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. 2010 Feb 1;53(2 Suppl 1):1–24.

Trauma 2010

Trauma Association of Canada (TAC) Annual Scientific Meeting, The Marriot Halifax Harbourfront Hotel Halifax, NS, Thursday, May 6 to Friday, May 7, 2010

PMCID: PMC8993489
Can J Surg. 2010 Feb 1;53(2 Suppl 1):2.

Tertiary survey: for all trauma patients

R van Heest *, N Garraway †, N Lakha †, R Simons †

Background

Missed injuries occur in 9%–65% of trauma patients. Studies have demonstrated the benefit of a trauma tertiary survey (TS) in reducing medical errors. Our trauma service implemented a TS form, and we wanted to know if the beneficial effect of a TS was maintained.

Methods

Trauma patients with missed injuries were identified by the BC Trauma Registry over 3 periods. Separate chart reviews were performed to determine clinical significance of error and compliance with the TS form.

Results

A significant reduction in diagnostic delay and unacceptable errors was identified before and after implementation of a TS (see Table). Implementation of a TS form did not further reduce the error rate despite a 77% compliance rate. The 2 unacceptable errors in 2007 occurred when trauma patients were admitted to a nontrauma service and a TS was not completed.

Table.

Impact of a trauma tertiary survey on medical error

Medical error Time period; no. (%) incidence
1997 No TS (n = 453) 2004 TS no form (n = 430) 2007 TS with form (n = 394)
Diagnosis delay 28 (6.2) 8 (1.7) 7 (1.7)*
Diagnosis error 3 (< 1) 7 (1.6) 7 (1.7)
Total errors 31 (6.8) 17 (4) 14 (3.6)
Unacceptable errors 18 (4) 3 (< 1) 2 (< 1)*
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TS = trauma tertiary survey.

*

p < 0.05 (1997 v. 2007).

Conclusion

A TS reduces clinically significant diagnostic errors. Once a trauma service routinely performs a TS, the effect is long lasting. To improve patient safety, a TS should be routinely performed within 24 hours of admission regardless of the admitting service.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):2.

Bearing surfaces: Who gets what hip? A literature review

C Menakaya 1, B Ilango 1

Background

The hip is a ball-and-socket joint (bearing), and arthroplasty is one of the most common orthopedic procedures. The choice of material used in the bearing affects the long-term durability of the joint replacement. Current results show about 95% implant survival after 10 years, which further “technical development” will only marginally improve. The choice of bearing used is still controversial and most interesting in the field of hip replacement. Our aim was to determine how surgeons choose implants given the numerous implant designs available.

Methods

We carried out a literature review across the United Kingdom, Australia and Sweden to determine surgeon choice of implant used. We looked at implant choices in terms of sizes, availability and durability of implants and fixation techniques based on patient sex and age.

Results

Studies in Sweden showed that factors affecting implant choices are limited by the variables available and recorded in databases, with continued work on “case-mix” variables being of greatest importance. The study divided the outcomes based on age intervals, and all observations were reported by sex and causes of revision. Women under 50 years had poorer results than men; however, when diagnosis and other contributory factors in a regression analysis were adjusted, the sex difference disappeared. The results improved using cemented fixation for both sexes. A study in Australia revealed that differences in outcome were age related. In patients 75 years and older, cementless fixation had over twice the risk of revision compared with cemented or hybrid fixation. In patients under 55 years, there was no difference. In the United Kingdom, the choice of bearing surface is dependent on surgeon and implant design availability.

Conclusion

Choices are dependent on surgeon training, colleagues’ preferences, trust policies and implant costs. Age and sex also affect the patient-related outcome; however, none of the existing implants or methods of fixation has shown to be better in terms of implant survival.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):2.

Alcohol-related history in trauma patients

B Tsang *, J Mckee †, D Sutherland *

Background

The purpose of this research initiative was to investigate the quality of alcohol-related histories in adult major trauma patients (ISS > 12) with a positive blood-alcohol concentration (BAC).

Methods

A retrospective chart review was performed for patients admitted to the University of Alberta Hospital from June 1, 2008, to Aug. 31, 2008.

