OF THE OPTIMISED RECOVERY AFTER TRAUMA (ORAT) PROGRAM REPORTED BY MULTIDISCIPLINARY TEAM MEMBERS AT A MAJOR TRAUMA CENTRE
Jennifer Dorrian1, Damien Ah Yen1, Bronwyn Denize 1, Michelle Tonks1, Jessica Steenson1, Kelsee Bax1, Annabelle Hastings1, Christo Creiffer 1, Kelly Leatherland 1, Grant Christey1, 2
Increasing requirements for standardisation and measurement of clinical processes impacting major trauma patients are amplifying the need for efficient multi-disciplinary care that consistently applies best practice to these complex and vulnerable patients and their families. Nurses and allied health professionals are central to the daily delivery of care in these clinical settings by virtue of their frequent contact with patients and their families, the knowledge acquired from those interactions, and the depth of relationships they form as a result. The Optimised Recovery After Trauma (ORAT) program is a clinical framework designed to maximise collaboration of multi-disciplinary team members through the use of a shared database containing key elements of clinical care to be addressed during and after admissions of major trauma patients to hospitals. The information obtained in the ORAT program is used primarily to support three clinical activities: the daily ward-round, regular multidisciplinary meetings and comprehensive discharge planning. Nurse and allied health professionals are primary contributors to the ORAT database and the three clinical activities it supports. We provide an assessment of the impacts of the program on their work and on their patients in the tertiary trauma centre where the ORAT program was developed and tested. We hope that these experiences will stimulate further discussion and development of similar programs for the benefit of patients and their families in trauma-receiving facilities in Australia and New Zealand.
A PROSPECTIVE REVIEW OF APPROACHES TO CERVICAL SPINE IMMOBILISATION PRACTICE IN A TERTIARY TRAUMA CENTRE
Andrew Coggins1, 2, Nargus Ebrahimi1, Ursula Kemp1, Kelly O’Shea1, Michael Fusi3
Background: A large number of trauma patients presenting to the Emergency Department (ED) receive Cervical Spine Immobilisation (CSI). However, there is conflicting evidence regarding CSI, with some evidence suggesting its harmful effects and also its ineffectiveness in preventing inadvertent movements. The objective of this study was to investigate current practices, adherence to guidelines and the attitudes of staff in relation to CSI.
Methods: We performed a mixed methods study in a single tertiary referral centre. Prospective observational data were collected on both a cohort of patients (n=54) and through an interdisciplinary provider survey (n=156).
Results: In our patient cohort, the mean age was 50.6 years and 72.2% were male. Patients presented with a variety of mechanisms including Motor Vehicle Accidents (37.0%) and Falls (40.7%). CSI was initiated prehospital in the majority of cases (77.8%). The median time spent immobilised was 325 minutes (IQR 108-409). Overall, there was a 63.6% reported compliance with local guidelines. Variations in compliance were multifactorial but commonly associated with conflicting approaches across disciplines.
Healthcare providers surveyed included nurses (29.5%), doctors (44.2%) and paramedics (26.3%). Qualitative content analysis revealed variance in staff approaches to current best practice and their approaches to standardised cases. There was a desire for a more uniform approach to CSI clearance.
Conclusions: There was a marked variation in the approach to CSI and use of guidelines in the ED setting. In conclusion, there is likely to be benefit from a more standardised approach to CSI.
RADIOLOGICAL FINDINGS OF ABDOMINAL INJURIES OF THE SOFT TISSUES WITHIN SEAT BELT SYNDROME ON COMPUTED TOMOGRAPHY (CT)
Claire Elliot1, Derek Teh1, Liz Wylie1
Publish consent withheld
VIDEO-TUBE THORACOSTOMY IN TRAUMA RESUSCITATION
Peter Finnegan1, 2, 3, Mark Fitzgerald1, 2, 3, De Villiers Smit1, 4, 5, Kate Martin1, 2, 3, Joseph Mathew1, 2, 3, Dinesh Varma6, Andrew Lim1, S Scott2, 5, Kim Williams1, 2, Yesul (Yen) Kim1, 2, 3, Biswadev Mitra1, 4, 5
Background: Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]).
Methods: A prospective, single centre, phase 1 feasibility study with a parallel control group was undertaken. The population studied were adult thoracic trauma patients requiring emergency TT who were haemodynamically stable. The intervention performed was V-TT. Patients in the control group underwent conventional TT. The primary outcome was tube position as defined by a consultant radiologist’s interpretation of chest x-ray (CXR) or CT. The trial was registered with ANZCTR.org.au (ACTRN: 12615000870550).
Results: There were 37 patients enrolled in the study – 12 patients allocated to the V-TT intervention group and 25 patients allocated to conventional TT. Mean age of participants was 48 years (SD 15) in intervention group and 46 years (SD 15) years in the control group.
In the V-TT group all patients were male; the indications were pneumothorax (83%), haemothorax (8%) and haemopneumothorax (8%). The median injury severity score was 23 (16-28). There were 1 insertional and 1 positional complications.
Conclusion: V-TT was demonstrated to be a feasible alternative to conventional thoracostomy and merits further investigation.
