Initial management of the poly-trauma patient: a practical approach in an Australian major trauma service.

The initial management of the poly-trauma patient is of vital importance to minimizing both patient morbidity and mortality. We present a practical approach to the early management of a severely injured patient as practiced at Liverpool Hospital in Sydney, Australia. Specific attention is paid to innovations in care and specific controversies in early management as well as local solutions to challenging problems.

Trauma training in Australia and New Zealand: results of a survey of advanced surgical trainees.

BACKGROUND: The surgical management of trauma within Australia and New Zealand has recently been undergoing major organizational changes. The aim of the present paper was to evaluate the attitudes and experience of Australian and New Zealand advanced surgical trainees in this changing climate and to identify problems with trauma training. METHODS: A survey assessing important areas of trauma management and training was sent to all advanced surgical trainees of the Royal Australasian College of Surgeons. RESULTS: Two hundred and seventy-two of 587 trainees responded (46%). Overall 85% of trainees believed they would be involved in trauma management in the future. The majority of trainees reported low rates of involvement and consultant supervision in trauma resuscitations. Only 32% of general surgical trainees believed that their exposure to major trauma operations was very adequate despite an average of 12.3 trauma operations per year. Seventy per cent of general surgical trainees reported a very adequate level of consultant supervision at trauma operations. In contrast 86% of orthopaedic trainees reported a very adequate exposure to trauma operations with an average of 221 orthopaedic trauma operations per year. Only 46% of orthopaedic trainees reported a very adequate level of consultant supervision at trauma operations. CONCLUSIONS: Regional rotations may need to be developed to even out trainees' experience in trauma management. The low level of supervision in trauma resuscitations and orthopaedic surgical training requires attention. This survey warrants repeating in a prospective manner.

Intra-abdominal hypertension is an independent cause of postoperative renal impairment.

HYPOTHESIS: Intra-abdominal hypertension exerts an effect on renal function independent of other confounding variables. DESIGN: A prospective study of all patients admitted to an intensive care unit following abdominal surgery was undertaken between September 1, 1994, and July 31, 1997, in a single university hospital. MAIN OUTCOME MEASURES: Intra-abdominal pressure (IAP) was measured every 8 hours (normal IAP, 0-17 mm Hg); 18 mm Hg or higher was considered increased. Forward stepwise logistic regression determined whether intra-abdominal hypertension is an independent cause of renal impairment. RESULTS: A total of 263 patients (174 after emergency surgery), whose mean +/- SD age was 61.0 +/- 18.7 years and Acute Physiology and Chronic Health Evaluation II score was 14.6 +/- 7.7, were studied. Intra-abdominal pressure was increased in 107 (40.7%) of the 263 patients. Renal impairment occurred in 35 (32.7%) of the 107 patients with intra-abdominal hypertension and in 22 (14.1%) of the 156 with a normal IAP (odds ratio, 1.62-5.42). Using the Wald maximizing model, renal impairment was independently associated with 4 antecedent factors: hypotension (P= .09), sepsis (P = .006), age older than 60 years (P = .03), and increased IAP (P = .004). CONCLUSIONS: To our knowledge, for the first time in a large clinical study, IAP has been shown to be an independent cause of renal impairment, and it ranks in importance after hypotension, sepsis, and age older than 60 years. Surgeons need to be aware of the importance of intra-abdominal hypertension in patients postoperatively.

Temporary abdominal closure: a prospective evaluation of its effects on renal and respiratory physiology.

This study prospectively analyzed outcomes in 49 consecutive patients undergoing temporary abdominal closure (TAC) between 1993 and 1996 at a single university hospital. There were 37 males and 12 females, mean age was 57 years (range, 25-79 years), mean Acute Physiology and Chronic Health Evaluation score was 27 (+7.8 SD), and mean Simplified Acute Physiology II score was 53.0 (+/-15.4). The reason for TAC was decompression in 22 patients, inability to close the abdomen in 10 patients, to facilitate reexploration for sepsis in 8 patients, and multifactorial in 9 patients. After TAC, there was a significant reduction in intra-abdominal pressure from 24.2+/-9.3 to 14.1+/-5.5 mm Hg and improvement in lung dynamic compliance from 24.1+/-7.9 to 27.6+/-9.4 mL/cm H2O (p < 0.05). Although 10 patients experienced brisk diuresis, there was no significant improvement in renal function; in fact, serum creatinine increased. The median length of stay was 35 days (range, 1-232 days). The mean number of abdominal operations after mesh insertion was 2.6+/-2.4. There were 21 deaths, for a standardized mortality rate of 0.80. Although it achieved significant reductions in abdominal pressures and improved lung dynamic compliance, TAC did not result in improved renal function or patient oxygenation.