Results

Three (4.3%) patients (n = 70) did not have a BAC drawn on presentation, and of the 27 patients transferred from peripheral hospitals, 11 (40.7%) had no BAC available. Most charts contained histories that documented the use of alcohol before the traumatic incident; however, only 7 (10%) charts (n = 70) had clear documentation of the amount of daily alcohol use. Twenty-six (37.1%) patients (n = 70) did not receive any form of alcohol withdrawal prophylaxis. The 44 patients who did receive alcohol withdrawal prophylaxis received various combinations and doses of thiamine, folate, multi vitamin and benzodiazepines. Six (8.6%) patients (n = 70) were diagnosed with alcohol withdrawal syndrome, and 2 (33.3%) of these patients suffered from complications as a result.

Conclusion

This study demonstrates a clear gap in the way alcohol-related histories are obtained on trauma patients. More interestingly, a large portion of these high-risk patients were not given any form of alcohol-withdrawal prophylaxis at all. Changes in the current system are needed to address these problems to better prevent alcohol withdrawal syndrome and the associated mortality and morbidity.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):2–3.

Infrequent temperature monitoring in major trauma patients

D Al-Adra *, J Mckee †, G Hickey †, D Sutherland *

Background

Trauma patients are particularly susceptible to the development of hypothermia, which can cause increased metabolic demand, coagulation derangements and cardiac arrhythmias. During the resuscitation of trauma patients, temperature monitoring is imperative to prevent/treat hypothermia, potentially increasing survival.

Methods

Information was collected on all adult major trauma (ISS 12) patients admitted to the University of Alberta Hospital from January to March 2008. Data were analyzed to determine the incidence and severity of hypothermia and how patient temperature acquisition changes throughout the emergency department evaluation.

Results

Of 126 patients, 78 met inclusion criteria. About 50% of these patients had only 1 or 2 temperatures recorded during resuscitation, and 6% had none. Of the patients who had temperatures monitored, most were normothermic (61/70), and 9 were mildly hypothermic at presentation. In each of these 2 groups, 2 patients had temperature decreases during resuscitation. Subgroup analysis of hypothermic patients was attempted to determine when the temperature decreases occurred. However, this analysis was incomplete because of the lack of temperature monitoring.

Conclusion

Consecutive temperature monitoring of major trauma patients at the University of Alberta hospital occurs infrequently. Owing to the lack of data available, it is difficult to draw conclusions regarding how patient temperature changes during emergency department evaluation. In light of the infrequent monitoring, new Foley catheters with temperature probes are being phased in to use for trauma patients. With additional data, future analysis will determine when temperature changes occur and how they correlate to patient outcomes.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):3.

The impact of country and culture on end-of-life care for injured patients: results from an international survey

CG Ball *, P Navsaria †, AW Kirkpatrick ‡, C Vercler §, E Dixon ‡, J Zink §, KB Laupland ‡, M Lowe §, JP Salomone §, CJ Dente §, AD Wyrzykowski §, SM Hameed , S Widder **, K Inaba ††, JE Ball ‡, GS Rozycki §, SP Montgomery ‡‡, T Hayward *, DV Feliciano §

Background

Up to 20% of all trauma patients admitted to an intensive care unit die from their injuries. End-of-life decision-making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms and clinician experience. The purpose of this study was to better understand end-of-life processes following injury by comparing clinician viewpoints from various countries and cultures.

Methods

A qualitative, physician-based, 38-question international survey was used to characterize the effects of medical, religious, social and system factors on end-of-life care following trauma.

Results

A total of 419 clinicians from the United States (49%), Canada (19%), South Africa (11%), Europe (9%), Asia (8%) and Australasia (4%) completed the survey. In America, the admitting surgeon guided most end-of-life decisions (51%), when compared with all other countries (0%–27%). The practice structure of American respondents also differed from other regions. Formal medical futility laws are rarely available (14%–38%). Ethics consultation services are often accessible (29%–98%) but are rarely employed (0%–29%) and are typically unhelpful (< 30%). End-of-life decision-making for patients with traumatic brain injuries varied extensively across regions with regard to the effect of patient age, Glasgow Coma Scale score and clinician philosophy. Similar differences were observed for spinal cord injuries (age and functional level). The availability and use of “donation after cardiac death” also varied substantially between countries.

Conclusion

This is the first large study to compare the effect of geographic differences in religion, practice composition, decision-maker viewpoint and institutional resources on end-of-life care after injury. These disparities reflect competing concepts (patient autonomy, distributive justice, religion).

Can J Surg. 2010 Feb 1;53(2 Suppl 1):3.