EVALUATING RESUSCITATIVE BALLOON OCCLUSION OF THE AORTA (REBOA) FOR EXSANGUINATING TRAUMA RELATED HAEMORRHAGE IN AN ADULT AUSTRALIAN TRAUMA CENTER
Mark Fitzgerald1, 2, 3, Stephen Bernard4, 5, Robert Lendrum6, John Moloney7, 6, Smit De Villiers1, 4, 7, Joseph Mathew1, 2, 3, 7, C Nickson8, 9, R M Lin8, 10, May Yeung1, 2, Kate Martin1, 2, Adam Bystrzycki1, 4, Louise Niggemeyer1, 2, Biswadev Mitra1, 4, 7
BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has recently been promoted for temporary haemorrhage control as life-saving intervention in patients with severe, non-compressible haemorrhage prior to definitive haemorrhage control.
Aim: To determine if the introduction of REBOA for Aortic Control of Exsanguinating Trauma Related Haemorrhage at an adult Australian Adult Major Trauma Centre would improve survival for major trauma patients until hospital discharge.
Results: During the study 3,032 patients were admitted direct from scene through the Alfred Emergency & Trauma Centre with an overall mortality of 97 (3.71%). Of these 3,019 had trauma centre vital signs recorded and 1,523 were between the ages of 18-60 including 143 with a Shock Index of >1.0 (4.74%) [indicative of haemorrhagic shock] – and 13 (0.43%) with a Systolic Blood Pressure <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was 6/13 (46.15%). Of these 13 patients, there were 2 where REBOA was attempted.
There were no eligible patients for whom REBOA was achieved. Although commenced, REBOA was abandoned during the resuscitation of the 2 patients. One 80-yo patient with multisystem trauma, including neurotrauma, underwent successful REBOA deployment despite temporarily losing cardiac output during insertion. The patient died in Intensive Care on day 2 secondary to severe neurotrauma. None of the other 6 patients who died would have benefited from REBOA.
Conclusion: Despite considerable training and resource allocation to ensure 24-hour availability, the introduction of REBOA failed to demonstrate any impact on patient outcome for this patient cohort.
AIIMS TRAUMA RECEPTION AND RESUSCITATION© (TRR©) SYSTEM: A PRELIMINARY TRIAL OF THE INTRODUCTION OF TRAUMA RESUSCITATION DECISION SUPPORT TO INDIA
Mark Fitzgerald2, 1, Yesul (Yen) Kim2, Amit Gupta3, Sanjeev K Bhoi3, Ankita Sharma3, Ashish Jhakel3, Gaurav Kaushik3, Joseph Mathew1, Teresa Howard2, Madonna Fahey2, Peter Finnegan2, Mahesh Misra3
The TRR© system provides the Trauma Team with computerised decision support for the management of major trauma, improves protocol compliance and reduces errors of omission. The primary outcome of this study was to determine whether the TRR© significantly improves real-time vital signs data capture and documentation. The secondary outcome measure evaluated the frequency of Life Saving Interventions (LSIs) and the time taken to perform them.
The TRR© system was installed into 2 of the 6 resuscitation area bays within AIIIMS JPN Apex Trauma Center. In the TRR group, 82 patients were enrolled with 41 non-TRR controls. Data was extracted automatically from the TRR© system. Matching control data was entered on-line via a purpose-built REDCap™ secure web application.
Resuscitation procedures were more accurately recorded, in real time by staff when TRR© system was in use. There was a statistically significant difference in the time taken to insert intercostal catheters between the TRR treatment group and the controls (p< 0.05). Moreover, the treatment group exhibited shorter time from arrival to endotracheal tube (M = 13, SD =0.09), as opposed to 23 minutes (SD =21.08) for controls (p < 0.005). Importantly, there was a greater variability in the time taken to perform LSIs in the control group in comparison to the clinicians assisted with computerised decision prompts.
The TRR© system was successfully introduced and applied at Level I trauma center in India. With continued use and further data analyses, it shows great potential to be implemented as standard of care for trauma management.
IMPLEMENTING A TRAUMA REGISTRY IN SAUDI ARABIA: A SAUDI TRAUMA REGISTRY (STAR) IS BORN
Jane E Ford2, 1, Abdulrahman S Alqahtani1, 3, Shatha AA Abuzinada1, Peter A Cameron2, 1, 4, Mark C Fitzgerald5, 6, 7, 8
King Saud Medical City (KSMC) in Riyadh, Kingdom of Saudi Arabia (KSA) requested collaboration with the Alfred Hospital and Monash University to establish a Level 1 Trauma Centre. An essential component of this project is a Trauma Registry that will collect the data needed to enhance clinical knowledge and monitor system performance.
Aim: To describe the implementation of the Saudi TraumA Registry (STAR) and present preliminary findings.
Methods: A 12 step implementation plan was created and followed at the KSMC. Specifications were written that enabled KSMC software developers to build a bespoke database. Operating procedures were provided to guide daily tasks and enable routine data collection. Regular reporting was initiated. Data collection commenced on August 1st 2017.
Results: From the commencement of data collection to March 30th 2018, 2488 patients that potentially met inclusion criteria presented to the Emergency Department at KSMC. Of these, 1056 records have been entered into the database. Preliminary analysis shows 20.5% were major trauma; mortality of major trauma was 8.8%; 84.7% were male and median age was 28.5 years.
Conclusion: The STAR is now fully operational. In the short term, process indicators will track the development of the KSMC into a Level 1 Trauma Centre. In the medium to long term the STAR will be deployed nationally to capture the impact of public health initiatives and socioeconomic change in the KSA. The effect of the STAR will be that the country is better equipped to deliver continuous improvements in trauma systems and quality of care.
