Should Infants with Blunt Traumatic Brain Injuries and Intracranial Hemorrhage Have Routine Repeat Imaging?

Introduction: The practice of repeat head CT imaging in infants as a distinct population is poorly studied. The purpose of this study was to evaluate the incidence and utility of repeat head CT in the infant population. Methods: A 10-year retrospective review was conducted of infants with blunt traumatic head injuries (N = 50) that presented to a trauma center. Information from the hospital trauma registry and patient medical records were extracted regarding the size and type of injury, number and results of computed tomography (CT) imaging, changes in neurological exams, and any interventions that were required. Results: Most patients (68%) had at least one repeat CT, with 26% showing progression of hemorrhage. Decreased Glasgow Coma Scale was associated with having repeat CT scans. Nearly one in four infants had a change in management associated with repeat imaging. Repeat CT scans resulted in operative interventions in 11.8% of cases and longer intensive care unit (ICU) stays in 8.8% of cases. Repeat CT scans were associated with increased hospital length of stay, but not with increased ventilator days, ICU length of stay, or mortality. Worsening bleeds were associated with mortality, but not with other hospital outcomes. Conclusions: Changes in management following repeat CT appeared to be more common in this population than in older children or adults. Findings from this study supported repeat CT imaging in infants, however, further research is needed to validate results of this study.

Marine biological injuries and their medical management: A narrative review.

The marine environment can be extremely dangerous, and the harm caused by marine organisms when they contact the human body can be especially harmful, even deadly. Contact includes stings, bites, wounds, and consumption as food. In this article, the characteristics of the common marine biological injuries are summarized, the major marine organisms causing damage in China's marine waters are described, and injury prevention and treatment methods are discussed.

National Follow-up Survey of Preventable Trauma Death Rate in Korea.

BACKGROUND: The preventable trauma death rate survey is a basic tool for the quality management of trauma treatment because it is a method that can intuitively evaluate the level of national trauma treatment. We conducted this study as a national biennial follow-up survey project and report the results of the review of the 2019 trauma death data in Korea. METHODS: From January 1, 2019 to December 31, 2019, of a total of 8,482 trauma deaths throughout the country, 1,692 were sampled from 279 emergency medical institutions in Korea. All cases were evaluated for preventability of death and opportunities for improvement using a multidisciplinary panel review approach. RESULTS: The preventable trauma death rate was estimated to be 15.7%. Of these, 3.1% were judged definitive preventable deaths, and 12.7% were potentially preventable deaths. The odds ratio for preventable traumatic death was 2.56 times higher in transferred patients compared to that of patients who visited the final hospital directly. The group that died 1 hour after the accident had a statistically significantly higher probability of preventable death than that of the group that died within 1 hour after the accident. CONCLUSION: The preventable trauma death rate for trauma deaths in 2019 was 15.7%, which was 4.2%p lower than that in 2017. To improve the quality of trauma treatment, the transfer of severe trauma patients to trauma centers should be more focused.

Survey of current trends in the management of traumatic subcutaneous emphysema in dogs.

BACKGROUND: Subcutaneous emphysema (SCE) is a common occurrence in emergency veterinary practice, but published information regarding treatment and management strategies is lacking. This study examined trends in diagnostic and treatment recommendations. STUDY DESIGN: An internet-based survey with cross-sectional analysis. There were 129 respondents: board-certified and nonboard-certified veterinarians in private practice and university settings. KEY FINDINGS: Significant differences in the choice of diagnostics and treatment were found based on the etiology and severity of SCE and between respondent groups. Computed tomography (CT) was selected more frequently for SCE resulting from blunt or penetrating traumas by the board-certified veterinarians practicing in a teaching hospital (VTH group; P < 0.001). All veterinarians were more likely to select tracheobronchoscopy as part of their workup for SCE as a result of endotracheal intubation trauma (P = 0.0093 [penetrating traumas]; P = 0.0002 [blunt force traumas]). Intermittent SC drainage and ventral cervical exploratory surgery were more likely to be chosen as treatments when SCE was classified as severe generalized (P < 0.0001). SIGNIFICANCE: There is significant variation in the treatment of SCE in veterinary medicine as well as associated diagnostics to determine severity and treatment options. Further studies are indicated to determine the optimal approach and provide guidance to clinicians.