Access to trauma systems in Canada

SM Hameed, N Schuurman, RK Simons, T Taulu, D Dyer, AW Kirkpatrick, JB Kortbeek, T Stelfox, M Stephens, S Logsetty, T Charyk-Stewart, A Nathens, S Rizoli, L Tremblay, F Brenneman, E Galbraith, N Parry, M Girotti, G Pagliarello, T Razek, N Tze, N Yanchar, J Tallon, A Trenholm, D Boone, U Hameed, O Amrau, M Berube, for the Research Committee of the Trauma Association of Canada

Background

Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. This study describes the current status of trauma systems in Canada and examines Canadians’ access to acute, multidisciplinary trauma care.

Methods

A national survey was used to identify the locations and capabilities of trauma centres across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of level 1 and level 2 trauma centres, and to define 1-hour road travel times around each trauma centre. Data from the 2006 Canadian census were used to estimate populations within and outside 1-hour access to definitive trauma care.

Results

Trauma centres and systems have evolved across the country in response to local health care, economic and geographic considerations. Whereas all Canadian trauma systems have established high standards for multidisciplinary trauma care, each is unique and faces distinct challenges. Access to definitive trauma care is high, with 77.5% of Canadians residing within 1-hour road travel catchments of level 1 or level 2 centres. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a level 1 or level 2 trauma centre, all are in rural and remote regions. Moreover, reasonable access to trauma care is limited to 5 provinces: British Columbia, Alberta, Ontario, Québec and Nova Scotia.

Conclusion

Access to high-quality acute trauma care is well established across parts of Canada, but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to prehospital care and acute trauma care in rural communities using locally relevant strategies.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):4.

Using Web 2.0 technologies for injury surveillance in low-resource settings

J Cinnamon *, N Schuurman *, SM Hameed †

Background

More than 90% of injury-related deaths occur in low- and middle-income countries (LMIC). Injury surveillance is rare in LMIC; thus, little is known about its causes, the spatial context or the populations at risk. Two traditional barriers to data collection and analysis are access to software and availability of trained personnel. With free and easy-to-use Web 2.0 technologies, there is the potential to develop injury surveillance systems that can be managed by existing staff in low-resource settings.

Methods

A pilot study was conducted in Cape Town, South Africa, in October 2008 to assess the feasibility of using Web 2.0 tools for injury surveillance. Epidemiological data were collected at a major hospital’s trauma unit. Free and simple Web 2.0 tools were used for all aspects of the study, including Google Spreadsheet for data entry and management and Google Earth for basic spatial analysis and visualization.

Results

Google Spreadsheet was useful for managing the collected data, particularly because it allows for multiple people to refine, edit and access the data set from any Web-enabled computer at anytime. Free online geocoding tools proved to be easy to use and reasonably accurate. Google Earth was useful for developing a basic geospatial analysis system for Cape Town.

Conclusion

The findings of the study suggest that Web 2.0 can facilitate streamlined data collection, management and visual analysis. This presents the possibility for hospitals with constrained resources to engage in injury surveillance. Overall, this exploratory study presents a step toward the development of injury surveillance systems that are appropriate for low-resource settings.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):4.

Injury surveillance in low and middle income countries: the Cape Town trauma registry

N Schuurman *, SM Hameed †, J Cinnamon *

Background

Injury is a major public health issue, responsible for 5 million deaths each year worldwide, equivalent to the total mortality caused by HIV, malaria and tuberculosis combined. The World Health Organization estimates that of the total worldwide deaths due to injury, more than 90% occur in low- and middle-income countries (LMIC). Despite the burden of injury sustained by LMIC, there are few, if any, continuing injury surveillance systems designed to collect and analyze injury data.

Methods

We developed a hospital-based trauma registry form, known as the Cape Town Trauma Registry (CTTR). A data capture pilot study at Groote Schuur Hospital in Cape Town was conducted for the month of October 2008 to demonstrate the utility and feasibility of systematic data collection and analysis and to explore challenges of implementing a trauma registry in a low-resource environment.

Results

Information collected during the pilot study included patient demographic details, spatial and temporal information, injury mechanism and type, patient vital signs, diagnostic and treatment information and patient outcome. A high rate of data capture was possible for most of the fields, although data capture rates for a small number was poor. Locations where injuries were sustained were aggregated to postal code areas to provide a simple visualization of areas with a high number of incidents. The cartographic evidence clearly pointed to the need for geographically specific intervention.

Conclusion

Evidence-based injury control, established by rigorous data collection, is urgently needed in LMIC. The CTTR, a trauma unit–based injury database, is a feasible strategy to describe the distribution and consequences of injury in a high-trauma volume, low-resource environment.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):4.