ACUTE TRAUMATIC COAGULOPATHY MANAGEMENT IN THE PRE-HOSPITAL SETTING – IT’S ABOUT BLEEDING TIME…
Acute Traumatic Coagulopathy (ATC) occurs in severely injured patients with haemorrhage, is associated with increased mortality and transfusion requirements, and is characterised by a fibrinogen deplete state.
Many trauma patients in Western Australia are injured in remote areas,and require prolonged transfer over vast distances to reach trauma centres.
Pre-hospital identification of trauma patients with TIC would enable early replacement of fibrinogen, and potentially improve outcomes.
However, neither fibrinogen level nor TEG testing is available in the remote and pre-hospital setting, and fibrinogen replacement with cryoprecipitate is impractical in the pre-hospital and transport environment.
Fibrinogen Concentrate (FC) is an alternative product, widely used in Europe, which is easily stored and administered to critically bleeding patients.
Can trauma patients with fibrinogen depletion and TIC be identified in the pre-hospital phase?
A review was performed of all patient transfers by RFDS WO between 2011 and 2016, to identify trauma patients who required blood products during flight.
117 patients were identified, and matched with the transfusion medicine database at Royal Perth Hospital. The initial fibrinogen level measured following RFDS transfer was recorded.
This presentation reports the outcomes of this review, the practicalities of fibrinogen replacement and the future of haemorrhage management in the pre-hospital environment.
COMPUTED TOMOGRAPHY (CT) BASED DIAGNOSIS AS AN ALTERNATIVE TO POST MORTEM IN TRAUMA PATIENTS
Vindya Abeysinghe1, Darren Karadimos1, Sudhakar Rao1
Purpose: Post mortem assessment is the current gold standard investigation to determine cause of death for trauma patients however the time consuming, costly, and invasive nature of this technique limits use amongst trauma patients. Routine computed tomography (CT) assessment is a highly sensitive technique for identification of injuries in trauma patients and may represent a non invasive and cheaper alternative to post mortem examination. We aim to retrospectively identify the discrepancy in reported injuries between the two assessments at Royal Perth Hospital (RPH) State Major Trauma Unit, a level one trauma centre in Western Australia.
Methodology: All trauma patients who were investigated by CT scan (head,chest,abdomen) in the emergency department at Royal Perth Hospital who died whilst in hospital between 1st January 2008 to 31 December 2017 were identified using the RPH Trauma Registry. Patients who underwent post mortem assessment from this group were identified. Demographic data was collected using a standardised data collection form. Comparison between the injuries identified on CT scan and post mortem examination was collected.
Results: Preliminary data is currently being collated.
Conclusion: Post mortem examination is an important tool to determine cause of death. In patients who have undergone CT scans prior, post mortem is unlikely to add further injury towards the cause of death. Implementation of prompt post mortem CT may eliminate the need for invasive post mortem assessment.
RIB FRACTURE MANAGEMENT IN AN INCREASING ELDERLY POPULATION
James P Laurent1
Rib fractures are one of the most common injuries related to blunt chest trauma and cause significant problems, especially in the elderly such as pneumonia and respiratory failure. The aim of the study was to audit rib fracture management to review current practice.
Patients admitted to Wellington hospital in the year 2017 with thoracic injuries were reviewed. Demographics, aetiology, complications and management were recorded.
144 patients were included in the study. Their mean age was 54 years, 35% over 65, and mean ISS of 16. Patients had a mean of 4 fractured ribs. The main cause of trauma was related to falls 41%, followed by road traffic collisions 25% and bicycle accidents 11%. 34% percent were admitted to cardiothoracic surgery, 18% orthopaedics and 13% general medicine. Patients admitted under cardiothoracic surgery had more epidural usage (22% v 6.3%, p = 0.006) and patient-controlled analgesia (44 % vs 20 %, p<0.001) compared with other units. More aggressive analgesia was used with increasing rib fractures. (Epidural 7.47, PCA 3.61, Oral 2.38, p<0.05). Patients with outcome complications, namely pneumonia and death, were more likely to be older with more comorbidities (65 v 51 years, p=0.02). With 45% having comorbidities compared to 11% without complications (p<0.01).
Older patients with comorbidities are more likely to have a poorer outcome. This indicates that they will require more intensive treatment and management to improve outcomes. This is important as a greater proportion of trauma is occurring in elderly patients who have a higher mortality.
SCAPULOTHORACIC DISSOCIATION: A NOVEL APPROACH IN THE MANAGEMENT OF A DEVASTATING TRAUMATIC INJURY.
Adam M Lawless, Jean-Louis Papineau, Rene Zellweger
Scapulothoracic Dissociation is an important and increasingly common traumatic injury of the upper limb. Scapulothoracic dissocation describes partial or complete disruption of the scapulothoracic articulation resulting from massive traction injury to the anterolateral shoulder girdle. It is associated with severe vascular and neurological injuries in more than 85% of cases and is accompanied by tremendous soft tissue injury. In this regard, it can be viewed as a partial or complete internal forequarter amputation.
Early management focuses on diagnosis and treatment of the neurovascular injuries however, musculoskeletal injury management remains controversial with some specialists advocating conservative management. Given the disruption of the superior shoulder suspensory complex we believe it appropriate to surgically manage this injury with internal fixation. With respect to the soft tissue injury we believe a more robust method of internal fixation will provide a more favourable clinical outcome.
This case series documents the surgical treatment of 7 patients diagnosed with scapulothoracic dissociation and utilises a locking compression medial or modified lateral proximal tibia plate, traditionally used for the treatment of tibial plateau fractures. The plates were removed after three months with the patients followed up in the outpatient clinic for functional, clinical and radiographic assessment.
