Trauma recent issues

Fluids as oxygen carriers and the potential role in trauma resuscitation

Shirley, P. J — 2008-08-29

Patients with major trauma present a challenge, often using large quantities of banked blood both at the time of injury and during their hospital stay. Blood transfusion is not without risk and is associated with high costs; it is immunosuppressive, rendering patients more susceptible to infection. In the western world, banked blood is fully screened and relatively safe; the same is not true in parts of the developing world, where high rates of HIV carriage make blood transfusion a risky undertaking. Additionally, blood transfusion as a vector for transmission of illnesses such as prion disease is a distinct possibility, for both the developed and developing world alike. The introduction of artificial blood substitutes would ameliorate some risk and also remove the cost of extensive blood testing. For trauma outside hospital, blood substitutes could compete directly with fluid resuscitation as donated blood is not usually available. Patients with prolonged transport times would appear to be the most obvious beneficiaries and volume expansion, along with improvement in oxygen-carrying capacity would be the ultimate goal. All clinicians confronted with the need for transfusion of homologous blood would welcome the development of a safe and reliable alternative to red blood cells in order to ensure oxygen transport to the tissues. However, even though research on red cell substitutes started more than 100 years ago, even now none of the heavily investigated compounds based on haemoglobin or perfluorocarbons has been released in Europe or the USA for routine clinical use.

Acetabular fractures in the 21st century

Rickman, M., Bircher, M. — 2008-08-29

Acetabular fractures are uncommon other than in the polytrauma setting, and most orthopaedic surgeons will never develop a wide exposure to them. The early management of these injuries can have profound effects on the long term outcomes from what is often a significant injury in a young patient. We present a current review of the anatomy, classification and management guidelines for acetabular fractures, including a comprehensive review of the major decision making processes, as well as describing the most common complications and the expected outcomes.

Injuries to the proximal humerus

Costan, L., Ashwood, N. — 2008-08-29

Five to seven percent of all fractures involve the humerus, with most occurring in ladies over the age of 60 who have osteoporosis. and suffer fractures after a simple fall. In younger individuals such fractures result from high energy injuries (road traffic accidents). Around 75% are non-displaced fractures according to Neer's classification and can be treated non-operatively. The remaining 25% require surgical intervention based on the understanding of the anatomy of the proximal, the mechanism of the injury and the quality of the patient's bone. The displaced fractures may lead to avascular necrosis, osteoarthritis, pseudoarthrosis, and reduced motion and function. Involvement of the specialist is needed at an early stage in order to restore the limb functionality and the quality of life.

Paediatric chest trauma (part 1) -- Initial Lethal Injuries

Kerr, M., Maconochie, I. — 2008-08-29

Chest trauma is the second greatest cause of mortality from trauma, a leading cause of death in children over the age of one. Prompt diagnosis can be difficult as the underlying thoracic injuries are often disproportionately severe compared to the visible surface injury and symptoms may not appear for several hours. Diagnosis is easily underestimated, delayed or missed. This is a two part article reviewing paediatric chest trauma and its current management. The injuries are usefully classified into six lethal injuries that need excluding in the primary survey and six hidden injuries that must be considered in the secondary survey. The first article reviews paediatric anatomy and biomechanics, and mechanisms of injury with a view to improving the awareness and understanding of the unique response of children to thoracic trauma. This is followed by an in depth review of each of the six lethal injuries. The subsequent article reviews the six hidden injuries as well as the role of chest trauma in non-accidental injury.

Paediatric chest trauma (part 2) -- Hidden Injuries

Kerr, M., Maconochie, I. — 2008-08-29

Chest trauma is the second greatest cause of mortality from trauma, a leading cause of death in children over the age of one. Prompt diagnosis can be difficult as the underlying thoracic injuries are often disproportionately severe compared to the visible surface injury and symptoms may not appear for several hours. Diagnosis are easily underestimated, delayed or missed. This is the second of a 2 part article reviewing Paediatric chest trauma and its current management. The injuries are usefully classified into 6 lethal injuries that need excluding in the primary survey and 6 hidden injuries that must be considered in the secondary survey. The 6 lethal injuries are covered in the first part of this article along with biomechanics and mechanisms of injury. This article looks in depth at the 6 hidden injuries, along with a review of chest trauma in non-accidental injury.

