Nurse-Initiated Protocol to Improve Timely Antibiotic Administration in Pediatric Open Fractures.

BACKGROUND: Early administration of antibiotics in the presence of open fractures is critical in reducing infections and later complications. Current guidelines recommend administering antibiotics within 60 min of patient arrival to the emergency department, yet trauma centers often struggle to meet this metric. OBJECTIVES: This study aims to evaluate the impact of a nurse-initiated evidence-based treatment protocol on the timeliness of antibiotic administration in pediatric patients with open fractures. METHODS: A retrospective pre-post study of patients who met the National Trauma Data Standard registry inclusion criteria for open fractures of long bones, amputations, or lawn mower injuries was performed at a Midwestern United States Level II pediatric trauma center. The time of patient arrival and time of antibiotic administration from preimplementation (2015-2020) to postimplementation (2021-2022) of the protocol were compared. Patients transferred in who received antibiotics at an outside facility were excluded. RESULTS: A total of N = 73 participants met the study inclusion criteria, of which n = 41 were in the preimplementation group and n = 32 were in the postimplementation group. Patients receiving antibiotics within 60 min of arrival increased from n = 24/41 (58.5%) preimplementation to n = 26/32 (84.4%) postimplementation (p< .05). CONCLUSIONS: Our study demonstrates that initiating evidence-based treatment orders from triage helped decrease the time from arrival to time of antibiotic administration in patients with open fractures. We sustained improvement for 24 months after the implementation of our intervention.

What is the ideal interval between dressing changes during negative pressure wound therapy for open traumatic fractures?

OBJECTIVE: Negative pressure wound therapy (NPWT) is effective in infection control during treatment of severe open fractures. However frequent dressing changes during NPWT are costly and cause patient discomfort. If the interval between dressing changes could be extended, these problems would be reduced. In this article we compare the outcomes of open IIIB fractures with 3-day versus 7-day intervals between dressing changes. METHOD: Patients who sustained Gustilo IIIB open fractures were included. All underwent conventional orthopaedic fixation with delayed latissimus dorsi flap coverage. Group 1 had 3-day intervals between dressing changes and group 2 had 7-day intervals. The final outcomes in the two groups were analysed. RESULTS: There were 38 patients in group 1 and 34 patients in group 2. Although the period between admission and final operation was similar in the two groups, the mean number of NPWT changes was 4.54 in 3 day in group 1 and 1.95 in group 2 (p<0.001). This led to a difference in NPWT-related costs; $341.26 in group 1 and $237.49 in group 2 (p<0.001). There was no difference in the frequency of complications such as infection or non-union of fractures. CONCLUSION: NPWT is useful treatment option for open fractures, to bridge between initial debridement and final microsurgical tissue transfer. Considering patient comfort, the costs related to the NPWT, and the final flap results, a 7-day interval between changes of the NPWT is acceptable.

Manejo de complicaciones en herida traumática. Terapia de presión negativa vac® con instilación / Managing complications in severe traumatic injury with vac® therapy with instillation

Las fracturas complejas de los miembros inferiores, ocasionadas por traumatismos de alta energía, suponen un reto terapéutico debido a la gravedad de las heridas. Desde la aparición en los años 90 de una nueva técnica, la Therapy Vacuum Assisted Closure (Terapia VAC®), que se basa en la aplicación de vacío o presión negativa sobre la herida, contamos con un recurso terapéutico que permite una pauta más conservadora de tratamiento de estas fracturas tan complejas, ayudando en la granulación de las heridas, y previniendo su colonización; en consecuencia, reduciendo los riesgos y la morbilidad, y minimizando las complicaciones. Se presenta un caso de fractura de miembro inferior compleja, muy demostrativo del excelente resultado clínico que se puede obtener mediante el empleo de la terapia con presión negativa con el Sistema VAC®, con la ventaja añadida de la terapia de instilación (AU)

The complex fractures caused by high energy trauma, poses a major surgical challenge. Vessels, skin and subcutaneous tissues. The Vacuum Assisted Therapy (VAC®) has become a very useful tool since the last century´s 90 decade. Based in the application of negative pressure to the wound bed, promotes healing by granulation tissue formation, keeping the wound clean and avoiding bacterial colonization. Used as a primary method or in combination with others, VAC® therapy allows more conservative options in the treatment of these wounds. We describe the application of the VAC® therapy in a clinical case with complex injury, showing its efficacy, added the benefit of the instillation therapy (AU)

Resuscitation of combat casualties: unique challenges and lessons learned.