Prospective evaluation of early missed injuries and the role of tertiary trauma survey.

BACKGROUND: This study prospectively evaluated the prevalence, clinical significance, and contributing factors to early missed injuries and the role of tertiary survey in minimizing frequency of missed injuries in admitted trauma patients. Missed injury, clinically significant missed injury, tertiary survey, and contributing factors were defined. Tertiary survey was conducted within 24 hours. RESULTS: Of 206 patients, 134 patients (65%) had 309 missed injuries composing 39% of all 798 injuries seen. Tertiary trauma survey detected 56% of early missed injuries and 90% of clinically significant missed injuries within 24 hours. Clinically significant missed injuries occurred in 30 patients with complications in 11 patients and death in two patients. Of 224 contributing errors, 123 errors were in clinical assessment, 83 errors were in radiology, 14 errors were patient related, and four errors were technical. The missed injury rate was significantly higher in patients with multiple injuries and in those involved in road crashes. CONCLUSIONS: Secondary trauma survey is not a definitive assessment and should be supplemented by tertiary trauma survey.

Long-term duct-occluded segmental pancreatic autografts: absence of microvascular diabetic complications.

BACKGROUND: Current insulin therapies for control of glucose metabolism in patients with type I diabetes mellitus prevent major metabolic consequences of insulin deficiency, but none prevents or arrests long-term complications. In experimental models of canine diabetes, retinopathy, neuropathy, and nephropathy have been shown to develop within 5 years. The aim of this study was to determine in a canine model whether glucose control provided by segmental duct-occluded pancreas autografts could prevent the long-term complications of diabetes. METHODS: Thirty-five outbred mongrel dogs underwent segmental pancreas autotransplantation with residual pancreatectomy. Follow-up over 5 years included endocrine, retinal fundus photography, fluorescein angiography, and nerve conduction studies. At endpoint, analysis of organ specific changes was undertaken. RESULTS: Long-term survival was achieved in 14 dogs for 4 to 5 years and in 3 dogs for 3 to 5 years. Glycosylated hemoglobin levels remained within normal limits, although response to glucose challenge was suboptimal. Fundus photography and fluorescein angiography demonstrated the absence of retinal vascular aneurisms, capillary leakage, and obliteration. Retinal digest showed no vascular changes and normal endothelial/pericyte ratios. Nerve conduction was normal, and histology of nerves revealed normal density of myelinated fibers and absence of intrafascicular vessels and glycogen deposits, with no change in spectrum of fiber diameters and ovoids. Renal histology revealed no evidence of nephropathy with normal glomerular basement membranes. CONCLUSIONS: We have demonstrated that duct-occluded segmental pancreatic autografts are capable of providing satisfactory metabolic control for up to 5 years, thereby preventing development of the long-term microvascular complications of diabetes.

Evaluation of the prevalence of drug and alcohol abuse in motor vehicle trauma in south western Sydney.

This study estimated prospectively the prevalence of high drug and alcohol levels in road trauma cases who met the criteria for activation of the Liverpool Hospital's trauma team. Urine analysis of road trauma victims between October 1992 and October 1993 was undertaken for drug and alcohol estimation. A total of 164 drivers were studied. A urine alcohol concentration (UAC) exceeding 0.08 g/dL was detected in 27 drivers (16.5%). Cannabinoids were detected in the urine of 25 drivers (15.2%), in 17 the concentrations exceeded 400 ng/mL. In one instance amphetamine, cocaine and heroin were detected in the same injured driver. Combined use of alcohol with some other drugs was detected in only four drivers. Alcohol and cannabinoid levels were prevalent in the urine of injured drivers in this study, particularly in young males who remain over-represented in the group of injured drivers. In the population surveyed other drugs were rarely detected. The role of cannabinoids in road trauma and the use of cannabinoids in young male drivers will however need to be monitored more extensively.

Hypothermia and severe trauma.