Ventilator-associated pneumonia and new airway technologies

Yarham, S., Young, P. — 2008-06-06

Current endotracheal and tracheostomy tubes have high volume low pressure cuffs. These cuffs are ineffective at preventing the ongoing pulmonary aspiration of oropharyngeal and gastric contents. This ubiquitous complication of intubation is the most important cause of ventilator-associated pneumonia (VAP), the commonest and most devastating nosocomial infection in the Intensive Care Unit (ICU). Current tracheal tubes are made of relatively fixed curved PVC, and this produces forces on the airway tissues which is associated with laryngeal and tracheal injury. There is a need for the development of tracheal tube technologies to prevent aspiration injury and the reduce airway injury associated with mechanical ventilation of the critically ill. Given the costs associated with VAP there is currently a massive mismatch in what we spend on prevention.

The evidenced-based care behind the early management of head injured children

Bayreuther, J., Maconochie, I. — 2008-06-06

Trauma remains the highest cause of death in children over the age of 1. Head injury accounts for the highest mortality. There is much information on the treatment of head injuries and indications for CT scanning. This review aims to summarise the key differences between paediatric and adult victims of trauma and outline the key steps in management of head injured children, from prevention through to who should have a CT scan and initial management in the emergency department (ED) if transfer is required to a PICU or neurosurgical unit. Information is also provided on recommendations for follow up of children who do not require PICU or neurosurgical care.

Focused assessment with sonography for trauma: the FAST scan

Christie-Large, M., Michaelides, D., James, S. — 2008-06-06

Focused assessment with sonography for trauma or focused abdominal sonography for trauma — the FAST scan, has become a useful modality for the initial evaluation of patients with blunt abdominal trauma. The technique is used to identify free fluid in the abdomen and pelvis and to detect the presence of a pericardial effusion. FAST can be performed by any trained individual, not necessarily a sonographer or radiologist, aiding in the immediate availability of this technique in the emergency situation. We will discuss the applications and sensitivity of this technique in trauma and review the potential pitfalls and limitations which need to be understood if this technique is to be safely applied. The use of FAST for the detection of pneumothoraces in trauma and other advances in FAST scanning, such as scoring systems and paediatric FAST are also reviewed.

Tying all together

Martin-Bates, A. — 2008-06-06

Coagulopathy in trauma: optimising haematological status

McDonald, V., Ryland, K. — 2008-06-06

It is estimated that 10 000 people per year die following trauma in England and Wales and 30—40% do so due to uncontrolled haemorrhage. By the time the patient reaches hospital, coagulopathy is often already installed and needs to be corrected promptly to prevent further haemorrhage and allow effective treatment of injuries. The coagulopathy is multifactorial with the leading causes being acidosis, hypothermia and massive transfusion. Early recognition of the condition is imperative using standard coagulation testing; however, there are limitations in this setting. Newer methods of testing `global haemostasis' using thromboelastography are becoming more popular but need further validation. Treatment of coagulopathy requires a multidisciplinary approach. Blood product transfusion remains the cornerstone of management but newer pharmacological agents such as recombinant factor VIIa are increasingly being used. Here we review the pathogenesis, investigation and management of the coagulopathy of trauma.

Fractures of the distal humerus

Youssef, B., Youssef, S., Ansara, S., Porter, K. — 2008-06-06

Fractures of the distal humerus are challenging injuries to treat. They are rare injuries and frequently involve the joint. The advent of modern operative fixation techniques has led to an increasing trend towards open anatomical reduction and internal fixation of these fractures. This review examines the basic anatomy of the distal humerus and the applied anatomy with regards to fracture classification and surgical approach. This is followed by a discussion of the methods and results of treatment.

Urinary tract trauma -- diagnosis and management

Brown, D. J., Martindale, A. D — 2008-04-21

Urological trauma is rare but is associated with significant morbidity and mortality if missed or not managed appropriately. The careful assessment and involvement of specialist investigations and treatments are paramount to a good patient outcome. This article is aimed at the non-urologist to highlight the potential pitfalls and the importance of clinical suspicion. It should be used as a guide, but should not negate the involvement of a urologist early on in the investigation and management of trauma patients.