Occult pneumothoraces: Truly occult or simply missed? Redux

MS Brar *, L Kmet *, G Brunet †, S Nicolaou ‡, I Bains *, CG Ball *, KB Laupland §, AW Kirkpatrick *,§

Background

As the use of CT scans in the evaluation of trauma patients increases, pneumothoraces (PTXs) seen on CT but not on chest radiography (CXR), known as occult pneumo thoraces (OPTXs), are becoming more prevalent. The incidence of PTXs simply missed on CXR among OPTXs is unclear. A previous retrospective review of CXR images at our institution generally confirmed the occult versus missed designation, but lower-fidelity images may have biased this determination. We thus repeated this evaluation using the highest-quality images and improved methods.

Methods

Seventy DICOM-quality CXR images were randomly selected from 2 prospectively-collected trauma databases, including 22 normal, 5 overt PTX and 43 OPTX images. All CXR images were corroborated with multidetector CT imaging. Two blinded fellowship-trained radiologists reviewed and evaluated all the images on an IMPAX viewer.

Results

All images were deemed “adequate” except for 1 CXR scan by a single reviewer. For PTX diagnosis, agreement was 60% for overt PTXs, 86% for normal CXRs and 81% for OPTXs, yielding a kappa statistic of 0.51 (95% CI 0.22–0.81) and indicating moderate agreement. Considering only the cases where the reviewers agreed, 80% of the OPTXs were truly occult versus missed (95% CI 63%–92%). In the 7 missed PTXs, subcutaneous emphysema (4), pleural line (3) and deep sulcus sign (2) were detected.

Conclusion

We estimate that 80% of PTXs considered occult in the trauma room were truly occult. The most common missed sign was subcutaneous emphysema. Pneumothoraces are poorly assessed by CXR, and accurate diagnosis should focus on other imaging modalities.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):4–5.

Facts survey: FAST use among Canadian residents training in general surgery

L Dubois *,†, K Leslie *, N Parry *,‡

Background

A survey of all Canadian general surgery residents was conducted to determine the prevalence of focused assessment with sonography for trauma (FAST) training, the nature of the training and their level of comfort with the technique. The presence of potential barriers to FAST training was also assessed.

Methods

A cross-sectional survey of all 549 residents in 16 Canadian general surgery programs was administered using the Tailored Design Method between December 2008 and February 2009.

Results

With a response rate of 58.5% (321/549), the prevalence of FAST training among Canadian residents was 21.2% (68/321, 95% CI 17.2–25.2). The median number of practice exams completed was 5 (interquartile range 2–10.5), and the median number of patients examined was 11.5 (interquartile range 1.75–50). Only 38.8% of residents with FAST training felt comfortable with their FAST exams. Those residents who were comfortable had completed more practice and patient exams (median 12.5 v. 4, p = 0.001 and 30 v. 4.5, p < 0.001, respectively) when compared with those who were uncomfortable. Most residents (80%) indicated they would need 20 exams or more before they would feel comfortable with the technique. Residents with FAST training were more likely to be from a program that offered FAST training (54.5% v. 10%, p < 0.001) and were less likely to perceive a turf war with other specialties (emergency, radiology) over FAST use (29.9% v. 48.2%, p = 0.007) than residents without training.

Conclusion

Only 21% of Canadian general surgery residents surveyed have FAST training, and most remain uncomfortable with this technique. If FAST skills are to be expected of future surgeons, initiatives must be put in place to address barriers and improve training opportunities.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):5.

Is the Kampala Trauma Score a useful triage tool for North America?

H Gill *, M Rousseau *, J Ng *, R Boniface †, K Khwaja *, T Razek *

Background

In North America, trauma systems have been shown to improve outcomes after injuries. Different injury severity scores have been used for the purpose of triage; however, there is no gold standard. The Kampala Trauma Score (KTS) is a simplified score created for use in under-resourced areas. It accurately predicts death and hospitalization at 2 weeks in both low-and high-income countries. There are no studies looking at the KTS as a triage tool in resource-rich environments; however, one study proved it was not useful for triage in Uganda. We sought to determine if the KTS could be a useful triage tool in North America.

Methods

Patients older than 16 with ISS scores of 16–74 from blunt trauma at a Canadian urban centre from November 2005 to July 2008 were identified using a prospective database. Outcomes measured were mortality and hospitalization status at 2 weeks. The sensitivities and specificities of the KTS were calculated for all cutoff values using a receiveroperator curve analysis.