All body region injuries are not equal: Differences in pediatric discharge functional status based on Abbreviated Injury Scale (AIS) body regions and severity scores.

PURPOSE: Functional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity. METHODS: Children with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores. RESULTS: The study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS< 9) compared to those with a higher GCS score (43% versus 9%; p < 0.01). Patients with AIS 3 extremity and severe head injuries had a higher proportion of abnormal FSS at discharge than AIS 3 abdomen or non-severe head injuries. CONCLUSIONS: AIS severity does not account for variability in discharge functional impairment within or between body regions. Benchmarking based on functional status assessment requires clinical factors in addition to AIS severity for appropriate risk adjustment. LEVEL OF EVIDENCE: 1 (Prognostic and Epidemiological).

Feridas de diabéticos tratados com LED e látex e o risco de glicemia instável / Diabetic wounds treated with LED and latex and the risk of unstable glycemia / Heridas diabéticas tratadas con LED y látex y el riesgo de glucemia inestable

Objetivo: caracterizar o Risco de Glicemia Instável de pacientes com feridas de membros inferiores em uso látex associado ao LED. Método: Estudo de coorte prospectivo com amostra n=15. Divididos em três grupos Grupo 1 curativo com látex e LED; Grupo 2 carvão ativado; e Grupo 3 realizavam autocurativo com látex e LED e identificação do Risco de glicemia instável. Análise de dados realizada pelo software SPSS®. Resultados: Os participantes 60% homens, idade 59,93±10,88 anos, fatores de Risco de glicemia instável: atividade física diária menor que o recomendado; conhecimento insuficiente do controle da doença, em todos os grupos; condição de saúde comprome-tida grupos I e III; controle insuficiente do diabetes grupo I; falta de adesão ao plano de controle do diabetes início ao fim, exceto pelo grupo II. Ocorreu redução das feridas em todos os grupos e melhor cicatrização no grupo III. Conclusão: A feridas maiores estavam no grupo I e ocorreu redução das feridas todos os grupos. Os principais fatores de risco de glicemia instável atividade física diária menor que o recomendado no início e final, condição de saúde comprometida grupos I e III, conhecimento insuficiente do controle da doença em todos os grupos

Objective: to characterize the risk of unstable blood glucose in patients with lower limb wounds using latex associated with LED. Method: Prospective cohort study with sample n=15. Divided into three groups Group 1 dressing with latex and LED; Group 2 activated charcoal; and Group 3 performed self-healing with latex and LED and identified the risk of unstable blood glucose. Data analysis performed by SPSS® software. Results: Participants 60% men, age 59.93±10.88 years, risk factors for unstable blood glucose: daily physical activity less than recommended; insufficient knowledge of disease control, in all groups; compromised health condition groups I and III; insuffi-cient control of group I diabetes; lack of adherence to the diabetes control plan from beginning to end, except for group II. There was a reduction of wounds in all groups and better healing in group III. Conclusion: The major wounds were in group I and there was a reduction of wounds in all groups. The main risk factors for unstable glycemia daily physical activity less than rec-ommended at the beginning and at the end, compromised health condition groups I and III, insufficient knowledge of disease control in all groups.