INTRODUCTION OF PRE-HOSPITAL NOTIFICATION OF INJURED PATIENTS PRESENTING TO TRAUMA CENTRES IN INDIA
Joseph Mathew1, 3, 2, Biswadev Mitra1, 4, 3, 5, Gerard O’Reilly1, 4, 5, Teresa Howard1, 2, Mark Fitzgerald1, 3, 2, On behalf of the AITSC Investigator Group
Prehospital notification is the communication by emergency service personnel to a receiving hospital of the impending arrival of a patient requiring emergency care. There is currently no standard system for pre-hospital notification in India.
Aim: To develop and introduce a system for prehospital notification and patient handover in India.
Methods: An environmental scan of four emergency departments, three pre-hospital services, and associated systems and processes was undertaken.
An android app (Suchana) was developed to facilitate the notification of major trauma cases from the ambulance to emergency department. Simple patient data is entered by an emergency medical technician, generating a trauma triage flag in a corresponding app on duty mobile phone held by a designated person within the ED. Only “red” major trauma patients are notified. Once notification is received, a SuchanaÓ Relay app can then send out a Trauma Team Activation to notify all other trauma team members for early preparation and readiness to receive the patient.
Results and Conclusion: Pre-hospital notification using Suchana commenced in May/June 2017 – Jan/Feb 2018 with a total of 470 injured patients. The use of Suchana reduced patient handover time and sped up initiation of treatment for critical patients. Benefits: improvement in care; proactive surveillance of patient care and immediate resolution of issues; increase in trauma patients being directed to trauma hospital; trauma team and trauma bay ready; increased communication with the trauma centre; and improved completion of patient records.
Ultimately the Indian public ambulance companies are looking to invest in pre-hospital notification.
THE AUSTRALIAN TRAUMA REGISTRY (ATR) – A NATIONAL VIEW OF SERIOUS TRAUMA
Kate Curtis1, 2, Mark Fitzgerald3, 5, 4, Jane Ford3, 6, Emily McKie3, 6, Teresa Howard3, 4, Peter Cameron3, 6, 7, On behalf of the Australian Trauma Quality Imporvement (AusTQIP) Collaboration Collaboration
Background: Early 2016, the Senate inquiry into Aspects of road safety in Australia recommended that the Commonwealth Government commit to funding the operation of the ATR, supported by the Royal Australasian College of Surgeons and the Australian Commission on Safety and Quality in Health. In December 2016, Prime Minister Malcolm Turnbull announced new funding for the ATR. Support was provided by the Department of Infrastructure, Regional Development and Cities and the Department of Health.
Aim: To characterize serious trauma across 26 major trauma centres in Australia.
Methods: Collaborators submit 67 data-points in accordance with the bi-national Trauma Minimum Dataset for Australia and New Zealand, for severely injured patients (ISS > 12) or death after injury.
Results: During the 2016-2017 year, data was collected for 8,423 seriously injured patients. Men were over-represented (72%) except for patients aged ³85 years where there were more females. Transport-related injuries accounted for 45 percent of cases, while falls accounted for 35 percent. Two-thirds of patients were transferred direct from the scene. The median time from scene to arrival to definitive care was 1.5 hours. The median time spent in the ED was four hours 16 minutes. The median length of stay in hospital was 7 days and the median ICU length of stay was four days. Overall mortality was 10.6 percent.
Conclusion: Commonwealth support enables the ATR to provide a national view of serious trauma. Data shows a wide variation in processes and outcomes, representing opportunities for improvement.
RENAL TRAUMA: A DECADE IN REVIEW
Munyaradzi G Nyandoro1, Simeon Ngweso2, Mary M Teoh3, Joseph Faraj2, Sana Nasim2, Sudhakar Rao2, Dieter Weber2
Introduction: Renal parenchymal injury is an important cause of morbidity in civilian trauma. Management varies between regions and institutions.
Objectives: To understand the epidemiology of traumatic renal injury at the sole major adult trauma unit in Western Australia.
Methods: A retrospective, single-centre review of all patients admitted to the Western Australia Adult State Major Trauma Unit (SMTU) based at Royal Perth Hospital was undertaken from 2005 to 2016.
A comprehensive review of medical and imaging records was completed, capturing key demographics and variables that underpin mechanisms of injuries and management strategies.
Results: 200 patients with traumatic renal injuries were identified – 77.2% (n=153) were male. The mean age was 31 (range 13 – 84). The mean International Severity Score was 24 (range 9 – 75). 184 patients (92%) sustained blunt force trauma – predominant mechanism was motor vehicle/bike accidents (n=114).
The most frequent grade of injury was Grade 4 with 47.4% (n=94). 47 patients (23.7%) had radiological signs of ureteric or collecting system injury with evidence of urinary extravasation. Surgical or radiological intervention was performed in 32.3% (n=64) of patients. The most common intervention was retrograde ureteric stenting (n=26; 40.6%).
Average length-of-stay in an acute care setting was 14 ± 2 days. Five deaths, not directly attributed to renal trauma, occurred between 0-10 days of admission.
Conclusions: Blunt force trauma accounts for the majority of renal trauma with non-operative management successful in the majority of cases. Future studies should address the effect of current management principles on long-term outcomes.
