Ian Civil

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

Abstract Objectives: To estimate the contribution of driver sleepiness to the causes of car crash injuries. Design: Population based case control study. Setting: Auckland region of New Zealand, April 1998 to July 1999. Participants: 571 car drivers involved in crashes where at least one occupant was admitted to hospital or killed (“injury crash”); 588 car drivers recruited while driving on public roads (controls), representative of all time spent driving in the study region during the study period. Main outcome measures: Relative risk for injury crash associated with driver characteristics related to sleep, and the population attributable risk for driver sleepiness. Results: There was a strong association between measures of acute sleepiness and the risk of an injury crash. After adjustment for major confounders significantly increased risk was associated with drivers who identified themselves as sleepy (Stanford sleepiness score 4-7 v 1-3; odds ratio 8.2, 95% confidence interval 3.4 to 19.7); with drivers who reported five hours or less of sleep in the previous 24 hours compared with more than five hours (2.7, 1.4 to 5.4); and with driving between 2 am and 5 am compared with other times of day (5.6, 1.4 to 22.7). No increase in risk was associated with measures of chronic sleepiness. The population attributable risk for driving with one or more of the acute sleepiness risk factors was 19% (15% to 25%). Conclusions: Acute sleepiness in car drivers significantly increases the risk of a crash in which a car occupant is injured or killed. Reductions in road traffic injuries may be achieved if fewer people drive when they are sleepy or have been deprived of sleep or drive between 2 am and 5 am. What is already known on this topic Driver sleepiness is considered a potentially important risk factor for car crashes and related injuries but the association has not been reliably quantified Published estimates of the proportion of car crashes attributable to driver sleepiness vary from about 3% to 30% What this study adds Driving while feeling sleepy, driving after five hours or less of sleep, and driving between 2 am and 5 am were associated with a substantial increase in the risk of a car crash resulting in serious injury or death Reduction in the prevalence of these three behaviours may reduce the incidence of injury crashes by up to 19%

Establishing the Evidence Base for Trauma Quality Improvement: A Collaborative WHO-IATSIC Review

BackgroundQuality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.MethodsThe review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.ResultsThirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.ConclusionsTrauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

Damage-control laparotomy in nontrauma patients: review of indications and outcomes.

BACKGROUND The principle of damage-control laparotomy (DCL) in trauma is well established. The DCL concept can be applied in emergency general surgery when an abbreviated laparotomy is performed at the initial stage. Subsequent definitive management and abdominal closure are achieved when the patient is stabilized. In this study, we report our experience with DCL in acute general surgical nontrauma patients. METHODS A retrospective review was performed of all nontrauma patients who underwent DCL at Auckland City Hospital from January 2008 to December 2010. Data including indications and outcome were collected and analyzed. RESULTS Forty-two nontrauma patients underwent DCL in the 3-year period. The median age was 66 years. There were 22 males and 20 females. The most common primary indications for DCL were bowel ischemia (13 patients), bleeding (13 patients), and peritonitis (10 patients). Majority of patients had an American Society of Anesthesiologists score of 3 or 4. Overall, 24 patients (57%) underwent closure of the fascia within 7 days, 7 patients were closed after more than 7 days, and 11 patients could not undergo primary closure at all. The main complications after DCL were sepsis (14 patients) and intra-abdominal collections (10 patients). There were significantly fewer postoperative complications in patients undergoing early closure. The medium length of stay in intensive care as well as in hospital was significantly less in the early closure group. However, postoperative respiratory failure was more common in those with early closure (5 vs. 0). The mortality rate overall was 19%, with no significant difference regarding timing of abdominal closure. CONCLUSION The DCL principle is often applied to the critically ill surgical patients in the nontrauma setting. This group of critical surgical patients has a high morbidity and mortality. However, early abdominal closure should be performed where possible to prevent complications. It is unclear whether patients with early closure were going to have a better outcome regardless, and prospective studies are needed to address. LEVEL OF EVIDENCE Therapeutic/care management, level V.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Acquired jejuno-ileal diverticular disease: a diagnostic and management challenge.

Background:  Acquired jejuno‐ileal diverticular disease (JID), a result of abnormalities in the smooth muscle or myenteric plexus of the small bowel, is less rare than was once believed. Approximately 1.3% of the population has JID, of whom approximately 10% present with life‐threatening complications such as inflammation, perforation, bleeding, obstruction and malabsorption. Jejuno‐ileal diverticular disease can be diagnostically and therapeutically challenging, and complications are often diagnosed only at laparotomy, while the best management is not agreed on in the literature. To increase the awareness of this condition and its complications, the Auckland Hospitals experience of JID was reviewed.

Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process.Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.

IS EXPLORATION MANDATORY IN PENETRATING ZONE II NECK INJURIES

Background:  A policy of mandatory neck exploration for zone II injuries deep to platysma was promoted in the 1950s and was associated with a reduction in mortality when compared with expectant or delayed exploration. Recently many trauma centres have been practising selective neck exploration using physical examination and imaging to stratify patients to different management strategies. In the Auckland region, patients with penetrating zone II injury deep to platysma have been managed with mandatory neck exploration. As penetrating injuries in the Auckland region are caused by a range of sharp objects, with gunshot wounds rare, outcomes of management of zone II neck injuries in this population warrant investigation. The aim of this study was to determine the rate of therapeutic neck exploration in patients with penetrating zone II neck injury in the Auckland region and to suggest optimum management strategies for such injuries.

Comparison of appendicectomy outcomes: acute surgical versus traditional pathway

The acute surgical unit (ASU) is an evolving novel concept introduced to address the challenge of maintaining key performance indicators (KPIs) in the face of an increasing acute workload.

Acute Surgical Unit at Auckland City Hospital: a descriptive analysis

Lack of timely assessment and access to acute operating rooms is a worldwide problem and also exists in New Zealand hospitals. To address these issues, an Acute Surgical Unit (ASU) was set up at Auckland City Hospital (ACH) in January 2009. This service has evolved and been modified to address the specific needs of acute surgical patients of ACH. Despite initial challenges inherent to setting up a new service, the Unit has been in steady operation and enhanced its performance over time. This paper is a descriptive analysis of the design of the ACH ASU and discusses some of the indications for streamlining acute surgical services at a large tertiary metropolitan hospital in New Zealand. Performance of the ASU has shown benefits for acute patients and the Hospital. The acute surgical rotation has also been beneficial for surgical training.

Denver screening protocol for blunt cerebrovascular injury reduces the use of multi-detector computed tomography angiography

Blunt cerebrovascular injury (BCVI) occurs in 0.2–2.7% of blunt trauma patients and has up to 30% mortality. Conventional screening does not recognize up to 20% of BCVI patients. To improve diagnosis of BCVI, both an expanded battery of screening criteria and a multi‐detector computed tomography angiography (CTA) have been suggested. The aim of this study is to investigate whether the use of CTA restricted to the Denver protocol screen‐positive patients would reduce the unnecessary use of CTA as a pre‐emptive screening tool.