Objetivo: caracterizar el riesgo de inestabilidad glucémica en pacientes con heridas en miembros inferiores utilizando látex asociado a LED. Método: Estudio de cohorte pros-pectivo con muestra n=15. Dividido en tres grupos Grupo 1 aderezo con látex y LED; carbón activado del grupo 2; y el Grupo 3 realizó autocuración con látex y LED e identi-ficó el riesgo de glucosa en sangre inestable. Análisis de datos realizado por el software SPSS®. Resultados: Participantes 60% hombres, edad 59,93±10,88 años, factores de riesgo para glucemia inestable: actividad física diaria inferior a la recomendada; conoci-miento insuficiente del control de enfermedades, en todos los grupos; condiciones de salud comprometidas grupos I y III; control insuficiente de la diabetes del grupo I; falta de adherencia al plan de control de la diabetes de principio a fin, excepto en el grupo II. Hubo reducción de heridas en todos los grupos y mejor cicatrización en el grupo III. Conclusión: Las heridas mayores estaban en el grupo I y hubo reducción de heridas en todos los grupos. Los principales factores de riesgo para la glucemia inestable activi-dad física diaria inferior a la recomendada al principio y al final, condiciones de salud comprometidas grupos I y III, y conocimiento insuficiente del control de la enfermedad en todos los grupos.

Functional status impairment at six-month follow-up is independently associated with child physical abuse mechanism.

BACKGROUND: Children with abusive injuries have worse mortality, length-of-stay, complications, and healthcare costs compared to those sustaining an accidental injury. Long-term functional impairment is common in children with abusive head trauma but has not been examined in a cohort with heterogeneous body region injuries. OBJECTIVE: To assess for an independent association between child physical abuse and functional impairment at discharge and six-month follow-up. PARTICIPANTS AND SETTING: Seriously injured children (<15 years) treated at seven pediatric trauma centers. METHODS: Functional status was compared between child physical abuse and accidental injury groups at discharge and six-month follow-up. Functional impairment was defined at discharge ("new domain morbidity") as a change from pre-injury ≥2 points in any of the six domains of the Functional Status Scale (FSS), and impairment at six-month follow-up as an abnormal total FSS score. RESULTS: Children with abusive injuries accounted for 10.5% (n = 45) of the cohort. New domain morbidity was present in 17.8% (n = 8) of child physical abuse patients at discharge, with 10% (n = 3) of children having an abnormal FSS at six-months. There were no differences in new domain morbidity at hospital discharge between children injured by abuse and or accidental injury. However, children injured by physical abuse were 4.09 (2.15, 7.78) times more likely to have functional impairment at six months. CONCLUSIONS: Child physical abuse is an independent risk factor for functional impairment at six-month follow-up. Functional status measurement for this high-risk group of children should be routinely measured and incorporated into trauma center quality assessments.

Patterns and Outcomes of dog bite injuries presenting to emergency department in a tertiary care hospital at Karachi.

OBJECTIVES: To assess patterns & outcomes of dog bite injuries coming to a public sector tertiary care hospital in Karachi, Pakistan. METHODS: This was a one-year descriptive cross sectional study from 1st June 2018- 31st May 2019 using consecutive sampling technique. Data of 7512 patients was collected from animal-bite clinic of a tertiary care hospital. Inclusion criteria was animal bite cases that were reported during the dates 1st June 2018 to 31st May 2019, Incomplete records were excluded. Data comprising of time of bite, the location of the victim at the time of bite within the city, animal responsible for the bite, gender and age of victim, date of presentation, site and category of bite (as per WHO criteria) was recorded by the primary investigator. The study was conducted at Jinnah Post-Graduate Medical Centre. RESULTS: Among 7512 participants 85.8% were males, 32.2% victims reported time of bite between morning and noon, 78.8% of bites involved lower limbs. 51.6% of the bites belonged to category 2. Stray dog bites were observed in 90.3% of cases. Outcome showed 54.9% completed their vaccination, while 44.3% did not show for complete follow up, 3.99% bites were grievous & 0.03% reported with developed rabies. CONCLUSION: Research reveals Males belonging to adult age group were most vulnerable, most bites were inflicted in early hours, most common animal inflicting the bites were stray dogs. Many victims did not complete their vaccination from the same centre. Peak of the summer was associated with a decline in number of incidents.

Systematic Preventable Trauma Death Rate Survey to Establish the Region-based Inclusive Trauma System in a Representative Province of Korea.

