Time to CT and Surgery for HPB Trauma in Scotland Prior to the Introduction of Major Trauma Centres.

AIMS: To assess the time taken to CT and emergency surgery for trauma patients with an injury to liver, spleen or pancreas prior to the introduction of major trauma centres (MTCs) in Scotland. METHODS: A search was performed of the Scottish Trauma Audit Group database for any patient with relevant injuries over a 2-year period. Primary outcome measures were time to CT and emergency surgery. Patient demographics were also recorded. RESULTS: A total of 211 patients were identified of whom 23 had more than one organ affected. There were a total of 234 injuries (123 liver, 99 splenic and 12 pancreatic) in these patients. A total of 160 injuries (75.8%) suffered blunt trauma. Of 211 patients, 157 underwent emergency CT with a median time to scan of 73 min (range 4-474). Hospitals provisionally designated as MTCs were 9 min faster than non-MTCs in time to CT. There was no difference in time of day. Ninety-nine patients had surgery within 24 h at a median time of 200 min. Twenty-five patients with hypotension on presentation took a median time of 130 min. Only 44 patients (27%) had a CT or emergency surgery within the expected MTC target of 1 h. Thirty-nine patients required transfer to another centre. CONCLUSIONS: Current management of patients with abdominal trauma and haemodynamic instability remains sub-optimal in Scotland when compared to recognized performance indicators of CT and emergency surgery within 1 h. Implementation of a major trauma network in Scotland should improve access to emergency radiology and surgery and efforts to shorten current timelines should improve patient outcomes.

Anxiety and depression following traumatic limb amputation: a systematic review.

BACKGROUND: Traumatic amputation can result in multiple physical, psychological and socio-economic sequalae. While there has been a significant increase in investment and public profile of the rehabilitation of patients who have experienced traumatic limb amputation, little is known about the prevalence of anxiety and depression, especially in the long term. OBJECTIVE: To determine the association between traumatic limb amputation and anxiety and depression. DATA SOURCES: A literature search of available databases including Cochrane, Medline, Embase, and PsycINFO was performed for relevant studies since 2002. Secondary outcomes included the effect on employment, substance misuse, relationships and quality of life. SELECTION CRITERIA: Randomised control trials, observational studies or reviews which met the inclusion, exclusion and quality criteria. RESULTS: Levels of anxiety and depression are significantly higher than in the general population. Significant heterogeneity exists between studies making meta-analyses inappropriate. Improved rehabilitation is having a positive effect on employment rates. There appears to be no significant effect on substance abuse and relationships. CONCLUSIONS: All studies demonstrated high prevalence of anxiety and depression in post-traumatic amputees. No good prospective data exists for levels of anxiety and depression beyond two years of follow up and this should be an area of future study.

Occult hypoperfusion--should the military surgeon care?

The treatment of traumatic shock has changed unrecognizably over the past decade as the combination of targeted research and lessons learnt from conflict have combined with a common goal. The term damage control resuscitation has emerged as the most likely strategy to treat the underlying cause, restore normal physiology and ultimately return to normal function. However, there is still a great deal that we do not understand as to the underlying mechanisms which control the traumatic shock process. Military surgeons have an integral part to play at every step of this process. Their role does not end once the initial damage control surgery is complete and indeed the decisions that are made during the initial resuscitation will have an effect on all future stages of care. The patient's physiology is delicately balanced with the possibility that a wrong treatment decision may be a fatal one. It is essential that the surgeon has an understanding of these underlying processes so that an informed decision can be made at the right time.