Efficacy of pre-hospital fracture manipulation following ketamine administration: the experience of a single civilian air ambulance trust

2019 ◽  
Vol 105 (3) ◽  
pp. 167-171
Author(s):  
A Follows ◽  
R H James ◽  
J Vassallo
Keyword(s):  
Emergency Department ◽  
Low Frequency ◽  
Trauma Centre ◽  
Air Ambulance ◽  
Major Trauma Centre ◽  
Limb Injuries ◽  
Retrospective Database Analysis ◽  
Clinical Records ◽  
Limb Fractures ◽  
Retrospective Database

AbstractAimsLimb fractures are common in pre-hospital care and can be associated with significant haemorrhage and neurovascular compromise. The pre-hospital management of these injuries centres around reduction and splinting. The aim of this study was to quantify the effectiveness of pre-hospital reduction of displaced fractures or dislocations and the incidence of the need for further manipulation in the emergency department.MethodsA three-year retrospective database analysis was conducted for all patients sustaining limb injuries who were attended by a single air ambulance and subsequently conveyed to the regional major trauma centre. Only patients who received ketamine, either as an analgesic or sedative, were included. Pre-hospital clinical records and emergency department (ED) notes were examined to determine outcomes.ResultsOver the study period, 122 patients sustained a limb injury and received ketamine; ED notes were available for 96 (78.7%). Of these, the majority (n=51, 41.8%) received ketamine for analgesia with n=10 (8.2%) receiving it to facilitate manipulation. The principal indication for pre-hospital manipulation was neurovascular compromise (n=7, 70.0%). Of those undergoing manipulation pre-hospital, the majority (n=7, 70.0%) required further manipulation in the ED.ConclusionPre-hospital manipulation by our regional air ambulance is a relatively low frequency event and in those undergoing a manipulation, a high proportion require further intervention in the ED or operative intervention within the acute phase of care.

scholarly journals Cardiac troponin T is associated with mortality in patients admitted to critical care in a UK major trauma centre: a retrospective database analysis

2018 ◽  
Vol 20 (2) ◽  
pp. 132-137 ◽  
Author(s):  
Kate Crewdson ◽  
Julian Thompson ◽  
Matt Thomas
Keyword(s):  
Cardiac Troponin ◽  
Major Trauma ◽  
Troponin T ◽  
Trauma Centre ◽  
Cardiac Troponin T ◽  
Trauma Patients ◽  
Major Trauma Centre ◽  
All Cause Mortality ◽  
Retrospective Database Analysis ◽  
Retrospective Database

Background Elevated levels of cardiac troponin T are associated with poor outcome in critically ill patients and have been proposed as a prognostic marker in major trauma. This study investigated the relationship between cardiac troponin T levels on admission to intensive care unit (ICU) and all-cause mortality in major trauma patients. Methods A retrospective database analysis of cardiac troponin T levels on admission to the ICU in major trauma patients between 1 August 2015 and 31 December 2016 at a UK Major Trauma Centre was performed. Results Of the 243 patients, 69 (28.4%) died. Cardiac troponin T levels were significantly higher in patients who died compared to survivors: 42 vs. 13 ng/L, respectively ( p < 0.0001); the odds of all-cause mortality increased significantly as troponin increased, independent of age or Acute Physiology and Chronic Health Evaluation score. Discussion This confirms cardiac troponin T at ICU admission as a marker of mortality in major trauma. Elevated cardiac troponin T may be seen in patients without evidence of direct cardiac trauma.

scholarly journals Paediatric orthopaedics in lockdown

2020 ◽  
Vol 1 (7) ◽  
pp. 424-430
Author(s):  
Ian Baxter ◽  
Graeme Hancock ◽  
Matthew Clark ◽  
Matthew Hampton ◽  
Adelle Fishlock ◽  
...  
Keyword(s):  
Trauma Centre ◽  
Supracondylar Fractures ◽  
Cast Immobilization ◽  
Fracture Clinic ◽  
Clinic Management ◽  
Orthopaedic Patients ◽  
Major Trauma Centre ◽  
Limb Injuries ◽  
Proportional Increase ◽  
The Impact

Aims To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS). Methods A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods. Results Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32). Conclusion During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast. Cite this article: Bone Joint Open 2020;1-7:424–430.

Pre-hospital and emergency department management of pelvic fractures and major trauma centre status: Has practice changed?