During the period from May 1992 until April 1993, 108 patients were admitted to Liverpool Hospital with Injury Severity Scores (ISS) > 15. Temperatures had been recorded in 100. Of these, 17 had a core temperature of less than 35 degrees C documented within 24 h of arrival. The hypothermic group presented with more severe injuries and contained a disproportionate number of females. Hypothermia was found to be more common in the winter months, but it was not associated with a delay in reaching hospital from the time of injury. When injuries were ranked by ISS, both hypothermic and normothermic patients were equally likely to have received a blood transfusion; however, the mean number of units of packed cells transfused was greater for the hypothermic group with ISS < 41 than for the similarly injured normothermic group. Two patients in the hypothermic group had sustained burns, and both of these were hypothermic on arrival. All of the hypothermic patients who required surgery developed hypothermia in the operating theatre.

Traumatic thoracic aortic rupture: investigation determines outcome.

Blunt thoracic aortic rupture (TAR) initially presents with subtle signs but is usually fatal if not diagnosed and treated early. Does the diagnostic process affect outcome? The definitive test most widely promoted is thoracic (arch) aortography but is usually only available in major teaching hospitals. Thoracic computerized tomography (CT) scanning is more readily available but its role in diagnosis of TAR is unproven. A retrospective review of trauma databases and medical record indexes over a 7 year period identified 38 patients presenting with TAR at Westmead and Royal North Shore Hospitals in the period 1984-91. Thirteen patients (34%) were dead on arrival or died within 15 min of arrival at either hospital. Five patients (13%) who arrived in cardiac arrest (with suspected TAR) died after immediate thoracotomy (two in the Emergency Department and three in the operating room). Two patients (5%) died from severe head injuries and were not investigated for TAR. Eighteen patients (47%) remained alive long enough for investigation and were considered potentially salvageable. Nine of these survived. Only 13 patients had arch aortography. No patient survived without an aortogram. Five patients had a chest CT scan; aortography followed in four patients. Computerized tomography scans delayed aortography or were misinterpreted. Review of all trauma thoracic (arch) aortograms for the same period at Westmead Hospital revealed a diagnosis of TAR in 7.4%. Blind thoracotomy did not result in survival. Computerized tomography scanning of the chest was of no value in the management of this injury. Early suspicion of possible thoracic aortic rupture demands urgent arch aortography and this remains the diagnostic 'gold standard'.

Sternal fractures: associated injuries and management.

Prospective data from blunt trauma victims admitted to one hospital were analyzed to determine the significance of sternal fractures and possible associated injuries. A total of 12,618 patients were admitted over a 6 1/2 year period, of whom 2226 (17.6%) were injured while in a motor vehicle. One hundred seventy-two sternal fractures were recorded with 152 (89%) occurring in motor vehicle occupants. Vehicle occupants with sternal fractures included a greater proportion of patients over 50 years (56% vs. 11%), more females (55% vs. 34%) and more seat belt wearers (70% vs. 40%). There was no association with serious visceral chest injury (including cardiac contusion). There was an association with thoracic spine fractures (Chi-squared 5.871, df = 1, p < 0.05). Sternal fractures in motor vehicle occupants were associated with less injury overall (median ISS = 5.5) compared with those without sternal fractures (median ISS = 13). Assessment of such patients should include age and injury mechanism to reduce the rate of admission and investigation of patients whose sole injury is a sternal fracture without significant pain.

Head injury and facial injury: is there an increased risk of cervical spine injury?

A series of 8285 blunt trauma victims from one hospital were analyzed to establish the possible association of cervical spine injuries with craniocerebral and facial injuries. Patients with clinically significant head injuries were at greater risk of cervical spine injuries than those without head trauma (4.5% vs. 1.1%, significant by Chi-squared analysis). Patients with Glasgow Coma Scale scores of 8 or less were at even greater risk of cervical spine injuries (7.8%). Facial injuries were not associated with cervical spine injuries. Procedures to achieve airway control in patients with serious head injuries must reflect these findings so that protection is afforded to the cervical spine during trauma resuscitation.

Non-iatrogenic trauma to the extrahepatic biliary tract.

Between 1980 and 1991, 15 cases of non-iatrogenic extrahepatic biliary tract trauma have been managed at Westmead and the Royal Canberra Hospitals. There were seven cases of gall-bladder injury and eight bile duct injuries. Four cases resulted from penetrating trauma whereas 11 resulted from blunt trauma. Associated injuries were common. Cholecystectomy was the preferred method of management for gall-bladder injuries whereas the bile duct injuries were managed by a variety of techniques. There were three deaths in the series, mostly related to associated injuries. Bile duct injuries were associated with longer hospitalization than gallbladder injuries.