Results

A KTS cutoff of 13 was associated with a sensitivity of 90% and a specificity of 58% for predicting mortality. For hospitalization status, the KTS had a 69% sensitivity and 74% specificity. Higher cutoff values resulted in unacceptably low specificities, whereas lower cutoffs were associated with unacceptably low sensitivities.

Conclusion

The KTS is not an effective triage tool for North American. It is, however, a useful, simple method for gathering data for quality control and injury prevention efforts in under-resourced areas.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):5.

Thromboprophylaxis use and clinical outcomes after isolated traumatic brain injury

A Mamtani *, S Rizoli *, W Geerts †

Background

Patients with severe traumatic brain injury (TBI) have increased risk for venous thromboembolism (VTE). We assessed the relation between VTE and thromboprophylaxis in patients with severe, isolated TBI.

Methods

Patients admitted to our level 1 trauma centre between 2002 and 2008 with frank intracranial hemorrhage and Abbreviated Injury Scale (AIS) head scores 3 and greater were included. Patients with lower extremity or spine fractures were excluded. Demographics, admission Glasgow Coma Scale, ISS and AIS scores, type of intracranial hemorrhage, details on timing and modality of thromboprophylaxis, and proven VTE were gathered. We assessed possible predictive factors in patients with and without VTE.

Results

Among the 522 patients with isolated TBI, 17 (3.3%) developed symptomatic VTE during their acute hospitalization. Higher ISS (p = 0.005, OR 1.07, 95% CI 1.02–1.12) and older age (p = 0.017, OR 1.03, 95% CI 1.00–1.05) were independent predictors of VTE. Severity of the head injury (AIS head), type of intracranial bleed and admission GCS were not predictive. Thromboprophylaxis use was similar in both groups: most patients were prescribed thromboembolic deterrent stockings on admission (77% in VTE group v. 92% in non-VTE group). Low-molecular-weight heparin was the preferred anticoagulant (47% v. 46%), whereas low-dose heparin was prescribed occasionally (6% v. 9%). The mean delay from admission to initiation of anticoagulant prophylaxis in patients without VTE was 6.3 days versus 7.4 days in patients with VTE (p = 0.07).

Conclusion

Patients with TBI have a high risk of VTE despite the use of thromboprophylaxis. Higher ISS and older age were independent predictors of VTE in this group.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):5.

Spatial modelling of patient evacuation and allocation to definitive care in mass casualty situations

O Amram 1, N Schuurman 1, RK Simons 1, T Taulu 1, SM Hameed 1

Background

The survival or recovery of people critically injured in incidents involving mass casualties is directly related to their access to timely and appropriate treatment. The management of mass casualty evacuation priorities has been underexplored from a spatial perspective.

Methods

We have created a model for decision-making for evacuation and definitive care priorities. Using a geographic information system, the model incorporates hospital capacity in addition to injury type and severity as the basis for decisions about which patients are sent to which facilities. The model incorporates specialized hospital services and driving distances as key components. A flowchart based on decision trees is the basis for rules about evacuation and allocation to various facilities.

Results

The analysis and visualization associated with the model incorporates spatial network analysis as well as specialized algorithms for calculating travel times. Modelling complex evacuation priorities using a geographic information system enables the examination of different scenarios in multiple mass casualty circumstances at varying locations.

Conclusion

This tool will potentially assist emergency service personnel to optimize decision-making processes during critical stages of evacuation.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):5–6.

Are both obstructive uropathy and lower extremity compartment syndrome associated with pelvic compartment syndrome? Report of 2 cases and literature review

HP Huynh 1, B Felemban 1, B Lawless 1, R Meek 1, DR Brown 1, RK Simons 1

Background

Obstructive uropathy due to pelvic hematoma has been previously described, although, to our knowledge, it has not been previously linked to the secondary development of bilateral lower extremity compartment syndrome, nor to the need for urgent pelvic hematoma decompression. Our objective is to describe a new syndrome: pelvic compartment syndrome, comprised of obstructive uropathy and bilateral lower extremity compartment syndrome associated with massive retroperitoneal hematoma following traumatic pelvic ring disruption, unresponsive to decompressive laparotomy and requiring pelvic hematoma decompression.

Methods

We conducted a retrospective case analysis and literature review.

