Matthew Oliver

Thromboembolic prophylaxis with low-molecular-weight heparin in patients with blunt solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes.

BACKGROUND Low-molecular-weight heparins (LMWHs) are effective in preventing thromboembolic complications after trauma. In the nonoperative management (NOM) of blunt solid abdominal organ injuries, the timing of the administration of LMWH remains controversial because of the unknown risk for bleeding. METHODS Retrospective study including patients aged 15 years or older who sustained blunt splenic, liver, and/or kidney injuries from January 2005 to December 2008. Patients were stratified according to the type and severity of organ injuries. NOM failure rates and blood transfusion requirements were compared between patients who got LMWH early (≤3 days), patients who got LMWH late (>3 days), and patients who did not receive LMWH. RESULTS Overall, 312 (63.8%) patients with solid organ injuries had NOM attempted. There were 154 splenic, 144 liver, and 65 kidney injuries (1.2 organs injured per patient). Forty-one patients (13.2%) received LMWH early, 70 patients (22.4%) received LMWH late, and 201 (64.4%) patients did not receive LMWH. The early LMWH group was less severely injured compared with the late LMWH group. However, the distribution of the risk factors for failure of NOM (high-grade injury, large amount of hemoperitoneum, and contrast extravasation) was similar between the three LMWH groups. Overall, 17 of 312 patients (5.4%) failed NOM (7.8% spleen, 2.1% liver, and 3.1% kidney). All but one failure occurred before LMWH administration. After adjustment for demographic differences, the overall blood transfusion requirements for the early LMWH group was significantly lower when compared with patients with late LMWH administration (3.0±5.3 units vs. 6.4±9.9 units; adjusted p=0.027). Pulmonary embolism and deep venous thrombosis occurred in four patients. The mortality rate for patients with splenic, liver, and kidney injuries was 3.2% and did not differ with LMWH application. CONCLUSION In patients with solid abdominal organ injuries undergoing NOM, early use of LMWH does not seem to increase failure rates or blood transfusion requirements.

Postdischarge Complications After Penetrating Cardiac Injury: A Survivable Injury With a High Postdischarge Complication Rate

HYPOTHESIS A significant rate of postdischarge complications is associated with penetrating cardiac injuries. DESIGN Retrospective trauma registry review. SETTING Level I trauma center. PATIENTS All patients sustaining penetrating cardiac injuries between January 2000 and June 2010. Patient demographics, clinical data, operative findings, outpatient follow-up, echocardiogram results, and outcomes were extracted. MAIN OUTCOME MEASURES Cardiac-related complications and mortality. RESULTS During the 10.5-year study period, 406 of 40,706 trauma admissions (1.0%) sustained penetrating cardiac injury. One hundred nine (26.9%) survived to hospital discharge. The survivors were predominantly male (94.4%), with a mean (SD) age of 30.8 (11.7) years, and 74.3% sustained a stab wound. Signs of life were present on admission in 92.6%. Cardiac chambers involved were the right ventricle (45.9%), left ventricle (40.3%), right atrium (10.1%), left atrium (0.9%), and combined (2.8%). In-hospital follow-up was available for a mean (SD) of 11.0 (9.8) days (median, 8 days; range, 3-65 days) and outpatient follow-up was available in 46 patients (42.2%) for a mean (SD) of 1.9 (4.1) months (median, 0.9 months; range, 0.2-12 months). Abnormal echocardiograms demonstrated pericardial effusions (9), abnormal wall motion (8), decreased ejection fraction (<45%) (8), intramural thrombus (4), valve injury (4), cardiac enlargement (2), conduction abnormality (2), pseudoaneurysm (1), aneurysm (1), and septal defect (1). No operative intervention was required for the complications. The 1-year and 9-year survival rates were 97% and 88%, respectively. CONCLUSIONS Penetrating cardiac injuries remain highly lethal. A significant rate of cardiac complications can be expected and follow-up echocardiographic evaluation is warranted prior to discharge. The majority of these, however, can be managed without the need for surgical intervention.

Performance of the New South Wales Ambulance Service major trauma transport protocol (T1) at an inner city trauma centre

Objective: To evaluate the performance of a newly implemented prehospital trauma triage (T1) protocol in New South Wales for patients transported to an inner city major trauma centre.

In-hospital small bowel obstruction after exploratory laparotomy for trauma.

BACKGROUND The purpose of this study was to examine the incidence and risk factors of in-hospital small bowel obstruction (SBO) after exploratory laparotomy for trauma. METHODS A retrospective review of patients surviving over 72 hours after an exploratory laparotomy for trauma. Patients with intestinal obstructive symptoms were reviewed by a consensus panel, which evaluated the clinical, laboratory, and radiologic findings to validate the diagnosis of SBO. RESULTS A total of 571 patients met inclusion criteria. The incidence of early SBO was 3.9%, with 22.7% of these patients requiring surgical intervention. Patients with gastrointestinal (GI) perforation had a significantly higher incidence of SBO, compared with those with no GI perforation (5.7% vs. 1.3%, p = 0.007). A forward logistic regression identified the presence of a GI perforation as the only factor independently associated with early SBO (adjusted odds ratio: 4.39; 95% confidence interval: 1.28-15.15; p = 0.019). The overall hospital stay was significantly longer for SBO patients (27.0 days ± 26.7 days vs. 16.0 days ± 22.8 days; adjusted mean difference: 11.5; 95% confidence interval: 1.6-21.3; p = 0.022). Development of SBO increased the cost by 59.7%. CONCLUSION The incidence of in-hospital SBO after laparotomy for trauma is significant at 3.9%. The presence of a GI perforation is independently associated with the development of this complication. Over a fifth of patients with early SBO will require a surgical intervention. The use of preventive strategies may be justified in selected, high-risk patients to reduce the burden associated with early SBO.

Level of agreement between prehospital and emergency department vital signs in trauma patients

Describe the level of agreement between prehospital (emergency medical service [EMS]) and ED vital signs in a group of trauma patients transported to an inner city Major Trauma Centre. We also sought to determine factors associated with differences in recorded vital sign measurements.

Limited evidence for screening for serious pathologies using red flags in patients with low back pain presenting to the emergency department: LETTER TO THE EDITOR

Gerben KEIJZERS , Louise CULLEN, Diana EGERTON-WARBURTON 5 and Daniel M FATOVICH 6,7 Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia, School of Medicine, Bond University, Gold Coast, Queensland, Australia, School of Medicine, Griffith University, Gold Coast, Queensland, Australia, Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Queensland University of Technology, The University of Queensland, Brisbane, Queensland, Australia, School of Clinical Science at Monash Health, Monash University Faculty of Medicine, Nursing and Health Sciences, Melbourne, Victoria, Australia, Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia, and Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia doi: 10.1111/1742-6723.12980

Impact of acutely behavioural disturbed patients in the emergency department: A prospective observational study: AGGRESSIVE PATIENTS IN THE EMERGENCY DEPARTMENT

The present study describes patients with acute behavioural disturbance presenting to the ED, the impact they have on the department and any complications that occur.