Krisztian Sisak

Population-based epidemiology of femur shaft fractures

BACKGROUND The management of patients with femoral shaft fractures (FSFs) is often a decision making dilemma (damage-control orthopedics vs. early total care), with equivocal evidence. The comprehensive, population-based epidemiology of patients with FSF is unknown. The purpose of this prospective study was to describe the epidemiology of patients with FSF, with special focus on patient physiology and timing of surgery. METHODS A 12-month prospective population-based study was performed on consecutive patients with FSF in an area with 850,000 population including all ages and prehospital deaths. Patient demographics, mechanism, Injury Severity Score (ISS), shock parameters (systolic blood pressure, base deficit and lactate), transfusion requirement, fracture type [Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (OA/OTA)], comorbidities, procedures, and outcomes were recorded. Patients hemodynamic status was described as stable, borderline, unstable, and “in extremis.” RESULTS A total of 126 patients (21 per 100,000 per year) with 136 femur fractures (62% male; age, 38 [28] years; ISS, 20 [19]; 51% multiple injuries) were identified in the region. Sixty patients (48.4%) sustained a high-energy injury with 19 (31.1%) of these being polytrauma patients (ISS, 28 [12]; systolic blood pressure, 98 [39]; base deficit, 6.5 [5.8]; lactate 4 [2]).Fifteen polytrauma patients (94%) required massive transfusion (12 [12] U of packed red blood cells, 8 [5] fresh frozen plasma, 1 [0.4] platelet, 13 [8] cryoprecipitate). Twenty-one patients (16.7%) died at the prehospital setting (3.5 per 100,000 per year). From the 105 hospital admissions, 68.3% was stable (14.3 per 100,000 per year), 8.7% was borderline (1.8 per 100,000 per year), 4.0% was unstable (0.8 per 100,000 per year) and 2.4% (0.5 per 100,000 per year) was in extremis. Six patients (5.7%) died. The length of stay (LOS) was 18 (15) days, and the intensive care unit LOS was 5 (6) days. Fourty-five patients sustained a low-energy injury that had in 85% of cases multiple comorbidities. Eight low-energy patients needed 3 (1) transfusions, and none of the patients died. The LOS was 15 (11) days. CONCLUSION Patients with low-energy FSF have a hospital admission rate similar to the patients with high-energy FSF. Sixty-eight percent of patients with FSF are complicated (open, compromised physiology, multiple injuries, bilateral, elderly with comorbidities, etc.), requiring major resources and highly specialized care. LEVEL OF EVIDENCE Epidemiology study, level III.

The definition of polytrauma: variable interrater versus intrarater agreement--a prospective international study among trauma surgeons.

BACKGROUND The international trauma community has recognized the lack of a validated consensus definition of “polytrauma.” We hypothesized that using a subjective definition, trauma surgeons will not have substantial agreement; thus, an objective definition is needed. METHODS A prospective observational study was conducted between December 2010 and June 2011 (John Hunter Hospital, Level I trauma center). Inclusion criteria were all trauma call patients with subsequent intensive care unit admission. The study was composed of four stages as follows: (1) four trauma surgeons assessed patients until 24 hours, then coded as either “yes” or “no” for polytrauma, and results compared for agreement; (2) eight trauma surgeons representing the United States, Germany, and the Netherlands graded the same prospectively assessed patients and coded as either “yes” or “no” for polytrauma; (3) 12 months later, the original four trauma surgeons repeated assessment via data sheets to test intrarater variability; and (4) individual subjective definitions were compared with three anatomic scores, namely, (a) Injury Severity Score (ISS) of greater than 15, (b) ISS of greater 17, and (c) Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions. RESULTS A total of 52 trauma patients were included. Results for each stage were as follows: (1) &kgr; score of 0.50, moderate agreement; (2) &kgr; score of 0.41, moderate agreement; (3) Rater 1 had moderate intrarater agreement (&kgr; score, 0.59), while Raters 2, 3, 4 had substantial intrarater agreement (&kgr; scores, 0.75, 0.66, and 0.71, respectively); and (4) none had most agreement with ISS of greater than 15 (&kgr; score, 0.16), while both definitions ISS greater than 17 and Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions had on average fair agreement (&kgr; scores, 0.27 and 0.39, respectively). CONCLUSION Based on subjective assessments, trauma surgeons do not agree on the definition of polytrauma, with the subjective definition differing both within and across institutions.