A TEN YEAR EXPERIENCE WITH TRAUMATIC RENAL PSEUDOANEURYSM
Munyaradzi G Nyandoro1, Simeon Ngweso2, Mary M Teoh3, Joseph Faraj2, Sana Nasim2, Sudhakar Rao2, Dieter Weber2
Introduction: Vascular pseudoaneurysms are a recognised complication following traumatic renal injury (TRI). Pseudoaneurysms in association with non-iatrogenic TRI are rare but an important cause of secondary haemorrhage. Optimum management and follow-up of pseudoaneurysms secondary to TRI is still indeterminate.
Methods: A retrospective, single-centre review of renal trauma patients admitted at the Western Australia Adult State Major Trauma Unit (SMTU) based at Royal Perth Hospital, was undertaken from 2005 to 2016.
A comprehensive review of medical and imaging records was completed to determine the incidence of renal pseudoaneurysm and management strategies. Follow-up CT angiogram was routine for patients with TRIs Grade 3 or higher.
Results: 200 patients were diagnosed with a TRI during the study period. 4.5% (n=9) patients developed a traumatic renal pseudoaneurysm, eight occurred following Grade 4 blunt force TRI. None of the eighteen Grade 5 TRIs developed a pseudoaneurysm, however eight required a nephrectomy.
Eight cases were successfully angio-embolised with only one repeat procedure. No surgical intervention was required. One patient was successfully managed conservatively.
Discussion: Traumatic renal pseudoaneurysms are rare with an incidence rate of 4.5% for the decade in review in this study. In this centre’s experience, angio-embolisation was a successful strategy in managing these lesions. Further prospective research is necessary to determine optimum management and follow-up strategies for traumatic renal pseudoaneurysms.
EVALUATING THE SEVERITY OF PAEDIATRIC AUSTRALIAN RULES FOOTBALL INJURY
Cameron Palmer1, 2, Leopold Simma1, 3, Helen E Jowett1, Warwick J Teague1, 4, 5
In many states, Australian Rules football (known eponymously as AFL) outranks all other sports in terms of ED presentations and hospital admissions; injury rates may be higher for AFL than any other code. However, no recent epidemiology has been published, and the overall profile of severe injury is unknown.
This study aimed to evaluate patterns in hospital-treated AFL-related injuries at a large paediatric hospital, and to compare the hospital-related burden of injury to that of other team ball sports (TBS) using ED presentation and Trauma Registry data over seven years.
521,790 ED presentations, including 100,075 injury presentations were reviewed. 10,003 presentations were TBS-related, including 4,751 AFL-related presentations. A total of 1,110 TBS patients were subsequently admitted including 616 AFL patients
The incidence of AFL injury increased with age; AFL accounted for one in seven trauma-related ED presentations amongst 14-15 year olds, and 13% of injury admissions.
Patients presenting to ED after AFL injury were twice as likely to sustain multiple injuries as other TBS patients, and significantly more likely to be classified as severely injured. Patients admitted after AFL injury were less likely to sustain fractures, but significantly more likely to sustain injuries to the head, neck, chest or abdomen. Numerically, AFL patients required substantially more bed days than other TBS patients despite similar patient numbers.
AFL is a common cause of ED presentations and results in substantial morbidity. Previously suggested strategies for reducing injury risk such as helmets and rule modifications for younger players should continue to be encouraged.
CRITICAL INCIDENTS AND TRAUMA DEATHS-IT’S ABOUT PERSPECTIVES
George Perrett1, Ryan Looney2, Katrina Coppin3, Michael Parr1
Analysis of critical incidents is crucial for quality improvement. The themes of critical incidents occurring in trauma patients, who subsequently died, at a designated Trauma Centre in Sydney were compared to themes associated with trauma deaths reported to the state-wide Incident Information Management System Root Cause Analysis (RCA) process.
Liverpool Hospital has an established rigorous multi-disciplinary trauma mortality peer review process to identify errors and classify deaths. Deaths are classified as ‘potentially, probably or definitely avoidable’ or ‘non-avoidable’. None met regional RCA referral criteria.
The CEC has a multi-disciplinary peer review committee that reviews all RCAs and identifies principal incident type, risk groups, interest groups, human factors, patient factors, system factors, and recommendation categories.
During 2015/16 69 trauma deaths, with 282 incidents, spread across 59 cases occurred at Liverpool. 6 deaths were rated as potentially avoidable with 56 associated incidents, of which 15 were considered major impact.
During 2016/2017 21 trauma related state-wide RCAs. 5 classified as inadequate treatment, 3 wrong treatment, 3 missed diagnosis, 2 not recognising significance of observations but only 2 relating to delay or non-timeliness of care.
The main theme for major impact incidents at Liverpool was ‘delays in treatment and diagnosis’ (10). Other categories included ‘errors in judgement or diagnosis’ (3) and ‘complications as a result of treatment’ (2).
Examples of delays included getting CT imaging, getting to the operating theatre, reversing coagulopathy and reinitiating usual medications.
The different review systems demonstrate different issues that may impact trauma deaths and provide potential for prevention.
CARDIAC CONTUSIONS: A COMPARISON OF NUCLEAR MEDICINE IMAGING AND TRANSTHORACIC ECHOCARDIOGRAPHY IN BLUNT TRAUMA
Adam Philipoff1, Dieter Weber1, Sudhakar Rao1
Purpose: The role of nuclear medicine studies in the evaluation of cardiac contusions (CC) remains unclear. Most studies examining myocardial perfusion scans (MPS) are relatively old (1980’s). Management guidelines for the screening of blunt cardiac injury recommend the selective use of transthoracic echocardiography (TTE). However, MPS may be clinically relevant in detecting CCs. This retrospective case series compares two different imaging modalities, TTE and MPS, in patients diagnosed with CC.