BACKGROUND: Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. METHODS: From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. RESULTS: Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within "1-3 hours" than those who arrived within "1 hour." When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. CONCLUSION: The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.

Patterns of Injuries in Drowning Patients - Do These Patients Need a Trauma Team?

INTRODUCTION: Drowning is a major public health hazard worldwide, but associated traumatic injuries are rare. This study examined injuries and interventions performed on this population to assess the need for the trauma team activation. METHODS: A 12-year retrospective review was conducted on all fatal and non-fatal drowning patients who underwent a trauma work-up. Data collection included demographics, injury characteristics, interventions, and outcomes. RESULTS: Forty-three patients met inclusion criteria. Median patient age was six years (interquartile range 2 - 20) with 27.9% of patients under the age of 2 years. Most patients were white (62.8%) and male (69.8%), with median GCS score of 3 (60.5% had initial GCS = 3 with 25.6% with GCS = 15). Only two patients suffered traumatic injuries. Only two patients required operations, neither of which suffered traumatic injury. Eleven patients suffered anoxic brain injury (25.6%). Overall mortality was 48.8% (n = 21). CONCLUSION: Patients who present with drowning and no traumatic mechanism have a very low rate of traumatic injuries. Work-up and treatment would be appropriate for emergency physicians without the need for a trauma activation.

Distribution of Trauma Deaths in a Province of Korea: Is "Trimodal" Distribution Relevant Today?

PURPOSE: This study was designed to provide a basis for building a master plan for a regional trauma system by analyzing the distribution of trauma deaths in the most populous province in Korea. MATERIALS AND METHODS: We investigated the time distribution to death for trauma patients who died between January and December 2017. The time distribution to death was categorized into four groups (within a day, within a week, within a month, and over a month). Additionally, the distribution of deaths within 24 hours was further analyzed. We also reviewed the distribution of deaths according to the cause of death and mechanism of injury. RESULTS: Of the 1546 trauma deaths, 328 cases were included in the final study population. Patients who died within a day were the most prevalent (40.9%). Of those who died within a day, the cases within an hour accounted for 40.3% of the highest proportion. The majority of trauma deaths within 4 hours were caused by traffic-related accidents (60.4%). The deaths caused by bleeding and central nervous system injuries accounted for most (70.1%) of the early deaths, whereas multi-organ dysfunction syndrome/sepsis had the highest ratio (69.7%) in the late deaths. Statistically significant differences were found in time distribution according to the mechanism of injury and cause of death (p<0.001). CONCLUSION: The distribution of overall timing of death was shown to follow a bimodal pattern rather than a trimodal model in Korea. Based on our findings, a suitable and modified trauma system must be developed.

Distribution of Trauma Deaths in a Province of Korea: Is “Trimodal” Distribution Relevant Today?

PURPOSE: This study was designed to provide a basis for building a master plan for a regional trauma system by analyzing the distribution of trauma deaths in the most populous province in Korea.MATERIALS AND METHODS: We investigated the time distribution to death for trauma patients who died between January and December 2017. The time distribution to death was categorized into four groups (within a day, within a week, within a month, and over a month). Additionally, the distribution of deaths within 24 hours was further analyzed. We also reviewed the distribution of deaths according to the cause of death and mechanism of injury.RESULTS: Of the 1546 trauma deaths, 328 cases were included in the final study population. Patients who died within a day were the most prevalent (40.9%). Of those who died within a day, the cases within an hour accounted for 40.3% of the highest proportion. The majority of trauma deaths within 4 hours were caused by traffic-related accidents (60.4%). The deaths caused by bleeding and central nervous system injuries accounted for most (70.1%) of the early deaths, whereas multi-organ dysfunction syndrome/sepsis had the highest ratio (69.7%) in the late deaths. Statistically significant differences were found in time distribution according to the mechanism of injury and cause of death (p<0.001).CONCLUSION: The distribution of overall timing of death was shown to follow a bimodal pattern rather than a trimodal model in Korea. Based on our findings, a suitable and modified trauma system must be developed.