Massive transfusion in trauma: blood product ratios should be measured at 6 hours.

Background:  Most potentially preventable haemorrhagic deaths occur within 6 h of injury. Conventionally, blood component therapy delivery is measured by 24‐h cumulative totals and ratios. The study aim was to examine the effect of a massive transfusion protocol (MTP) on early (6 h) balanced component therapy.

Intercostal catheter insertion: are we really doing well?

Introduction:  Intercostal catheters (ICC) are the standard management of chest trauma, but are associated with complications in up to 30%. The aim of this study was to evaluate errors in technique during ICC insertion to characterize the potential benefit of improved training programmes.

Time to computed tomography scanning for major trauma patients: the Australian reality

Computed tomography (CT) can facilitate the diagnosis of life‐threatening injuries in polytrauma patients. Reported times to imaging vary widely, but it has been suggested that rapid whole body scanning improves mortality rates. The aim of this study was to determine the time to CT for severe polytrauma patients presenting to a level I trauma centre in Australia.

Recalled pain scores are not reliable after acute trauma

INTRODUCTION Pain research in emergency settings can be problematic, as data collection is logistically difficult and pain levels are often poorly documented. Short-term recall of acute pain has been evaluated in postoperative, labour and procedural pain, with variable reported accuracy. The reliability of pain recall in trauma resuscitation patients is unknown. This study aims to determine the accuracy of short-term pain recall 1-2 days after trauma. METHODS Prospective, cohort study of trauma resuscitation patients transported by ambulance to a major trauma centre. Patients with haemodynamic instability (SBP<90, HR>120) or GCS<14 on arrival were excluded. Momentary pain scores were measured on an 11-point verbal numerical rating scale by paramedics during prehospital management. Patients were evaluated within 48 h of injury on the recall of their initial pain, pain during transport, and lowest pain score achieved by prehospital analgesia. Spearmans rank correlation and Bland-Altman tests were used to compare ambulance and hospital data. RESULTS 88 trauma resuscitation patients (mean age 44 years ± 18 SD, male 74%, mean ISS: 7 ± 5 SD) were enrolled over a 5 month study period. Comparison of immediate and recalled pain scores produced Spearmans correlation coefficients of 0.71 for initial pain, 0.56 for pain during transport, and 0.45 for minimum pain scores. DISCUSSION In our study patients did not accurately recall their pain levels 1-2 days after acute trauma. The results suggest that retrospective pain ratings are not reliable in trauma patients.

Epidemiology of Acute Transfusions in Major Orthopaedic Trauma

Objectives: The orthopaedic trauma–related blood product usage is largely unknown. Aim of this study was to describe the epidemiology of early (<24 hours of arrival) blood component use in major orthopaedic trauma. Design: 12-month prospective observational study. Setting: John Hunter Hospital, Level 1 Trauma Center, New South Wales, Australia. Patients: 64 consecutive trauma admissions identified, who had an orthopaedic injury and required at least 1 unit of packed red blood cells (PRBC) <24 hours of arrival. Intervention: Epidemiological study. Main outcome measures: Demographics, orthopaedic injury type, procedure type, injury severity score, timing, place of first unit of transfusion, and blood component volumes were collected. Activation of the massive transfusion protocol was recorded. Primary outcome measures were intensive care unit admission and mortality. Results: From 965 major trauma admissions, 64 had one or more orthopaedic injuries and were transfused <24 hours. Forty-eight percent (31/64) required massive transfusion protocol activation. Average age was 41 ± 21 years, 73% (47/64) men. Eighty-four percent (54/64) required emergent orthopaedic intervention, 41% (22/54) having multiple procedures. Overall mortality was 13% (8/64). Twenty-five percent (16/64) required ≥10 units of PRBC. Average PRBC use was 7.2 ± 6.6 units and fresh frozen plasma use 4.3 ± 5.2 units. Thirty-nine percent (25/64) had a pelvic ring injury or acetabular fracture. Thirty-seven percent (24/64) had at least one femoral shaft fracture. Twenty patients had a total of 23 tibia fractures. Conclusions: Orthopaedic trauma patients consume the majority of the blood products <24 hours among blunt trauma patients. This resource-intensive group requires frequent urgent surgical interventions and intensive care unit admission. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prehospital nausea and vomiting after trauma: Prevalence, risk factors, and development of a predictive scoring system.