Methods: All patients diagnosed with CC (positive cardiac troponin and blunt thoracic trauma) between 2008-2013 were identified from the trauma registry. Only patients who underwent both a TTE and MPS during their index admission were analysed. Data including demographics, injury characteristics, troponin studies and imaging results were obtained.
Results: 71 patients were included. 23 patients had imaging evidence (MPS and/or TTE) of CC. The sensitivity of MPS and TTE were 31% (22/71) and 11.3% (11/71), respectively. Troponin levels were significantly higher in patients diagnosed with CC on imaging. Admission troponin level (mean) for the contusion and non-contusion group were 2.32ug/L and 0.49ug/L respectively, p-value 0.022. An admission Troponin threshold value >0.75ug/L was the point at which CCs were more likely to be identified on imaging, p-value 0.027. TTE Image quality was generally poor or limited (46/71).
Conclusions: MPS is more sensitive than TTE in detecting CCs in blunt trauma patients that have an elevated troponin level. Troponin levels strongly correlate with imaging evidence of CCs. MPS is complimentary to TTE for ruling out CCs and impacts patient follow up pathways.
MANAGEMENT INTERVENTION SIGNIFICANTLY IMPROVES TRAUMA OUTCOMES AT ONE OF THE BUSIEST EMERGENCY DEPARTMENT IN PERTH.
Joondalup Health Campus (JHC) is a 716 bed private/public non tertiary hospital operated by Ramsay health care located 20km north of Perth CBD, treating adult and paediatric patients in the rapidly growing northern suburbs of Perth. The Emergency department has 57 beds including 3 resuscitation beds. There were 69,238 ED Presentations in 2010 and 98,549 in 2017. JHC was designated a Level 4 trauma facility (Level 3 NRTAC) which includes 24hr surgical, anaesthetics and ICU cover.
JHC Trauma Registry (JHCTR) commenced in January 2010 to capture accurate data for major and minor trauma. We identified a need to improve our hospital trauma call system and introduced a 2 tier system (ED and Hospital) in 2011. During 2010-2017 12,353 patients were recorded in the JHCTR with 299 major trauma transferred to tertiary facilities.
State trauma introduced a Tertiary Trauma Survey form in 2014. This was implemented to accurately document a tertiary trauma survey on all trauma patients ensuring a full systemic assessment prior to discharge.
The systems introduced have been monitored by the trauma registry with improvements recorded in all areas including the following four key performance indicators adopted by the State Trauma Registries:
Management of all trauma patients has significantly improved especially stabilisation of major trauma patients prior to transferring to the tertiary hospital and major trauma centres.
FINGER THORACOSTOMY IN CHILDREN: AN OVERVIEW OF THE PAEDIATRIC EXPERIENCE IN TRAUMA IN VICTORIA
Nuala Quinn1, 2, Cameron Palmer3, 2, Helen Jowett2, Warwick Teague4, 5, 6, 2
Introduction: Tension pneumothorax as a result of chest trauma may be a rapidly life-threatening event. Immediate management is lifesaving. Traditionally needle thoracostomy was performed, however it has been shown to be an unreliable method of pleural decompression. Finger thoracostomy has been introduced as procedure at RCH in 2017 and by the Victorian ambulance services in 2016.
Aim: To describe the state experience of finger thoracostomy in paediatric trauma patients in Victoria.
Methods: Patient records since 2016 were reviewed to identify instances of finger thoracostomy performed by Ambulance Victoria prior to RCH arrival, and within RCH. Patient records were then gleaned and data obtained pertaining to: mechanism of injury, indication for thoracostomy, procedures performed and complications which occurred as a result of thoracostomy or intercostal catheter insertion.
Results: Seven patients were identified: 4 prior to RCH arrival, 2 performed in the ED at RCH and one patient had a thoracostomy performed in both settings. 6 patients had bilateral thoracostomies performed. The mechanism was a motor vehicle accident in 3 of the patients, bike versus car in two. A quadbike and tractor rollover were the remaining mechanisms. One patient was pronounced dead in ED. All the remaining patients were admitted to PICU and had serious associated injuries;the most common being intracranial haemorrhages, intra-abdominal lacerations and rib fractures.
Conclusion: This is a descriptive study of Finger Thoracostomy in paediatric patients at a large tertiary trauma centre. It includes those done pre-hospital. Finger thoracostomy is a lifesaving procedure. Associated injuries are very serious and the patients have long inpatient stays.
LIVE PATIENT SIMULATION: AN EXCITING TOOL IN TRAUMA EDUCATION
Tom Ryan1, Andrew Challen1, Andrew Lamb1, Matthew Harper1, Jim Cooper1
Introduction: Simulation is a common tool for health professional education, particularly in critical care. We aimed to utilise a live patient to enhance realism and participant engagement during a trauma simulation.
Planning- A session in the scheduled emergency department multidisciplinary in-situ simulation timetable was identified. Participation was confirmed with the live patient actor, facilitators and relevant hospital departments. Participants received a pre-briefing covering guidelines for the simulation including safety.
Simulation- An unstable penetrating trauma scenario was created; with participants expected to identify the need for damage control surgery and facilitate a rapid transfer from the emergency department to the operating theatre. Simulation parameters were chosen to avoid ambiguity in the clinical picture. Extensive moulage was utilised to enhance realism and all actions were completed in real time using actual hospital systems and equipment.