Resuscitation and trauma anesthesia of combat casualties is very similar to trauma care in any US hospital--except for the setting. Using case examples, this article describes the principles of trauma anesthesia and resuscitation and the lessons learned regarding the modifications required when caring for a combat casualty. Examples of a massive trauma resuscitation (>10 units of packed red blood cells in 24 hours) and burn resuscitation are presented.

[Catastrophic left leg V.A.C. Therapy First Prize in 2008. Second convocation]. / Pierna catastrófica izquierda. Primer Premio Terapia V.A.C. Segunda convocatoria.

This report received the V.A.C. Therapy Prize, second convocation, in the clinical case category of note is the spectacular nature of its results.

Pierna catastrófica izquierda / Catastrophic left leg

Trabajo que ha recibido el Premio Terapia V.A.C.® en su segunda convocatoria, en la modalidad de: «Exposición de un caso clínico». A destacar la espectacularidad de los resultados(AU)

This report received the V.A.C.® Therapy Prize, second convocation, in the clinical case category. Of note is the spectacular nature of its results(AU)

Case study: traumatic hemipelvectomy.

Open pelvic fractures have a greater than 40% mortality rate. Traumatic hemipelvectomy, a severe form of open fracture, is a life-threatening injury that requires rapid resuscitation, surgical intervention, and critical-care monitoring. Survivors benefit from aggressive and consistent rehabilitation. This case presentation discusses the multiple aspects of care of a traumatic hemipelvectomy and the ways in which the staff were able to accommodate the cultural needs of an Amish patient and family.

Surgical treatment of patients with open tibial fractures.

Open tibial fractures are true surgical emergencies because of the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is osteomyelitis, which usually can be prevented by prompt surgical intervention within six to eight hours after injuries occur. Open tibial fractures often are the result of trauma from motor vehicle collisions, farm accidents, falls from heights, or gunshot wounds. Initial management of patients with multiple trauma injuries focuses on their life-threatening injuries before or during orthopedic surgical intervention for open tibial fractures. Orthopedic surgeons often work in collaboration with general, vascular, and plastic surgeons and perform multiple surgical procedures (eg, fasciotomy procedures for compartment syndromes, irrigation and debridement of wounds, application of external fixation devices, placement of intramedullary nails, possible limb amputations). The type and extent of open tibial fractures and soft tissue injuries determine the best treatment options for patients. Perioperative nurses should help patients focus on treatment choices for their open tibial fractures that ensure optimal surgical outcomes and maintain their quality of life.

Management of the patient with complex orthopaedic fractures.

Patients who sustain complex orthopaedic fractures related to a traumatic event can develop devastating complications. Patients who sustain open fractures are at greater risk for complications such as wound and systemic infections and nonunion of the fracture itself. This article describes the management of open complex extremity fractures through a case study approach.

Early assessment and management of musculoskeletal injuries.

Permanent disability following musculoskeletal injury can often be prevented with prompt recognition and appropriate temporary or definitive management. This article has highlighted some specific injuries and guidelines for emergency treatment.

Guidelines for treatment of open fractures and infected pseudarthroses by external fixation.

There are three phases in the treatment of open fractures and infected pseudarthroses by the Hoffmann external fixator. During the initial phase a careful surgical debridement is performed in the bony tissues, and the external fixator is applied in a manner appropriate to the type and level of the lesion site (double- or triple-frame mounting; additional anchorages; neutralization, compression, or distraction; ligamentotaxis). During the intermediate phase both the nursing of the patient and care of the apparatus are critical for the avoidance of complications; it is during this period that granulation tissue must develop and bone infections must be controlled. In the final phase the loss of osseous substance must be treated by various means (regular tightening of the external fixator; Papineau's technique; intertibiofibular graft; free microvascular bone transplantation technique.