BACKGROUND: Nausea and vomiting are common problems in trauma patients and potentially dangerous during trauma resuscitation. These symptoms are present in up to 10% of ambulance patients, but their prevalence in trauma patients is largely unknown. The aim of this study was to determine the prevalence of prehospital nausea and vomiting in trauma patients and evaluate antiemetic usage. METHODS: Prospective, cohort study of trauma resuscitation patients transported by ambulance to a major trauma centre. Patients with hemodynamic instability (systolic blood pressure <90, heart rate >120) or Glasgow Coma Scale score <14 on arrival were excluded. Nausea, vomiting, and antiemetic use were recorded. RESULTS: Convenience sample of 196 trauma resuscitation patients (68% men; age, 42 ± 18 years, mean Injury Severity Score 8 ± 7) were interviewed over the 5-month study period, of a total 369 admitted trauma patients (53%). Seventy-five (38%) patients reported some degree of nausea, 57 (29%) moderate or severe nausea, and 15 (8%) vomited. Older age and female gender were associated with vomiting (p < 0.01). Seventy-nine patients (40%) received a prophylactic antiemetic. Of these, four became nauseous (5%), compared with 71 of 117 (61%) for patients not given an antiemetic (p < 0.0001). CONCLUSIONS: Prehospital nausea and vomiting are more common in our cohort of trauma patients than the reported rates in the literature for nontrauma patients transported to hospital by ambulance. Only 40% of patients receive prophylactic antiemetics, but those patients are less likely to develop symptoms. LEVEL OF EVIDENCE: V, epidemiological study.

Tissue oxygen saturation changes during intramedullary nailing of lower-limb fractures.

BACKGROUND The systemic complications of acute intramedullary nailing (IMN) in trauma patients are well known. There are no reliable methods available to predict these adverse outcomes. Noninvasive near-infrared spectroscopy (NIRS) allows measurement of oxygen saturation within muscle tissue (StO2) and quantification of the potential metabolic and microcirculatory effects of IMN in real time. The aim of this study was to characterize tissue oxygenation changes occurring during reamed IMN. METHODS Patients undergoing reamed IMN for fixation of a tibia or femur fracture and patients having an open reduction and internal fixation of the ankle (to control for potential effects of anesthesia) had a noninvasive NIRS probe attached to the thenar eminence of the hand. Tissue oxygenation was monitored continuously throughout the operation and digitally recorded for later analysis. Vascular occlusion tests, an established technique with the NIRS device, were performed before canal opening and after nail insertion (at equivalent times in the control group), to establish the presence and nature of changes in systemic microcirculation occurring during the duration of the operation. RESULTS Tissue oxygenation data were collected on 23 patients undergoing 26 IMN. (mean [SD] age, 36 [19] years; median Injury Severity Score [ISS], 9; interquartile range, 9–12). The control group consisted of 19 patients (mean [SD] age, 41 [18] years; ISS, 4). Remote muscle tissue desaturated significantly faster after IMN compared with the control operation (mean [SD] difference in IMN desaturation rate, 1.8% per minute [2.6% per minute]; mean [SD] difference in control group desaturation rate, −0.6% per minute [1.5% per minute]; p = 0.014). Near infrared-derived muscle oxygen consumption (NIR VO2) was significantly increased during the course of IMN compared with the control (mean [SD] difference in IMN NIR VO2, 19.9 [32.1]; mean [SD] difference in control NIR VO2, −4.2 [17.9]; p = 0.041). CONCLUSION IMN causes significant remote microcirculatory changes. The responsiveness of the microcirculation could be a predictor of secondary organ dysfunction. LEVEL OF EVIDENCE Epidemiologic study, level III.