Trauma

Geriatric trauma is a burgeoning public health problem. In Australia and New Zealand, there has been a 21% increase in geriatric major trauma presentations over the past 4 years, with persons over 65 year-of-age now accounting for almost one third of all severely injured patients. Whole-body computed tomography (WBCT) is often used in the emergency department to assess patients for traumatic injuries. Recent studies have suggested more selective use of WBCTs for trauma patients, but the benefit of WBCTs in older persons is undefined. This systematic review aims to identify whether geriatric trauma patients that underwent WBCT have different outcomes compared to those that have selective CT-scans.

A systematic literature search was conducted on PubMed, MEDLINE and EMBASE according to the PRISMA guidelines for studies about imaging in geriatric trauma from 1946 to June 2023. Outcomes of patients that had WBCT were compared with those that had selective CT scans on presentation.

Five publications including 14,908 geriatric trauma patients were reviewed for analysis. Analysis of mortality showed that WBCTs are not significantly associated with a reduced risk of mortality (OR: 0.88, 95% confidence interval [CI] 0.46–1.67, p = 0.69). Analysis of hospital length of stay showed that patients investigated with WBCTs had no significant difference to patients that had selective CT scans (MD: −0.39, 95% CI −1.09 to 0.30, p = 0.27). WBCTs also are not associated with a higher likelihood of being discharged home (OR: 1.05, 95% CI 0.56–1.98, p = 0.87).

WBCTs are not associated with reduced mortality, reduced hospital or ICU LOS or discharge destination in geriatric trauma when compared to selective CT-scans. There is presently insufficient evidence to support a routine approach of WBCT in the assessment of geriatric trauma patients.

Fragility ankle fractures are becoming increasingly common with an ageing population. Underlying co-morbidities, osteoporosis and a poor soft tissue envelope makes their management challenging.

The aim of this study was to compare the results of fibular nail (FN) versus hindfoot nail (HFN) for the treatment of fragility ankle fractures.

This was a retrospective comparative study from a level 1 trauma centre. All patients over the age of 60 with a low energy fragility ankle fracture between January 2017 and February 2021 were included in the study. Primary outcome was Olerud-Molander ankle score. Secondary outcomes were postoperative complications and re-operation rates. Mean follow-up was 6.2 months.

Fifty six patients were identified with a mean age of 74 years. Time to radiographic union rate was not significantly different between both groups (p = 0.626). No cases of non-union or malunion were identified. The mean Olerud-Molander ankle score was significantly higher in FN group (p < 0.01). There was a higher wound complication rate in the HFN group (p = 0.04). The incidence of reoperation did not significantly differ between both groups (p = 0.118).

Hindfoot nails and fibular nails can lead to equivalent union rates. However, better functional outcomes and reduced complication rate are observed after fibular nails.

In 2000, Pape and colleagues designed the Thorax Trauma Severity Score (TTSS) that integrated the anatomical and physiological parameters to predict the outcome following trauma to chest. Given the wide variability in the cut-off level for predicting outcome, we intended to analyze the cut-off and study the sensitivity and specificity of TTSS in our population in predicting the mortality. We also aimed to quantify the utility of TTSS at presentation in predicting the need for ICU care, and need for mechanical ventilation.

A prospective cohort study was conducted on 300 blunt chest trauma patients presenting to Emergency Department of our level 1 Trauma Centre. Patients aged 18 years or above with blunt trauma chest with GCS > 13 at presentation were included. Data analysis was performed using IBM SPSS. The receiver operator curve (ROC) was used to evaluate the statistical significance of sensitivity and specificity and to choose suitable cut-off points to make a decision.

Out of 300 patients, 230 were male (76.7%) and aged 38 ± 14.5 years. Road Traffic Accident was the commonest mode of injury (71.6%). Out of 239 patients who were admitted, 137 patients needed hospitalization for less than 7 days (good prognosis), 44 patients had fair prognosis, 27 needed admission to ICU and ventilator support and therefore had poor prognosis while 31 patients had fatal outcome. A cutoff of TTSS 11 or more had 96% sensitivity & 90% specificity for predicting poor outcome (p < 0.001; AUC = 0.921) and 87.4% sensitivity & 86.5% specificity for predicting fatal outcome (p < 0.001; AUC = 0.933).