Debrief-The simulation concluded with separate debriefs for the emergency department and theatre. This was to ensure relevant feedback and also to facilitate a timely return to clinical duties.
Results: Over 30 medical, nursing and technical staff from three departments were involved in the scenario. The patient arrived in theatre within 20 minutes of presentation to the emergency department, with the realism of the scenario praised by participants. Themes explored during the debrief included leadership, communication and patient flow.
Conclusions: The use of a live patient represents a powerful tool to engage clinical staff in simulation activities. Our scenario generated useful feedback to improve skills and processes at an individual, department and hospital level.
EXTERNAL BENCHMARKING OF TRAUMA SERVICES IN NEW SOUTH WALES: RISK-ADJUSTED MORTALITY AFTER MODERATE TO SEVERE INJURY FROM 2012 – 2016
David Gomez, Pooria Sarrami, Hardeep Singh, Zsolt Balogh, Michael Dinh, Jeremy Hsu
Objective: To generate risk-adjusted mortality for the purpose of external benchmarking of trauma services in New South Wales (NSW).
Design: Retrospective cohort study using data from the NSW Trauma Registry. We focused on adults (>16 years), with an Injury Severity Score >12, that received definitive care at either Major Trauma Services (MTS) or Regional Trauma Services (RTS) between 2012-2016.
Main outcome measure: In-hospital death.
Methods: Given the nested structure of the data, hierarchical logistic regression models were used to generate risk-adjusted outcomes. Demographic, vital sign, and injury characteristics were included as fixed effects. Median Odds Ratios (MOR) and centre-specific Odds Ratios of death with 95% confidence intervals were generated. Centre-level variables were then explored as sources of variability in outcomes.
Results: We identified 14,452 patients whom received definitive care at one of seven MTS (n=12,547) or one of ten RTS (n=1,905). Unadjusted in-hospital death was lower at MTS (9.4%) compared to RTS (11.2%). The MOR was 1.33, suggesting that the odds of in-hospital death was 1.33-fold greater if a patient was admitted to a worse performing as opposed to a better performing centre. Definitive care at MTS was associated with a 41% lower likelihood of death (OR 0.59 95%CI 0.35-0.97) compared to RTS.
Conclusion: Risk-adjusted outcomes favoured MTS; however, there was moderate between-centre variability. Best practices should be identified and disseminated throughout the system. The ongoing evaluation of system performance, as well as targeted interventions derived from such analyses, are instrumental in the delivery of high-quality care for injured patients.
MOTORCYCLE CRASH TRAUMA ADMISSIONS IN THE MIDLAND REGION OF NEW ZEALAND: WHAT THE POLICE DON’T SEE.
Alastair Smith1, Alicia Ferrer Costa2, John Garvitch3, Kaye Clark4, Grant Christey5, 6
During 2012-2016, the New Zealand Transport Agency (NZTA) ‘Crash Analysis System’ (CAS) recorded a total of 1,331 motorcycle crashes occurring on roads within the Midland Region of New Zealand as collected by NZ Police. During the same period, the Midland Trauma System (MTS) trauma registry (located at Waikato Hospital) recorded 694 persons being admitted to hospital due to on-road motorcycle crashes within the same geographical area. Merging of the two datasets has revealed an under-reporting of motorcycle crashes among police derived recording by 19%. Furthermore, only 54% of hospital admitted motorcycle crash casualties were captured among police motorcycle crash records. A range of factors appear to underlie this mismatch including high rates of self-presentation to hospital among trauma registry-only patients (non-CAS-matched), low reporting of pillion passenger casualties among police records, and geographic location of point of injury. Mapping of point of injury further suggests that those patients who were not among police records tended to be more rural in nature. Where CAS-Police and hospital admitted records were matched, concordance between crash severity, recorded by police, and hospital admission rates, and injury severity (ISS – Injury Severity Score) highlighted further mismatch. Significant numbers of casualties from crashes recorded as minor by police still resulted in hospital admission including Major (ISS>12) trauma admissions. By merging these two datasets, a rich new source of insight surrounding motorcycle crashes, their fuller extent, circumstances, and nature of injuries has been created.
VALIDATION OF TWO PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR QUESTIONNAIRES IN ORTHOPAEDIC TRAUMA PATIENTS
William G Veitch1, Rachel E.D Climie2, Belinda J Gabbe1, David W Dunstan2, Neville Owen2, Christina L Ekegren1, 2
Introduction: Orthopaedic trauma can be a catalyst for substantially reduced physical activity and increased sedentary behaviour that can persist post-recovery. While objective measures provide rigorous approaches to assessing physical activity and sedentary behaviour, valid self-report measures provide potential alternatives in some patient groups. The aim of this study was to determine, in orthopaedic trauma patients, the agreement and concordance of physical activity and sedentary behaviour data from the International Physical Activity Questionnaire (IPAQ) and the Australian Diabetes, Obesity and Lifestyle General Questionnaire 3 (AusDiab3), with data derived from objective measures.
Methods: 64 patients with isolated upper- or lower-limb fractures wore two activity monitors (ActiGraph, ActivPAL) for 10 days, from 2-weeks post-surgery. Participants then completed the IPAQ and AusDiab3 questionnaires relating to the previous 7 days of monitoring. Bland-Altman plots, Lin’s Concordance Correlation Coefficients (LCCCs) and weighted kappa statistics were used to assess agreement and concordance across several variables.
