Peter Danne

Trauma management in Australia and the tyranny of distance

Major trauma presents a time-critical medical emergency. Successful and expeditious management with early definitive treatment is required to prevent secondary injury. The resources in the prehospital setting, at the hospital of first treatment, and at the tertiary referral (major trauma) center all have an impact on the ability of an integrated trauma system to deliver optimal care to a patient. The time between leaving the injury site and instituting definitive care does not always equate with distance. Retrieval resources must be allocated carefully. Potentially preventable morbidity and mortality has been identified and is specifically related to the time between injury and definitive care and the efficiency of the retrieval and hospital transfer processes. These problems are being addressed with a further sophistication of integrated trauma systems. Regional trauma committees, unified and sophisticated ambulance services, good communication lines, adequate resources at major trauma services, and well developed surgical services are all essential for the appropriate and expeditious management of major trauma patients injured at a distance from tertiary referral (major trauma) centers.

Trial of interpersonal counselling after major physical trauma.

Objective: The purpose of the present study was to determine if interpersonal counselling (IPC) was effective in reducing psychological morbidity after major physical trauma. Methods: One hundred and seventeen subjects were recruited from two major trauma centres and randomized to treatment as usual or IPC in the first 3 months following trauma. Measures of depressive, anxiety and post-traumatic symptoms were taken at baseline, 3 months and 6 months. The Structured Clinical Interview for DSM IV diagnoses was conducted at baseline and at 6 months to assess for psychiatric disorder. Results: Fifty-eight patients completed the study. Only half the patients randomized to IPC completed the therapy. At 6 months the level of depressive, anxiety and post-traumatic symptoms and the prevalence of psychiatric disorder did not differ significantly between the intervention and treatment-as-usual groups. Subjects with a past history of major depression who received IPC had significantly higher levels of depressive symptoms at 6 months. Conclusion: IPC was not effective as a universal intervention to reduce psychiatric morbidity after major physical trauma and may increase morbidity in vulnerable individuals. Patient dropout is likely to be a major problem in universal multi-session preventative interventions.

The Victorian Major Trauma Transfer Study

AIMS To comprehensively examine the inter-hospital transfer of major trauma patients-including the reason for transfer, duration, escorts, interventions and unexpected events. METHODS This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form. RESULTS A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min. Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%). Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p<0.001). Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p<0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p<0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p<0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p=0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p=0.001). CONCLUSION Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.

Colon trauma: Royal Melbourne Hospital experience

Background: Recent studies from the USA and South Africa suggest that primary repair or resection and primary anastomosis have become the recommended treatment for most traumatic colon injuries. The aim of the present review is to determine the applicability of these studies to the urban Australian setting.

A benchmarking study of two trauma centres highlighting limitations when standardising mortality for comorbidity

IntroductionA continuous process of trauma centre evaluation is essential to ensure the development and progression of trauma care at regional, national and international levels. Evaluation may be by comparison between pooled datasets or by direct benchmarking between centres. This study attempts to benchmark mortality at two trauma centres standardising this for multiple case-mix factors, which includes the prevalence of individual background pre-existing diseases within the study population.MethodsTrauma patients with an Injury Severity Score (ISS) >15 admitted to the two centres in 2001 and 2002 were included in the study with the exception of those who died in the emergency department. Patient characteristics were analysed in terms of 18 case-mix factors including Glasgow Coma Scale on arrival, Injury Severity Score and the presence or absence of 9 co-morbidity types, and patient outcome was compared based on in-hospital mortality before and after standardisation.ResultsCrude mortality was greater at UHNS (18.2 vs 14.5%) with a non-significant odds ratio of 1.31 prior to adjusting for case-mix (P = 0.171). Adjustment for case mix using logistic regression analysis altered the odds ratio to 1.64, which was not significant (P = 0.069).DiscussionThis study did not demonstrate any significant difference in the outcome of patients treated at either hospital during the study period. More importantly it has raised several important methodological issues pertinent to researchers undertaking registry based benchmarking studies. Data at the two registries was collected by personnel with differing backgrounds, in formats that were not completely compatible and was collected for patients that met different admissions criteria. The inclusion of a meaningful analysis of pre-existing disease was limited by the availability of robust data and sample size. We suggest greater communication between trauma research coordinators to ensure equivalent data collection and facilitate future benchmarking studies.