A TTSS score of 11 and above was associated with poor (ICU admission and need for mechanical ventilation) and fatal outcome. A higher score is associated with higher morbidity & mortality [Level of evidence: Level 2].

Acute colonic pseudo-obstruction (ACPO) is a common and potentially serious complication of surgical and trauma care. A possible contributor to ACPO development is impaired mobility. Major trauma patients, particularly those with spinal trauma, are at risk of prolonged mobility restrictions. The aim of this study was to assess the association between impaired mobility and the development of ACPO in major trauma patients undergoing acute thoraco-lumbar spinal fixation.

A retrospective cohort study involving major trauma patients admitted to a tertiary trauma facility was performed. The Hospital Trauma Registry was utilised to identify consecutive major trauma patients having urgent thoraco-lumbar spinal fixation. ACPO was defined as dilation of the transverse colon >6 cm or caecum >9 cm without mechanical cause. Immobility was defined by proxy as surgeon-prescribed mobility restrictions. Analysis was performed using multivariable logistic regression.

ACPO occurred in 34 of 454 patients studied (7.5%). Colonoscopic decompression was required twice. Neostigmine or surgical resection were not required. There was no ACPO-related mortality. On multivariable regression, adjusted for confounding variables, post-operative mobility restrictions were associated with a three-fold increase in odds of ACPO (odds ratio 3.1; 95% confidence interval 1.1–8.9, P = 0.04).

ACPO was a common, although low-morbidity complication in this cohort. Surgically prescribed mobility restrictions were associated with higher odds of ACPO in major trauma patients having thoraco-lumbar spinal fixation. Attention should be given to early mobilisation, where possible, in these patients.

Physicians and other first-line medical care providers may find themselves in an airway management emergency where they cannot ventilate, cannot oxygenate, and have limited resources to aid them. The rise in use of tele-health and other virtual interfaces creates the opportunity to bring experienced guidance to a resource-poor critical airway situation. We aimed to compare in-person mentoring (IPM) by an emergency medicine (EM) physician to tele-mentoring (TM) by a trauma surgeon for an emergent surgical airway.

Thirty EM residents were randomized to cricothyroidotomy on a model with IPM or TM. The IPM preceptor was an EM attending, and TM preceptors were trauma surgeons. The procedure was timed and graded on a Global Rating Scale (GRS). Post-procedure, mentor and trainee completed a NASA Task Load Index (TLX).

There was no difference in procedure success; however, the IPM group took longer (163.6 vs. 107.6 s, p < 0.05). TM trainees experienced greater temporal demand (4.27 vs. 2.73, p = 0.03). Telementors recorded improved performance compared to in-person mentors (2.30 vs. 4.17, p < 0.05). Comparing mentors and trainees in each arm, IPM trainees felt more temporal demand than their mentors (4.63 vs. 2.73, p < 0.05) while TM trainees felt they had worse performance than their mentors perceived (4.23 vs. 2.3, p = 0.01).

Performance based on GRS between groups was equal; however, those with telementors secured the airway more rapidly. Telementors reported higher performance and lower time pressure than in-person preceptors. This data suggests that TM is effective for precepting cricothyroidotomy and may be the superior option in some settings.

Cervical spine fractures are common in older adults, although reports of the epidemiology and outcomes of this patient cohort are scant. The aim of this study was to review the epidemiology, management and outcomes (hospital-based and patient-reported) of older patients with cervical fractures admitted to a level 1 trauma centre.

Patients aged ≥65 years who were admitted to The Alfred and included on the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) with a cervical spine fracture were included. Demographics and management (surgery, halo thoracic orthosis or conservative), as well as hospital and 6-month outcomes were analysed. Factors associated with cervical spine management and outcomes (discharge destination and being at home at 6 months post-injury) were assessed using logistic regression.