Trauma ◽  
2016 ◽  
Vol 19 (3) ◽  
pp. 207-211
Author(s):  
Jonathan Barnes ◽  
Philip Thomas ◽  
Ramsay Refaie ◽  
Andrew Gray
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Pelvic Fracture ◽  
Major Trauma ◽  
High Energy ◽  
Trauma Centre ◽  
Pelvic Fractures ◽  
Major Trauma Centre ◽  
Initial Imaging ◽  
One Year

Introduction Pelvic fractures are indicative of high-energy injuries and carry a significant morbidity and mortality and pelvic binders are used to stabilise them in both the pre-hospital and emergency department setting. Our unit gained major trauma centre status in April 2012 as part of a national programme to centralise trauma care and improve outcomes. This study investigated whether major trauma centre status led to a change in workload and clinical practice at our centre. Methods A retrospective analysis of all patients admitted with a pelvic fracture for the six-month periods before, after and at one-year following major trauma centre status designation. Data were retrospectively collected from electronic patient records and binder placement assessed using an accepted method. Patients with isolated pubic rami fractures were excluded. Results Overall, 6/16 (37.5%) pelvic fracture admissions had a binder placed pre-major trauma centre status, rising to 14/34 (41.2%) immediately post-major trauma centre status and 22/32 (68.8%) ( p = 0.025) one year later. Binders were positioned accurately in 4 patients (80%, one exclusion) pre-major trauma centre status, 12 (92.4%) post-major trauma centre status and 22 (100%) at one year. CT imaging was the initial imaging used in 9 (56.3%) patients pre-major trauma centre status, 29 (85.3%) ( p = 0.04) post-major trauma centre status and 27 (84.4%) at one year. Discussion Pelvic fracture admissions doubled following major trauma centre status. Computed tomography, as the initial imaging modality, increased significantly with major trauma centre status, likely a reflection of the increased resources made available with this change. Although binder application rates did not change immediately, a significant improvement was seen after one year, with binder accuracy increasing to 100%. This suggests that although changes in clinical practice often do not occur immediately, with the increased infrastructure and clinical exposure afforded through centralisation of trauma services, they will occur, ultimately leading to improvements in trauma patient care.

scholarly journals Management of open fractures of the lower limb during the COVID-19 pandemic: are the standards of treatment being maintained? a study from a major trauma centre in England

2021 ◽  
Author(s):  
Rajan Choudhary ◽  
Madhumita Gupta ◽  
Shahidul Haq ◽  
Wareth Maamoun
Keyword(s):  
Soft Tissue ◽  
Lower Limb ◽  
Major Trauma ◽  
Trauma Centre ◽  
Open Fractures ◽  
Trauma Service ◽  
Major Trauma Centre ◽  
Notable Increase ◽  
Definitive Surgery ◽  
Limb Fractures

<p class="abstract"><strong>Background: </strong>Coronavirus disease 2019 (COVID 19) has created an immense strain on the NHS. During the height of the pandemic, trauma services were affected by redeployment, reduced theatre capacity and staff illness, and COVID BOAST guidelines were introduced.</p><p class="abstract"><strong>Methods: </strong>This retrospective study aimed to evaluate the standards of management of open fractures of the lower limb at a Major Trauma Centre in the United Kingdom during the COVID-19 pandemic and compare the same with the pre-pandemic period. Patient demographics, mechanism of injury, timing and mechanism of initial debridement and definitive soft tissue and skeletal fixation were noted. Outcomes including duration of hospital stay, 30 day and 1 year mortality were also assessed.</p><p class="abstract"><strong>Results: </strong>There was an overall 21% reduction in admissions with open lower limb fractures during the pandemic period with a 48% reduction during the first lockdown. There was a significant reduction in time taken from Emergency Department presentation to first debridement as well as a notable increase in operating outside of regular theatre hours. There was little difference in operative technique used for skeletal or soft tissue management at initial and definitive surgery, though fewer cases were performed as a two stage procedure. There was no difference in amputation rate in the two years. Length of stay was reduced from 21 days to 17, and 30 day mortality remained the same.</p><p class="abstract"><strong>Conclusions:</strong> Our study shows this Major Trauma Centre was able to provide a trauma service in accordance to the BOAST4 guidelines despite the increased pressures of the COVID-19 pandemic.</p>

scholarly journals Paediatric orthopaedics in lockdown

2020 ◽  
Vol 1 (7) ◽  
pp. 424-430
Author(s):  
Ian Baxter ◽  
Graeme Hancock ◽  
Matthew Clark ◽  
Matthew Hampton ◽  
Adelle Fishlock ◽  
...  
Keyword(s):  
Trauma Centre ◽  
Supracondylar Fractures ◽  
Cast Immobilization ◽  
Fracture Clinic ◽  
Clinic Management ◽  
Orthopaedic Patients ◽  
Major Trauma Centre ◽  
Limb Injuries ◽  
Proportional Increase ◽  
The Impact