Preventable Trauma Death Rate after Establishing a National Trauma System in Korea.

BACKGROUND: This study aimed to evaluate the current overall preventable trauma death rate (PTDR) in Korea and identify factors associated with preventable trauma death (PTD). METHODS: The target sample size for review was designed to be 1,131 deaths in 60 emergency medical institutions nationwide. The panels for the review comprised trauma specialists working at the regional trauma centers (RTCs); a total of 10 teams were formed. The PTDR and factors associated with PTD were analyzed statistically. RESULTS: Of the target cases, 943 were able to undergo panel review and be analyzed statistically. The PTDR was 30.5% (6.1% preventable and 24.4% possibly preventable). Those treated at a RTC showed a significantly lower PTDR than did those who were not (21.9% vs. 33.9%; P = 0.002). The PTDR was higher when patients were transferred from other hospitals than when they directly visited the last hospital (58.9% vs. 28.4%; P = 0.058; borderline significant). The PTDR increased gradually as the time from accident to death increased; a time of more than one day had a PTDR 14.99 times higher than when transferred within one hour (95% confidence interval, 4.68 to 47.98). CONCLUSION: Although the PTDR in Korea is still high compared to that in developed countries, it was lower when the time spent from the accident to the death was shorter and the final destined institution was the RTC. To reduce PTDR, it is necessary to make an effort to transfer trauma patients to RTCs directly within an appropriate time.

Preventable Trauma Death Rate after Establishing a National Trauma System in Korea

BACKGROUND: This study aimed to evaluate the current overall preventable trauma death rate (PTDR) in Korea and identify factors associated with preventable trauma death (PTD). METHODS: The target sample size for review was designed to be 1,131 deaths in 60 emergency medical institutions nationwide. The panels for the review comprised trauma specialists working at the regional trauma centers (RTCs); a total of 10 teams were formed. The PTDR and factors associated with PTD were analyzed statistically. RESULTS: Of the target cases, 943 were able to undergo panel review and be analyzed statistically. The PTDR was 30.5% (6.1% preventable and 24.4% possibly preventable). Those treated at a RTC showed a significantly lower PTDR than did those who were not (21.9% vs. 33.9%; P = 0.002). The PTDR was higher when patients were transferred from other hospitals than when they directly visited the last hospital (58.9% vs. 28.4%; P = 0.058; borderline significant). The PTDR increased gradually as the time from accident to death increased; a time of more than one day had a PTDR 14.99 times higher than when transferred within one hour (95% confidence interval, 4.68 to 47.98). CONCLUSION: Although the PTDR in Korea is still high compared to that in developed countries, it was lower when the time spent from the accident to the death was shorter and the final destined institution was the RTC. To reduce PTDR, it is necessary to make an effort to transfer trauma patients to RTCs directly within an appropriate time.

[Surgical treatment of bites]. / Chirurgische Behandlung von Bissverletzungen.

OBJECTIVE: Thorough and profound debridement for acute bite injuries while sparing nerves, vessels and tendons. INDICATIONS: Acute traumatic and late presented bite injuries. CONTRAINDICATIONS: General contraindication for anesthesia or surgery. SURGICAL TECHNIQUE: Extensive flabellate local anesthesia/general anesthesia, wound irrigation using 0.9% NaCl or antiseptic solutions, removal of avital tissues, wound debridement, wound edge excision, anew extensive irrigation, drainage if necessary, wound closure where applicable (except older or punctual deep injuries), bandage, elastic wrapping and immobilization. If necessary, plastic surgery with coverage of remaining defects. POSTOPERATIVE MANAGEMENT: Immobilization with initially daily wound evaluation, removal of drainage/loop on postoperative day 2; if necessary, antibiotic therapy with amoxicillin and clavulanic acid in high-risk wounds (e.g., puncture wounds, joint or bone involvement, extensive soft tissue squeezing), suture removal on day 10-12 after surgery. RESULTS: Of 142 bite injuries that were treated and retrospectively evaluated, 46% were caused by dogs and 32% by cats. Patients were on average 44 years old; 55% of all dog bites affected women, but 67% of all cat bites. In 48% of the cases, general anesthesia was necessary. The postoperative infection rate was 6.3%.