Regionalization of trauma services in western Sydney: predicted effect on ambulance and hospital utilization rates.

A previous study has demonstrated the effectiveness of ambulance staff in identifying the majority of trauma victims who warrant admission to a Level 3 Hospital. This paper applied the results of that study in order to estimate the likely effect of a system of bypass whereby these identified patients are transported to a Level 3 hospital rather than the nearest Level 1 or 2 Hospital. Under the proposed plan whereby both Westmead and Liverpool Hospitals would be granted Level 3 status, the effect of Westmead would be negligible. However, Liverpool's caseload would increase (25% for total admissions, 136% for serious admissions) and, consequently, its level of resources would need to be upgraded before this plan can be put into action. Meanwhile, Level 1 and 2 hospitals would see little change to total patient admissions, although there would be a substantial drop in serious admissions (-63%). Under the proposed system, the effects on the Ambulance Service would also be negligible in terms of both the number of transports and total transport hours. However, the nature of these transports would change. More time would be required in bypass cases, although this would be compensated for by a corresponding fall off in interhospital transfers (28% decline in time spent on transfers). Ultimately, this means that patients would be getting to the hospital of definitive care much sooner. These results have implications for the development of trauma services in other sectors.

Longitudinal histopathologic assessment of rejection after bladder-drained canine pancreas allograft transplantation.

In preparation for assessment of percutaneous biopsies in our clinical pancreas transplant program, a working knowledge of the histopathologic changes after transplantation was obtained in a longitudinal open biopsy study of 16 dogs receiving bladder-drained whole pancreas allografts. Edema, extravasation of polymorphs, and lymphocytes associated with focal parenchymal injury were early, invariable, and probably nonspecific findings. The initial feature of unmodified rejection was the appearance of capillary and small vein endothelial changes with mainly perivascular inflammatory cell infiltration. Acinar cell loss occurred early and was progressive, whereas islets and ducts were relatively preserved, indicating that acinar tissue may be more vulnerable to lytic necrosis when damaged. Functional rejection, determined by fasting urinary amylase levels, was at a stage of extensive and irreversible necrosis. Functioning grafts in immunosuppressed dogs had minor and transient endothelial changes with absence of class II antigen staining of parenchymal cells.

Canine pancreas and kidney transplantation following total-lymphoid irradiation.

The effect of total-lymphoid irradiation on survival of canine pancreas and kidney allografts was studied. TLI had a marked immunosuppressive effect as measured by in vitro immune responses and reduced circulating leukocytes. Despite the changes, median graft survival times for animals treated with 800 cGy (9 days) or 1800 cGy (9.5 days) were not significantly different from untreated control animals (7 days). The addition of low-dose antithymocyte globulin (10 mg/kg/day) on post-transplant days 0, 2, 4, 6, 8, and 10 had no measurable synergistic effect. Similarly, median segmental pancreas allograft survival times after 1700-2200 cGy of TLI treatment (16.5 days) were only marginally longer than those of untreated controls (9 days). The only animal to maintain a graft for greater than 200 days was matched to the donor in mixed lymphocyte culture (MLC). This animal was able to reject a third-party skin graft after 8 days while a graft from the original donor was still surviving after 21 days when the pancreas graft failed from a chronic-type rejection. These results indicate that TLI alone or in combination with ATG will not be predictably effective as a method of prolonging allograft survival. The role of matching major histocompatibility complex antigens in TLI treatment requires clarification.

The accuracy of the first chest X-ray in the trauma patient.

Chest X-rays (CXR) are important in assessing chest trauma. This study assessed the accuracy of the first CXR in diagnosing moderate to severe chest injuries. One hundred patients presenting during 1985 and identified in the prospective Westmead Trauma Registry as having a chest injury with Abbreviated Injury Scale (AIS) scores of 3 or greater were included (males:females = 4.9:1; age range, 5-74 years). The officially reported interpretations of the first CXR were compared to the chest injuries finally diagnosed. In 19 of 77 survivors and 8 of 17 patients who had a CXR before dying, significant abnormalities (most commonly pneumothorax, haemothorax, spinal and sternal injuries) were not diagnosed on CXR. Although erect CXR with postero-anterior (PA) and lateral projections are said to show accurately most major intrathoracic pathology, CXR of trauma patients are often taken supine, suboptimally, and soon after arrival, whereas chest injury may take time to become apparent. The limitations of mobile CXR must be appreciated, and more formal CXR (antero-posterior and lateral) are advisable at a later stage if the clinical situation permits.