Results

Two patients sustained pelvic ring disruption after blunt trauma with resultant massive retroperitoneal hematoma. Subsequently, both developed compressive bilateral ureteral obstruction with anuria and symptoms of bilateral lower extremity compartment syndrome associated with iliac vein compression. Neither patient responded to decompressive laparotomy, both requiring surgical decompression of the hematoma after pelvic stabilization with on-table reversal of anuria and lower extremity compartment syndrome.

Conclusion

We describe a previously unrecognized syndrome: pelvic compartment syndrome due to massive retroperitoneal hematoma. Although the obstructive uropathy from distal ureteral compression has been previously described, the associated bilateral lower extremity compartment syndrome has not. We believe that this pelvic compartment syndrome, which may mimic abdominal compartment syndrome, may remain largely unrecognized. Surgical decompression of the pelvic hematoma remains the treatment of choice and not decompressive laparotomy, which has no therapeutic value.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):6.

Serum S100B levels in isolated head injury versus hemorrhagic shock patients: a randomized controlled trial

SB Rizoli *, SG Rhind †, PN Shek †, AJ Baker ‡, AD Romaschin ‡, WG Junger §, J Cuschieri , EM Bulger

Background

S100B is an established biomarker of traumatic brain injury (TBI) that is commonly used for assessment of primary and secondary insults and prognosis. Recent studies suggest extracerebral release of S100B, which may limit its prognostic utility in neurotrauma. We evaluated serum S100B in patients with isolated TBI, hemorrhagic shock (HS) or a combination of both.

Methods

This ancillary study of the Resuscitation Outcomes Consortium enrolled adult patients (n = 81) with severe TBI (Glasgow Coma Scale score ≤ 8) or HS (systolic blood pressure ≤ 90 mm Hg), receiving prehospital treatment of normal saline or 7.5% hypertonic saline ± 6% dextran 70. Blood samples were collected within 4 hours of injury for determination of S100B concentrations using electrochemoluminometric immunoassay (Elecsys 2010; Roche Diagnostics). Values above a cut-off of 0.105 μg/L−1 were considered abnormally high. Healthy participants (n = 25) served as controls.

Results

On admission, 95% of patients had significantly (p < 0.05) elevated levels (2.370 ± 0.313) of S100B compared with controls (0.012 ± 0.008). Isolated TBI patients displayed higher S100B (2.257 ± 0.299) than HS (1.656 ± 0.448), but peak S100B values were observed in the combined injury cohort (3.635 ± 1.047) (see Figure).

Figure.

Figure

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Levels of serum S100B in neurotrauma patients.

Conclusion

Our findings support the use of S100B to distinguish severe TBI from HS. Compared with isolated TBI, extracranial injury caused modest elevation of serum S100B, with the greatest increases in patients sustaining both insults, which may reflect the combined pathophysiology of severe tissue hypoxemia and hypotension and should be considered when S100B is used as biomarker.

Funded by Defence R&D Canada and NIH R01GM076101.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):6–7.

Emergency thoracotomy in the emergency department versus operating room: 17-year comparison in a level 1 trauma centre

EM Passos *, AC Amaral †, SB Rizoli *,†

Background

The outcome of emergency thoracotomy for trauma is a source of controversy. We hypothesize that survival rates are higher for thoracotomies performed in the operating room (OR) compared with those in the emergency department (ED).

Methods

The study reviewed 17 years of emergency thoracotomy for trauma at Sunnybrook. Only patients who had surgery for life-threatening injuries within 3 hours of admission were included. Univariate analysis was performed with χ2 for categorical variables and Student t tests for continuous variables. Adjustment was performed with logistic regression, forcing a model including both clinically relevant variables and statistically associated (p < 0.2) variables, if collected in more than 90% of patients; p < 0.05 was considered significant.

Results

Over the 17-year study period, 136 patients underwent emergency thoracotomy in the ED and 190 in the OR within 3 hours of admission. Survival was 2% (95% CI 0.5%–6%) versus 48% (95% CI 41%–55%), respectively (p < 0.0001). After adjusting for age, type of injury, time elapsed from trauma to hospital admission, prehospital arrest, ISS, hospital Glasgow Coma Scale score and thoracic injuries, OR thoracotomy remained associated with lower mortality compared with ER thoracotomy (ER thoracotomy odds ratio for death was 55 [95% CI 6–530]).

Conclusion

Our findings suggest that survival following ED thoracotomy is infrequent, whereas OR thoracotomy carries significantly lower mortality, even after adjustment for major differences. The retrospective nature of the study did not allow adjustment of all confounders, thus the conclusion should be interpreted cautiously.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):7.