Split-thickness skin grafting: early outcomes of a clinical trial using different graft thickness.

OBJECTIVE: In clinical practice, split-thickness skin graft (STSG) transplantation remains the gold standard for covering large skin defects. Currently, there is no consensus on the optimal thickness of skin grafts. The purpose of our study was to compare the early healing processes of recipient and donor wounds after STSG transplantation using grafts of different thickness. METHOD: This prospective, randomised clinical trial included 84 patients that underwent STSG transplantation surgery for post-burn, post-traumatic or postoperative skin defects. Patients were randomised to receive a skin graft of either 0.2mm, 0.3mm or 0.4mm thickness. After skin transplantation, the wound healing parameters of both the recipient and donor wounds were evaluated after three days, one week, two weeks and one month. RESULTS: The greatest mean epithelialisation scores and highest rate of complete wound epithelialisation were identified in the recipient and donor wounds of the 0.2mm transplant group, at all time points. When the recipient wound pain scores were evaluated, the greatest visual analogue scale (VAS) values were found in the 0.2mm transplant group. The opposite result was found for the donor wound, where the highest VAS scores were identified in the 0.4mm transplant group. There were no significant differences, at any follow-up period, when wound secretion, erythema, swelling, localised warmth and fluctuation were compared. CONCLUSION: The early healing of recipient wounds after STSG transplantation with grafts of various thickness differed considerably, especially regarding wound epithelialisation and pain.

Pre-hospital transfusion of red blood cells in civilian trauma patients.

INTRODUCTION: The current management of severely injured patients includes damage control resuscitation strategies that minimise the use of crystalloids and emphasise earlier transfusion of red blood cells (RBC) to prevent coagulopathy. In 2012, London's air ambulance (LAA) became the first UK civilian pre-hospital service to routinely carry RBC to the trauma scene. OBJECTIVE: To investigate the effect of pre-hospital RBC transfusion (phRTx) on overall blood product consumption. METHODS: A retrospective trauma database study compares before implementation with after implementation of phRTx in exsanguinating trauma patients transported directly to one major trauma centre. Pre-hospital deaths were excluded. Univariate and multivariate Poisson regression analyses on data subject to multiple imputation were conducted. RESULTS: We included 137 and 128 patients in the before and after the implementation of phRTx groups, respectively. LAA transfused 304 RBC units (median 2, inter quartile range 1-3). We found a significant reduction in total RBC usage and reduced early use of platelets and fresh-frozen plasma (FFP) after the implementation of phRTx in both univariate (P < 0·001) and multivariate analyses (P < 0·001). No immediate adverse transfusion reactions were identified. CONCLUSION: Pre-hospital trauma transfusion practice is feasible and associated with overall reduced RBC, platelets and FFP consumption.

Horse-related injuries in children - unmounted injuries are more severe: A retrospective review.