Between 2016 and 2021, a total of 853 patients were included. Median age was 79 (IQR 72–86) years, with most (57.7%) being male. Low falls (59%) were common. Most patients were managed non-operatively [765 (89%)]. The median acute hospital length of stay was 6.8 (IQR 3.8–11.6) days and 90.6% of patients survived to hospital discharge. After adjusting for confounding factors, increasing age, female gender and having an intensive care unit stay were associated with discharge to another inpatient facility as well as not returning to live at home at 6 months. There was no association between the cervical spine management and 6-month quality of life outcomes.

Overall mortality rate was low with most patients returning to independent living at home 6 months post-injury. Considering those factors associated with poorer outcomes may provide useful information to determine optimal pathways for this cohort.

The purpose of our study is to identify risk factors associated with unplanned or early reoperations in trauma patients with truncal injuries who received damage control surgeries.

This was an Institutional Review Board approved, single center, retrospective cohort evaluation. Trauma patients with truncal injuries who required an index surgery for damage control followed by a reoperation were divided into two groups based on the timing of their reoperation, planned (reoperation within 24–48 h) and unplanned groups (reoperation < 24 h). The primary outcome was to identify risk factors associated with unplanned trips to the operating room following the index surgery.

Of the 142 trauma patients who underwent a damage control surgery, 42 patients were included for analysis (24 in the planned group and 18 in the unplanned group). The most common causes for unplanned reoperations were hemodynamic instability (n = 7) and bleeding (n = 8). Vasopressor administration (OR = 10.5, 95% CI [2.475, 44.54]), shock index > 1.2 (OR = 5.9, 95% CI [1.35, 25.88], and hemoglobin (Hgb) < 10 and/or a hematocrit (Hct) < 29 (OR = 8, 95% CI [1.5, 46.65] and/or OR = 17, 95% CI [1.94, 148.85], respectively) were associated with an increased odds of an unplanned return to the operating room.

Following damage control surgery, vasopressor administration, elevated shock index, and decreased Hemoglobin/Hematocrit may help identify patients who are at risk of requiring early or unplanned returns to the operating room.

Penetrating nail gun injuries are a common presentation to Australian Emergency Departments (EDs). Despite a paucity of evidence, routine surgical debridement and intravenous antibiotics are the current practice to prevent subsequent infection. We aim to provide evidence on the efficacy of surgical debridement and antibiotics in preventing infection following a penetrating nail gun injury.

A retrospective study was conducted, that included all patients who presented to The Alfred between 2012 and 2020 with penetrating nail gun injuries. Patients were sub-grouped into those managed with surgical intervention at the time of the presentation and those who were not. Patients who were managed without initial surgical intervention were further sub-grouped to those given prophylactic antibiotics or not. The primary outcome was wound infection at 30 days post injury.

There were 157 patients included of which 43 (27.4%) patients underwent surgical debridement. There was no statistical difference in rates of infection between the non-surgical versus surgical management groups (2.6% vs 0%, p = .78). Among those who did not undergo formal surgical debridement, there was also no significant association between prophylactic antibiotics and infection (OR 0.25; 95% CI: 0.21–2.81).

Blanket operative debridement and prolonged antibiotics for penetrating nail gun injuries may not be necessary to prevent subsequent infection. The interventions should be tailored for specific indications.

The study aimed to evaluate the functional outcome of distal thumb amputations (Allen's type 3, 4) that were not replantable when treated with a dorsoulnar flap.

A retrospective review was conducted in 15 patients who underwent dorsoulnar flap for Allen's type 3 and 4 thumb amputations in a single hand surgery center. The patient demographics, level of injury, complications, and functional outcomes were analyzed. Functional outcome was assessed using the Fingertip Injuries Outcome Score (FIOS).

The mean age was 26 years (range 19–35 years). The most common mechanism of injury was motorcycle spokes wheel injury (n = 9), followed by road traffic injury, door crush, and fall. The FIOS was good in 13 patients and fair in 2 patients. The complications included hairy skin (n = 3), absent nails (n = 4), and cold intolerance (n = 2).