Serious injuries from airbags

cles caused a major reduction in mortality and morbidity from collisions. The more recent introduction of airbags has caused a smaller, but also significant, further reduction in mortality and morbidity. Airbags are, however, not without some definite injury patterns due to the bags themselves. It is important that medical practitioners managing trauma patients are aware of the possible injuries caused by airbags, their patterns, incidence and how these may be minimized by attention to preventative measures. In this issue of the Journal there are two case reports of serious injuries suffered due to airbag deployment in collisions. Cullinan and Merriman report a case of frontal impact resulting in airbag deployment, with rupture of the distal oesophagus in a postprandial situation, in a middle-aged man who had an underlying oesophageal motility abnormality (the ‘corkscrew oesophagus’).1 This complication would appear to be related as much to the particular individual’s underlying oesophageal abnormality as to the airbag specifically. Similar perforations have been reported after forceful vomiting episodes, unrelated to the forceful impact of a motor vehicle accident and airbag deployment. Thomson and Davis report a case of carotid dissection following air bag deployment.2 In a case report recently published in this journal, Nabarro and Myers reported the commonly recognized minor injuries of upper limb fractures.3 More than 96% of all reported occupant injuries related to airbag deployment are considered minor and include abrasions, contusions or lacerations to the face (42%), wrist (14.8%), forearm (16.3%) and chest (9.6%). The American Highway Transportation Safety Administration (AHTSA) collected this information over a period of 14 years,4 and were able to demonstrate, together with insurance industry data, that moderate to severe injury in crashes involving airbags is up to 29% lower than that in similar cars equipped only with automatic safety belts. The principal reduction has been in head and torso injuries because airbags help prevent whiplash-type motions. Airbags are designed to work as an adjunct to a wellpositioned lap-sash seat belt with appropriate pretensioning devices. The airbag is, by its nature, a round inflatable, rubber-lined, woven nylon bag, slightly bigger than the steering wheel when fully inflated. It is inflated by the ignition of gases (mainly nitrogen) with a small amount of alkaline aerosol. The airbag is propelled from its compartment at a speed of more than 160 kph. Within 2 s of deployment it deflates by the release of hot gases from rear exhaust ports into the passenger compartment. Burns from airbag injuries can be thermal (from the hightemperature gases), chemical (related to the alkaline corrosives), or frictional (due to direct contact of the bag on the skin, particularly that of the face). Most of these burns are light and superficial. Burns to the face and sclera are well reported and are considered to be due to the residue of gases, such as sodium hydroxide, from the airbag deployment. Minor upper limb injuries may be related to trapping of the upper limb between the airbag and the torso, or in the spokes of the steering wheel during deployment of the airbag. Eye injuries can be significant, principally from the alkaline keratitis caused by residue. Small adults and children may be at significant risk of cervical spine injury from airbag deployment. The study by Kaplain et al. of computerized crash simulation revealed a prediction of no benefit from airbags, in their current design, to restrained children.5 There have been well over 30 reports of children, either inproperly restrained or in rear-facing safety seats in front seat positions in motor vehicle collisions, who have died after airbag deployment.6 A unique report is of a small 17-year-old girl, 150 cm tall, who sustained a fatal basilar skull fracture following her vehicle’s airbag deployment in a low-speed accident.7 This person had not been wearing a seat belt. Small adults and children appear to have hyper-extension injuries during airbag deployment and this risk is significantly higher if the person is unrestrained by a seat belt. Extreme forward positioning of the driver or front-seat passenger in relation to airbag deployment appears to be a risk factor for severe cervical spine injury, according to a case report of a fatality due to cervical spine injury and diffused axonal injury of the brain.8 There is good evidence that the high risk for cervical spine injuries, given the risk factors outlined, is operative in lowspeed impact with airbag deployment. There are data to suggest that children under the age of 10 years, seated in the front seat of motor vehicles, have a 21% increased risk of fatality when an airbag is deployed.9 The mechanism of severe head and cervical spine injury to children and short-statured adults would appear to be in the close proximity of the head to the site of deployment of the airbag, either with children in rear-facing child restraint systems in the front passenger seats, or with front-facing situations but with the seat brought forward. Recommendations are that children should ride in the back seat of vehicles at all times, properly restrained by seat belts, and away from airbags. All airbags have been designed based around medium-sized adults. They have not been designed to accommodate the needs of small children located in the front seat of vehicles in minor collisions. The potential for side impact airbags to depose further risks to children in front seats has yet to be estimated. Apart from the stature of the occupant and the absence of seatbelt wearing as defined risk factors for injury in airbag deployment, there are specific mechanisms of injury related to the airbag themselves and other related objects. These include the cover of the airbag module itself, which can be released at high speed and, if faulty, can be a source of injury; foam particles from the airbag deployment; the alkali and chemical gases (if the airbag bursts); direct abrasions from the airbag; the trapping of upper limbs in odd positions; and the effect of other objects such as spectacles, pipes, rings etc. which the person may be using or wearing. Other unusual and rare injuries described include bilateral pneumothorax, presumably due to rupture of the airbag, allowing high-pressure gases to lead to explosive barotrauma through the patient’s airways. 10 ANZ J. Surg. (2001) 71, 507–508

Lumbar plexus schwannoma causing recurrent syncope

Retroperitoneal schwannomas are rare and present non-specifically. They usually manifest secondary to their compressive effects on adjacent structures. We describe a patient who presented with recurrent syncope resulting from a large retroperitoneal schwannoma stretching the inferior vena cava and compromising venous return. We also discuss the salient aspects of preoperative investigations leading to definitive diagnosis and surgery.