INTRODUCTION: Horse-related injuries account for one quarter of all paediatric sports fatalities. It is not known whether the pattern of injury spectrum and severity differ between children injured whilst mounted, compared with those injured unmounted around horses. We aimed to identify any distinctions between the demographic features, spectrum and severity of injuries for mounted versus unmounted patients. PATIENTS AND METHODS: Trauma registry data were reviewed for 505 consecutive paediatric patients (aged<16years) admitted to a large paediatric trauma centre with horse-related injuries over a 16-year period. Patients were classified into mounted and unmounted groups, and demographics, injury spectrum, injury severity, and helmet usage compared using odds ratios and Wilcoxon rank-sum tests. RESULTS: More patients (56%) were injured in a private setting than in a sporting or supervised context (23%). Overall, head injuries were the most common horse-related injury. Mounted patients comprised 77% of the cohort. Mounted patients were more likely to sustain upper limb fractures or spinal injuries, and more likely to wear helmets. Unmounted were more likely to be younger males, and more likely to sustain facial or abdominal injuries. Strikingly, unmounted children had significantly more severe and critical Injury Severity Scores (OR 2.6; 95% CI 1.5, 4.6) and longer hospital stay (2.0days vs 1.1days; p<0.001). Unmounted patients were twice as likely to require intensive care or surgery, and eight times more likely to sustain a severe head injury. CONCLUSIONS: Horse-related injuries in children are serious. Unmounted patients are distinct from mounted patients in terms of gender, age, likelihood of personal protective equipment use, severity of injuries, and requirement for intensive or invasive care. This study highlights the importance of vigilance and other safety behaviours when unmounted and around horses, and proposes specific targets for future injury prevention campaigns, both in setting of organised and private equestrian activity.

Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science.

The purpose of this review is to summarize tourniquet science for possible translation to wilderness settings. Much combat casualty data has been studied since 2005, and use of tourniquets in the military has changed from a last resort to first aid. The US Government has made use of tourniquets a health policy aimed to improve public access to bleeding control items. International authorities believe that education in first aid should be universal, as all can and should learn first aid. The safety record of tourniquet use is mixed, but users are reliably safe if trained well. Well-designed tourniquets can reliably attain bleeding control, may mitigate risk of shock progression, and may improve survival rates, but conclusive proof of a survival benefit remains unclear in civilian settings. Even a war setting has a bias toward survivorship by sampling mostly survivors in hospitals. Improvised tourniquets are less reliable than well-designed tourniquets but may be better than none. The tourniquet model used most often in 2016 by the US military is the Combat Application Tourniquet (C-A-T), and civilians use an array of various models, including C-A-T. Evidence on tourniquet use to date indicates that most uses are safe and effective in civilian settings. Future directions for study relevant to the wilderness setting include consideration of research priorities, study of the burdens of injury or capability gaps in caregiving for various wilderness settings, determination of the skill needs of outdoor enthusiasts and wilderness caregivers, and survey of wilderness medicine stewards regarding bleeding control.

Salvage of Combat Hindfoot Fractures in 2003-2014 UK Military.

BACKGROUND: Hindfoot fractures pose a considerable challenge to military orthopaedic surgeons, as combat injuries are typically the result of energy transfers not seen in civilian practice. This study aimed to characterize the pattern of hindfoot injuries sustained by UK military casualties in recent conflicts, define the early amputation and infection rate, and identify factors associated with poor early outcomes. METHODS: The UK Joint Theatre Trauma Registry was searched for British military casualties sustaining a hindfoot fracture from Iraq and Afghanistan between 2003 and 2014. Data on the injury pattern and management were obtained along with 18-month follow-up data. Statistical analysis was performed with the chi-square test and binomial logistic regression analysis. The threshold for significance was set at P < .05. One hundred fourteen patients sustained 134 hindfoot injuries. Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%). RESULTS: The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, 32 (28%) underwent K-wire fixation, and 30 (26%) underwent internal fixation. Nineteen patients (17%) required transtibial amputation during this time. A deep infection requiring operative treatment occurred in 13 cases (11%) with Staphylococcus aureus, the most common infectious organism (46%). A deep infection was strongly associated with operative fracture management ( P = .0016). When controlling for multiple variables, the presence of a deep infection was significantly associated with a requirement for amputation at 18 months ( P = .023). There was no association between open fractures and a requirement for amputation at 18 months ( P = .640), nor was conservative management associated with a requirement for amputation ( P = .999). Thirty-six fractures (32%) required unplanned revision surgery within the first 18 months following salvage, of which 19 (53%) involved amputation. CONCLUSION: A deep infection was the sole variable significantly associated with a requirement for amputation by 18 months. These results suggest that attempts at salvaging these injuries are at the limits of orthopaedic technical feasibility. LEVEL OF EVIDENCE: Level III, comparative series.