Our study suggests that the dorsoulnar flap is a simple and reliable reconstructive option for severe crush injuries resulting in Allen type 3 and 4 thumb amputations, with the potential to achieve good functional outcomes.

Trauma patients are at higher risk of complication than general acute admissions. Understanding the complications associated with trauma care can provide insights into avoidable morbidity and guide quality improvement activities. This study aims to quantify the volume and prevalence of complications affecting trauma admissions in one of the four health regions of New Zealand (NZ).

A retrospective, observational study utilised data from the Te Manawa Taki Trauma Registry (TMTTR) to identify individuals who were hospitalised in the region due to injuries from 2015 to 2023. Data from the TMTTR was linked with the New Zealand National Minimum Dataset (NMDS) that contains in-hospital complications records mapping across multiple fields, including the patient's unique identifier, facility name and admission and complication episode date field elements. This investigation focuses on the epidemiological parameters of complications in trauma admissions.

During 2015–2023, a total of 3294 trauma admissions of all severities to Te Manawa Taki facilities involved one or more hospital-acquired complications, representing 6.2% of the total 52,899 admissions. The volume of complications in non-major trauma patients is 2.3 times that of major trauma. Complications were associated with increasing age, female gender and non-Māori ethnicity (p < 0.01). Acute kidney failure, urinary tract infections and pneumonia are the top three complication irrespective of severity. Admissions with complications have a significantly higher mean hospital Length Of Stay (LOS) 13.6 days compared to 3.8 days for those without complications (t = 76.6, p < 0.001).

Analysis of complications in trauma admissions has shown important variation in demographic characteristics and types of complications that may be amenable to mitigation and reduction of the impact on patients and the health system. This study has set the scene for further investigation into the clinical, in-hospital, socio-demographic and pre-existing health status factors that increase the risk of complications in trauma admissions.

Takotsubo cardiomyopathy is an uncommon, reversible disease process of the left ventricle that typically occurs in the setting of physiological or psychological stress. Cases following neurological injury are becoming increasingly recognized, with development of takotsubo cardiomyopathy reported in as many as 28% of intensive care patients with traumatic brain injuries (TBI) during their hospital course.

We present a case involving a patient hospitalized following TBI with subsequent development of Takotsubo cardiomyopathy complicating the management of her primary traumatic injuries.

This case demonstrates the importance of early recognition of this entity in patients with TBI and suggests the role for management by interdisciplinary teams. Given the incidence, risk factors, and complexity of stress cardiomyopathy in patients with TBIs, future prospective studies are needed to develop evidence-based guidelines to define treatment standards for takotsubo cardiomyopathy in patients with traumatic injuries.

Injury to the spleen caused by blunt trauma is common and may be associated with traumatic diaphragmatic injury. We describe a unique presentation with haemoptysis due to complications of concurrent splenic and diaphragmatic injuries resulting in a spleno-pulmonary fistula.

A healthy 37-year-old man presented with severe abdominal pain 3 days after blunt abdominal trauma. Contrast-enhanced computed tomography (CT) of the thorax and abdomen showed an American Association for the Surgery of Trauma grade 3 splenic injury with a large subcapsular haematoma, intraperitoneal blood and ongoing intraparenchymal extravasation managed by successful angioembolization of the proximal splenic artery. The patient returned to the emergency department 5 weeks later with a three–day history of progressively worsening haemoptysis. A new CT showed an increase in the splenic haematoma with protrusion into the thorax and a diaphragmatic rupture. Thoracotomy identified a spleno-pulmonary fistula – the splenic haematoma was evacuated, a non-anatomic lung resection was performed and the diaphragmatic defect closed. Cultures from the splenic haematoma grew Cutibacterium acnes which was treated with intravenous antibiotics.

We report a unique complication of concurrent splenic and diaphragmatic injury with the development of a spleno-pulmonary fistula possibly due to infection of the splenic haematoma at the time of angio-embolization of the spleen. This case shows the importance of diagnosing diaphragmatic injuries promptly, adhering to sterile technique and considering giving prophylactic antibiotics before angio-embolization.