Chance and his fracture

Kingsbury-Smith, R. — 2008-04-21

Angiography and embolisation in blunt splenic injury: a review

Klapheke, W., Harbrecht, B. — 2008-04-21

The surgical care of patients has evolved over the last 50 years. Operative intervention in the face of blunt spleen injury has been supplanted by non-operative techniques. Two of the newest techniques, angiography and embolisation, are reviewed in this article with references to patient selection, technique used and outcomes. Furthermore, current weaknesses in the data available are discussed in order to provide surgeons with a complete overview of the techniques.

Scapula fractures: A review

Theivendran, K., McBryde, C. W, Massoud, S. N — 2008-04-21

Fractures of the scapula are uncommon and are generally the result of high energy trauma with associated serious injuries. A majority can be managed conservatively but significant displacement of fracture fragments especially involving the glenoid articular surface may require operative fixation to prevent serious functional disability. This review discusses the diagnosis, classification and treatment of these injuries.

Prevention of secondary brain injury following Head Trauma

Cowley, N. J, da Silva, E. J — 2008-04-21

Over half of admissions to hospital with severe trauma have associated head injury. Suboptimal management of traumatic brain injury greatly increases mortality and morbidity. This article reviews current practice in the management of head injury resulting from trauma with particular attention to management strategies that have been proven to minimise secondary brain injury in the early resuscitation period. Ongoing management of confirmed severe brain injury is detailed, including maintenance of cerebral perfusion and the control of raised intracranial pressure.

Fractures of the neck of the femur

Parker, M. J — 2008-04-21

A hip fracture represents one of the commonest reasons for an elderly patient to be admitted to an acute orthopaedic ward. The average age of patients is about 80 years and the most patients are female. Surgical treatment is recommended for the majority of fractures. For intracapsular fractures internal fixation is indicated for all undisplaced fractures and displaced fractures in those aged less than about 65—70 years. Arthroplasty is more appropriate for the elderly patient with a displaced intracapsular fracture. A cemented unipolar hemiarthroplasty is generally used, but for the fitter active patients a total hip replacement may be superior. The sliding hip screw remains the implant of choice for trochanteric hip fractures with intramedullary fixation being mainly used for subtrochanteric fractures. Aggressive rehabilitation methods with minimally transfer of patients and early community support programmes can reduce the length of hospital stay.

Resuscitation of patients after traumatic brain injury

Hulme, J. — 2008-04-21

Traumatic brain injury (TBI) is the commonest worldwide cause of death and disability in people under 45 years of age. Following an injury of this nature, physiological derangements, both systemic and within the brain, rapidly progress and have a deleterious effect on outcome. There is a lack of brain specific treatments that significantly improve outcome and management must therefore be best care of appropriate physiology, along the familiar ABC lines. There are international guidelines that describe targets to be achieved. Methods to do this plus the rationale for doing so are discussed in this article.

Diaphragmatic injuries: challenges in the diagnosis and management

Petrone, P., Leppaniemi, A., Inaba, K., Soreide, K., Asensio, J. A — 2008-02-21

Establishing the clinical diagnosis of diaphragmatic injuries (DI) can be challenging for the trauma surgeon, as it is often clinically occult. Accurate diagnosis is critical however as a missed DI may result in grave sequelae due to herniation and strangulation of displaced intra-abdominal organs. The etiology of DI includes the following mechanisms: blunt, penetrating, and iatrogenic. Vital information about the mechanism of injury should be obtained from the emergency medical personnel. Left-sided hemidiaphragmatic injuries are considerably more common than right-sided injuries. Patients with right-sided hemidiaphragm rupture have higher pre-hospital mortality resulting from the greater impacting force require to produce a right-sided DI, associated with significant vascular injury. The diagnosis of a DI by imaging studies presents a challenge, as evidenced by the large number of investigative procedures employed to establish the diagnosis. Minimally invasive technology in the form of laparoscopy and thoracoscopy is in the trauma surgeon's diagnostic and therapeutic armamentarium. The surgical care of DI can be classified according to the phase of clinical presentation, into injuries requiring management in their acute phase versus those in their chronic phase. The patient's survival depends on the severity of their associated injuries, but if DI is not diagnosed promptly a missed injury can be associated with a high morbidity and mortality.