Aims To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS). Methods A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods. Results Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32). Conclusion During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast. Cite this article: Bone Joint Open 2020;1-7:424–430.

scholarly journals Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre

2020 ◽  
Vol 9 (1) ◽  
pp. e000550
Author(s):  
Alex Peter Magnussen ◽  
Christopher Watura ◽  
Nicola Torr ◽  
Miny Walker ◽  
Dimitri Amiras ◽  
...  
Keyword(s):  
Emergency Department ◽  
Major Trauma ◽  
Delayed Diagnosis ◽  
Trauma Centre ◽  
Current Evidence ◽  
Shoulder Injury ◽  
Posterior Shoulder ◽  
Major Trauma Centre ◽  
Fracture Dislocations ◽  
Axial View

BackgroundA high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that these missed injuries were causing serious consequences due to the need for surgical intervention and poor functional outcome.ObjectiveTo identify factors contributing to missed diagnosis and propose solutions.MethodsA local quality improvement report was performed investigating time from admission to diagnosis of simple posterior dislocations and fracture dislocations over a 5-year period. Factors contributing to a delayed diagnosis were analysed.ResultsThe findings supported current evidence: a posterior shoulder dislocation was more often missed if there was concurrent fracture of the proximal humerus. Anteroposterior and scapular Y view radiographs were not always diagnostic for dislocation. Axial views were more reliable in assessment of the congruency of the joint and were associated with early diagnosis and appropriate treatment of the injury.DiscussionAs a result of these findings a new protocol was produced by the orthopaedic and radiology departments and distributed to our emergency department practitioners and radiography team. The protocol included routine axial or modified trauma axial view radiographs for all patients attending the emergency department with a shoulder injury, low clinical suspicion for dislocation and a low threshold for CT scan. Reaudit and ongoing data collection have shown significant increase in axial view radiographs and improved diagnosis.

The sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre.

2013 ◽  
Vol 99 (1) ◽  
pp. 16-19
Author(s):  
D Potter ◽  
A Kehoe ◽  
JE Smith
Keyword(s):  
Major Trauma ◽  
Injury Severity ◽  
Trauma Centre ◽  
Research Network ◽  
Trauma Network ◽  
Trauma Patients ◽  
Major Trauma Centre ◽  
Injury Assessment ◽  
Trauma Response ◽  
Retrospective Database

AbstractThe identification of major trauma patients before arrival in hospital allows the activation of an appropriate trauma response. The Wessex triage tool (WTT) uses a combination of anatomical injury assessment and physiological criteria to identify patients with major trauma suitable for triage direct to a major trauma centre (MTC), and has been adopted by the South-West Peninsula Trauma Network (PTN). A retrospective database review, using the Trauma Audit Research Network (TARN) database, was undertaken to identify a population of patients presenting to Derriford Hospital with an injury severity score (ISS) > 15. The WTT was then applied to this population to identify the sensitivity of the tool. The sensitivity of the WTT at identifying patients with an ISS>15 was 53%. One of the reasons for this finding was that elderly patients who are defined as having major trauma due to the nature of their injuries, but who did not have a mechanism to suggest they had sustained major trauma (such as a fall from standing height), were not identified by these triage tools. The implications of this are discussed.

scholarly journals A health economic analysis of the management of open lower limb fractures in the elderly

2020 ◽  
Vol 30 (8) ◽  
pp. 1383-1391
Author(s):  
Caitlin Pley ◽  
Katie Purohit ◽  
Matija Krkovic ◽  
Ali Abdulkarim
Keyword(s):  
Lower Limb ◽  
The Elderly ◽  
Trauma Centre ◽  
Median Cost ◽  
Financial Loss ◽  
University Hospitals ◽  
Health Economic Analysis ◽  
Lower Limb Fractures ◽  
Major Trauma Centre ◽  
Limb Fractures

Abstract Aim The aim of this study was to investigate the financial implications of the inpatient management of open lower limb fractures in adults over 65 years old. Further, the study compares the calculated cost to the income received by the hospital for these patients and to the existing body of literature. Methods This study employed direct inpatient costing analysis to estimate the cost of treating the open lower limb fractures incurred by 58 patients over the age of 65 years treated in our centre (Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust) between March 2014 and March 2019. Results The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. Conclusion This study provides a valuable estimate of the expense of treating open lower limb fractures in patients over the age of 65 years in a Major Trauma Centre in England. The study highlights the large losses incurred by hospitals in treating these cases, and supports revision of the remuneration structures in the National Health Service to adequately cover their cost.

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