Rural trauma teaching in Newfoundland: initial experience with the rural trauma team development course

AN Porte 1, MP Hogan 1, J Hapgood 1, DC Boone 1

Background

The goals of optimal rural trauma care include rapid assessment, diagnosis and intervention for life-threatening injuries and timely transfer to definitive care. The Rural Trauma Team Development Course (RTTDC) was developed by the Rural Subcommittee of the American College of Surgeons Committee on Trauma to foster these goals. This study assessed the initial value of RTTDC as an educational tool for hospital staff in rural Newfoundland, a province with twice the landmass of Great Britain and less than 1% the population.

Methods

The RTTD courses were conducted using rural hospital emergency departments for simulated clinical scenarios. Performance was evaluated by scoring team Situation Awareness Global Assessment Technique (SAGAT), pre- and postcourse written tests and post-course participant evaluation surveys (Likert 5-point scales).

Results

Three courses were completed (26 participants). The mean Likert score for the evaluation surveys was 4.56. Level 1 postcourse SAGAT scores showed 11% improvement (SD 23%); postcourse test scores improved 6% (SD 13%).

Conclusion

The RTTDC increased participant confidence in managing rural trauma as manifested by positive feedback and postcourse test improvement. Teamwork performance scores using team SAGAT improved after the course was completed. Indices of provider performance improved with this course. Further work will be necessary to determine if these changes will result in enhanced patient care.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):7.

Comparing thromboelastography and international normalized ratio: diagnosing Coumadin-induced coagulopathy in trauma

M Al Mahroos *, J Pacher Hoffmann *, S Scarpelini †, B Nascimento *, V Speers *, S Rizoli *

Introduction

Many trauma patients die of coagulopathy. The care of trauma patients on Coumadin is challenging, and early identification is crucial since drug-induced coagulopathy is reversible. Coumadin affects vitamin K–dependent clotting factors. Thromboelastography (TEG) has been proposed but scarcely investigated as a diagnostic test in trauma. We studied TEG and international normalized ratio (INR) values in diagnosing Coumadin-induced coagulopathy in trauma.

Methods

Posthoc analysis of a large observational study enrolling all adult trauma patients admitted to Sunnybrook between February and October 2007, undergoing TEG, INR and clotting factors (CF) assays. All patients with coagulopathy due to vitamin K–dependent CF deficit (< 50% activity), on Coumadin or not, were analyzed using TEG (TEG-R parameter) and INR (abnormal ≥ 1.3) to calculate sensitivity and specificity. Ongoing bleeding was recorded.

Results

Of 628 patients enrolled, only 8 used Coumadin: whereas only 7 had CF deficit, all had abnormal INR and TEG-R. Thirteen other patients not taking Coumadin had vitamin K–dependent CF coagulopathy: TEG-R diagnosed 10 (77%) and INR diagnosed 12 (92%). Thus, TEG-R has a sensitivity of 85% and specificity of 96.5%, whereas INR has a sensitivity of 90% and specificity of 94%. TEG-R did not identify any coagulopathic patients not detected by INR. All patients with bleeding were identified by both. Estimated time from sampling to results was similar for both: 45–50 minutes.

Conclusion

TEG-R is useful to diagnose Coumadin-induced coagulopathy in trauma. However, INR had better sensitivity and specificity and identified more coagulopathic patients. Since INR is universally available and less costly, adding TEG to identify Coumadin-induced coagulopathy is not justified by our findings.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):7–8.

Coagulopathy: a predeath event in traumatic brain injury

M Al Mahroos *, V Speers *, A Capone Neto *, L Tremblay *, H Tien *, S Scarpelini *,†, SB Rizoli *

Introduction

Traumatic brain injury (TBI) and bleeding are the leading causes of death following trauma. It is widely accepted that coagulopathy is common in TBI, caused by the release of tissue factor leading to systemic consumptive coagulopathy. We hypothesize that TBI is not associated with higher incidence of early coagulopathy; however, when present, TBI-associated consumptive coagulopathy is a predeath event.