rFVIIa in trauma: a review and opinion-based guidelines

Bruder, E., Howes, D. W — 2008-02-21

Recombinant activated factor seven (rFVIIa) is a novel and emerging therapy for the acquired coagulopathy associated with massive bleeding and hemorrhagic shock. The intent of this paper is to review the mechanism of action of rFVIIa, to discuss the current state of evidence regarding the safety and efficacy of rFVIIa, and to offer guidance regarding its use in severely traumatized patients. No study has demonstrated a survival benefit in humans. rFVIIa, is safe to use in the setting of severe trauma associated with ongoing bleeding and acquired coagulopathy. Doses of 80—200 µg/kg may be used after correction of thrombocytopenia and acidosis. Hypothermia should be corrected in any traumatized patient, but should not be a barrier to its administration. Definitive evidence supporting the use of rFVIIa is lacking, but ongoing studies will delineate survival benefits, dosing regimens, and adverse events associated with its use.

Damage control orthopaedics

Philipson, M. R, Parker, P. J — 2008-02-21

Damage control orthopaedics (DCO) describes a philosophy for the management of the patient with multiple bony injuries. The fundamental principles are that fractures and traumatic soft tissue injuries (the `wound organ') should be stabilised promptly with the minimum physiological insult to the patient, and that initial surgery should be regarded as a staged part of the resuscitation process. This article discusses the history of DCO; the scientific basis behind DCO principles; patient selection for DCO; the principles of resuscitation in the multiply injured; the evidence for and against DCO; and possible future advances.

Prevention and treatment of post-traumatic acute respiratory distress syndrome

Benfield, R., DuBose, J., Demetriades, D. — 2008-02-21

Post-Traumatic Acute Respiratory Distress Syndrome (ARDS) is a major cause of morbidity and mortality in the acutely injured patient. The American-European Consensus Conference Report established the most widely accepted definition of ARDS in 1994. In recent years it appears the incidence and impact of the disease are on the decline. This article reviews strategies to prevent and treat post-traumatic ARDS. Well-accepted, proven strategies include lung protective ventilation strategies, as well as conservative transfusion and crystalloid resuscitation policies and the adoption of leukoreduction techniques. Other modalities including hypertonic saline resuscitation, use of albumin and diuretics, positive end expiratory pressure, high-frequency ventilation, prone positioning, recruitment maneuvers, extracorporeal membrane oxygenation, corticosteroids, exogenous surfactant, and inhaled nitric oxide are also reviewed.

Ankle fractures in adults: an overview

Westerman, R.W., Porter, K. — 2008-02-21

Before attempting to treat ankle fractures it is vital to appreciate the normal functional anatomy of this complex joint. The objectives of treatment, as with all fracture management, are to restore the anatomy and return normal function to the injured joint. This article describes the functional anatomy of the ankle and the epidemiology, assessment and definitive management required for a routine ankle fracture.

Humeral shaft fractures: a review of literature

Mohammed Saqib Zafar, , Porter, K. — 2008-02-21

Humeral shaft fracture account for nearly 3% of all fractures. Trauma specialists should be aware of a range of possible injuries, complications and be confident in their management. This article reviews the various aspects of humeral shaft fractures and details different treatment options available. We found that in the majority of cases non-operative management has excellent results provided attention is paid to follow up and rehabilitation.

Does pre-hospital ventilation effect outcome after significant brain injury?

Warner, K. J, Bulger, E. M — 2008-02-21

Traumatic brain injury has a devastating impact on society, utilizing many resources and disproportionately affecting the young. Recent evidence demonstrates the early care of the brain injured patient impacts patient outcomes. While prevention of systolic hypotension and hypoxia are mainstays of prehospital management of the injured patient ventilatory management performed in the prehospital environment has recently been shown to impact outcomes. Hypocapnea from hyperventilation has been shown in several trials to cause deleterious effects from cerebral vasoconstriction and ischemia. The importance of balancing the prevention of both hypocapnea and hypercapnea has led to the idea of a target ventilation range for arterial carbon dioxide tension, the ideal way to achieve this balance in the prehospital setting remains elusive. This article reviews the background, physiologic effects, impact on outcomes, and implications for prehospital care of prehospital ventilation.