Results: The IPAQ overestimated objectively–assessed overall physical activity (median METmins: 550 vs.0) and underestimated median daily sitting time (8.00 vs.10.59 hrs). The AusDiab3 questionnaire underestimated median daily sitting time to a lesser degree than the IPAQ (9.21 vs.10.53hr/day). There was moderate concordance between IPAQ-reported and objectively-derived overall physical activity (ρ=0.431, p<0.001), and moderate concordance between AusDiab3-reported and objectively measured sitting time (ρ=0.551, p<0.001).
Conclusion: There was disagreement and discordance between the IPAQ and Ausdiab3 questionnaire and objectively-derived data, suggesting that these measures cannot be used interchangeably in orthopaedic trauma patients without appropriate modifications.
EVALUATION OF THE MAJOR TRAUMA RECOVERY COORDINATOR ROLE: EARLY FINDINGS
William Veitch1, Sara Calthorpe2, Lara Kimmel1, 2, Mark Fitzgerald3, 4, 5, 6, Sandra Braaf1, Belinda Gabbe1, 7
Background: Previous research involving Victorian trauma services has highlighted issues with discharge planning, coordination of post-discharge care, and the quality of information provided to patients about their care and outcomes. The Major Trauma Recovery Coordinator (MTReC) role was designed to provide a single point of contact for major trauma patients to overcome the identified issues. A 2-year pilot project was established to evaluate the MTReCs. The aim of this analysis was to provide an overview of MTReC engagement in the first 8 months.
Methods: Linkage of the purpose-built MTReC REDCap database with the Victorian State Trauma Registry (VSTR) was undertaken to compare the engagement rate between MTReCs and major trauma patients admitted through the trauma service.
Results: From February to September 2017 (inclusive), 956 major trauma patients were managed at The Alfred and 304 were coordinated by the MTReCs. MTReC patients were more commonly road trauma and compensable patients, had a higher Injury Severity Score, longer length of stay, and lower socioeconomic status. A higher proportion were also discharged to rehabilitation. There was a significant improvement in the rate of MTReC engagement over time, and a shift towards coordination of cases more representative of the wider major trauma population. Further data from the evaluation will be available for presentation.
Conclusions: This preliminary analysis summarises the pattern of engagement of the MTReCs with major trauma patients, the early bias in engagement with more severely injured patients and the changing focus of the MTReCs over time as the role became more established.
WORK-RELATED TRAUMATIC INJURY IN AUSTRALIAN TRUCK DRIVERS
Ting Xia1, Ross Iles1, Alex Collie1
Objectives: The trucking industry is one of the highest risk industries for work-related injury and disease in Australia. The objective of this study was to compare the rate and distribution of work-related traumatic injury in truck drivers and other workers in Australia.
Method: All accepted workers’ compensation claims from 2004 to 2015 were extracted from the National Dataset for Compensation-based Statistics. We used standardized industry and occupation coding systems to identify truck drivers and other occupational groups, and the Type of Occurrence Classification System (TOOCS) to identify work-related traumatic injury.
Results: Traumatic injuries were the second most common condition in truck drivers’ (24% of total), after musculoskeletal conditions. However, traumatic injury due to vehicle incidents was the most common cause of work-related fatality claims in truck drivers, accounting for over 70% of all fatality claims. Truck drivers also recorded an elevated rate of traumatic injury, at 16.6 claims per 1000 workers per year which was 66% higher than bus, delivery and automobile drivers. The incidence rate of traumatic fatality claims in truck drivers was 15 times higher (23.7 per 100,000 workers) than all other workers (1.6 per 100,000 workers). In addition, traumatic injury resulted in 15,315 weeks (12.9%) of working time loss per year, on average.
Conclusion: Truck drivers are at significantly higher risk of traumatic injury than other workers. Our findings support the continued focus on occupational health and safety and road safety research to reduce the number of traumatic injuries in truck drivers.
A RETROSPECTIVE ANALYSIS OF THE UTILITY OF CERVICAL SPINE MRI IN PATIENTS WITH NORMAL CT AND PLAIN RADIOGRAPHS
Adeline Yap1, Sana Nasim1, Sudhakar Rao1, Swithin Song2
Introduction: Following acute blunt cervical injury, there is ongoing debate regarding the reliability of Computed Tomography (CT) and plain radiographs versus the need for Magnetic Resonance Imaging (MRI).1
Objectives: To determine the incidence of abnormalities found on MRI following normal CT or plain radiographs in patients with persistent cervical tenderness, focal neurology or are clinically unevaluable and to assess if management was altered following MRI.
Results: 301 patients were included in this single-centre retrospective analysis. 155 (51.5%) had no acute injury found on MRI. Of the remaining 146 abnormal MRI scans, there were 107 with ligamentous injury, 44 with vertebral disc injury, 34 with soft tissue swelling, 13 with microtrabecular fracture, 9 with dural haematoma, 5 with cervical cord injury and 3 with joint effusion (some patients sustained >1 type of injury). Post-MRI, 67.1% were spinally cleared, 29% conservatively managed eg brace, soft collar, mobilise as tolerated or bedrest, whereas 1.3% underwent surgical management.
Discussion: There was a statistically significant correlation between having a positive MRI result and the likelihood of receiving some form of treatment, highlighting that MRI not only has the ability to alter management but also reduce the risk of long-term morbidity secondary to missed injuries. However, no correlation was found between the type of injury on MRI with the type of management a patient received.
Conclusion: In patients with acute blunt cervical injury, MRI is useful for detecting injuries that would have been missed on CT or plain radiographs and would have otherwise altered management.