The hospital trauma team: a model for trauma management.

A triage system was established as the initiating mechanism for a trauma team response to assist the assessment and early management of patients presenting to an accident and emergency department. A checklist of triage criteria was used. During a 6-month period, 342 patients (29.7% of trauma admissions) satisfied the triage criteria, which should have resulted in an average of 1.9 trauma team calls per day. Staff compliance with the triage tool was 75.4%. The overtriage rate for the checklist criteria was 52.7%. The triage tool identified patients with severe injuries who were not initially considered sufficiently injured to justify initiation of the trauma team response. The sensitivity of the triage tool in identifying patients with serious injury was 95.0%. Comparison of the review with a similar review performed 12 months earlier demonstrated that staff compliance with initiating the trauma team response had improved. Using data from 564 patients from both series, logistic regression analysis of the power of the triage criteria to predict serious injury contributed to a revision of the triage criteria. This trauma triage tool and trauma team response constitute a valid approach to the early hospital management of trauma patients. This system may be more appropriate or achievable in many hospitals than the construction of dedicated trauma reception units or permanent surgical staffing of general Accident and Emergency departments.

Interhospital transfer in the management of acute trauma.

During an 8-month period, 538 injured patients were transferred from primary hospitals to a referral hospital for further management of their injuries. Delay at the primary hospital was identified in 20% of all transfers and in 40% of patients transferred for management of head injury or multisystem injury. Delay at the primary hospital resulted in a median time from injury to arrival at the second hospital of 4 h. Defects in clinical management during transport included inexperienced escorts, inadequate airway control, ventilation, fluid resuscitation and stabilization of chest injuries. Nearly half of transfers were inappropriate because of the relatively minor nature of the injuries. Most of these had solitary musculoskeletal injuries to the extremities. These patients reflect the marked deficiency of specialist orthopaedic services in western Sydney during the study. Development of a metropolitan regional system of trauma care in western Sydney requires urgent action towards reducing the frequency of transfer, minimizing delays in transfer and maximizing basic resuscitation of seriously injured patients. Some designation of hospital roles is required and needs to be accompanied by a prehospital triage process. The population also has a right to expect adequate specialty services at suburban hospitals to enable treatment of minor and moderate single system injuries. Future trauma system developments should adequately reflect population growth and technological advances in clinical care.

Percutaneous fine needle aspiration biopsy of canine pancreas allograft provides diagnosis of treatable rejection.

Despite improved pancreas transplant graft survival, early diagnosis of rejection remains a clinical challenge. Using a canine model of whole pancreas transplantation with bladder exocrine drainage we have shown fine needle aspiration biopsy (FNAB) to provide an earlier diagnosis of rejection than fall in urinary amylase (UA). The aim of this study was to assess the ability of anti-rejection therapy to reverse rejection when the diagnosis was based on either FNAB findings or a fall of UA. Sixteen dogs received a total pancreas allograft with an inadequate dose of oral cyclosporine (5 mg/kg/day). Fasting UA levels were measured daily and percutaneous FNAB with ultrasound guidance was performed three times weekly on all dogs. The diagnosis of rejection was made in alternate dogs with either a fall of UA to a level of less than 5000 IU/liter (median 7 days) or when the total corrected increment (TCI) of aspirated infiltrating cells was greater than 2.6 (median 5 days). Anti-rejection therapy consisted of methylprednisolone 10 mg/kg/day iv for 5 days and an increase of oral cyclosporine dosage to 25 mg/kg/day. Early vascular thrombosis (Day 2) occurred in three allografts. Diagnosis of rejection based on a low level of UA permitted the successful reversal of rejection in only one of six grafts, whereas five of seven grafts were successfully treated when rejection diagnosis was based on FNAB. Median allograft survivals were 9 days (range 8-19) and 32 days (range 11-63), respectively (P less than 0.01). The earlier diagnosis of allograft rejection made by FNAB improved the ability of conventional anti-rejection therapy to reverse pancreas allograft rejection and significantly improved allograft survival.