Methods

We performed a retrospective chart review (January 2001 to December 2008) of all patients admitted to Sunnybrook within 6 hours of injury with severe isolated TBI (Abbreviated Injury Scale [AIS] head score ≥ 3 and nonhead < 2) or severe non-TBI trauma (AIS head < 2 and nonhead ≥ 3). Coagulopathy was defined as international normalized ratio (INR) greater than 1.3, activated partial thromboplastin time (aPTT) greater than 40 or a platelet count less than 150 × 109/L; consumptive coagulopathy was deteriorating coagulation tests with INR prolonging greater than 1.3 and platelets dropping below 150 × 109/L. Univariate analysis and logistic regression modelling included clinically relevant variables and statistically associated (p < 0.2) variables; p < 0.05 was considered significant.

Results

A total of 1696 patients met the inclusion criteria: 641 severe isolated TBI, 1055 severe non-TBI. Fewer TBI patients had coagulopathy on admission than non-TBI patients (6.6% v. 10%, p < 0.0359). Analyzing isolated severe TBI patients, those who died within 24 hours were significantly more coagulopathic than survivors. Consumptive coagulopathy was strongly associated with death (OR 75, 95%CI 10–566). In multivariate analysis, age, Glasgow Coma Scale score, ISS and abnormal INR, aPTT and platelet counts were independent predictors of death among TBI patients.

Conclusion

Patients with severe TBI do not have a higher incidence of coagulopathy compared with non-TBI patients. Coagulopathy is an independent predictor of death in severe TBI, in which TBI-associated consumptive coagulopathy is almost always a predeath event.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):8.

When minutes count: regional variations in transfer times of severely injured patients

D Gomez *, B Haas *, B Zagorski †, J Ray ‡, G Rubenfeld §, AB Nathens *

Background

As a result of geographic isolation and the pre-dominantly urban distribution of trauma centres (TC), not all injured patients can be transported directly from the scene to a TC. These patients receive initial care at nontrauma centres (NTC) and subsequently undergo transfer to a TC. Significant transfer delays exist, with a mean time at NTCs of 3 hours. We sought to evaluate whether there is regional variation in transfer times of injured patients.

Methods

A population-based data set was used to identify severely injured adults (ISS > 15), who were transferred from an NTC to a TC in Ontario (2002–2007). Emergency department length of stay at an NTC (ED-LOS) was calculated and aggregated at the census division level. Census division population density was used as a measure of rurality.

Results

There were 3476 patients transferred from 160 NTCs to 9 TCs across 48 census divisions. The median ED-LOS was 3.1 hours. There was significant variation across census divisions, with a range of median ED-LOS from 1.6 to 5.6. Spatial representation of the 90th percentile of ED-LOS identifies areas with significant challenges: the far north, both eastern and western borders and selected metropolitan areas (see Figure). There was a strong relation between rurality and ED-LOS, with the longest LOS in the most urban census divisions.

Figure.

Figure

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90th percentile emergency department length of stay at non trauma centres by census division.

Conclusion

Considerable delays before transfer were identified. Moreover, we identified significant disparities: ED-LOS at NTCs in the most urban census divisions was significantly longer than in the most rural census divisions. Availability of ED resources may be driving prolonged ED-LOS at urban census divisions.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):8–9.

Falls from height: injury characteristics and health care costs

MAM Tuma *, AI Al-Hassani *, J Acerra †, S Khoschnau *, J Recicar *, M Sebastian *, KI Maull *

Background

Falls from height account for 16% of injured patients and are second only to motor vehicle crashes as a cause of trauma deaths. In an effort to reduce this preventable injury, a study was designed to quantify both clinical characteristics and actual costs to the health care system.

Methods

During a recent 12-month period, all construction workers (n = 281) falling more than 3 m and requiring hospital admission were included. Seventeen died at the scene. Demographics, nationality, injuries by location and ISS, length of stay in intensive care and in hospital, resource use and costs were recorded. Actual costs were obtained using established methods.

Results

All patients were male and almost exclusively expatriate workers (97%). Average age was 33 years. The most common injury was to the spine, followed by the head and chest. Spine injuries were more commonly accompanied by permanent neurologic loss (7% v. 1% other causes). Mean ISS was 13. There were 12 additional in-hospital deaths (mortality 10%). Total acute care costs are cited in the Table.

Table.

Total acute care costs of falls from height

Acute care Cost, US$1000s*
Prehospital 123
Resuscitation room 82
Radiology and imaging 106
Operating room 130
Intensive care unit 496
In-hospital 3040
Rehabilitation services 434
Mean cost per patient 15 697
Total cost, US$ 4 410 000
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*

Unless otherwise indicated.

Conclusion

Falls from height at construction sites cause serious injury and place a significant burden on the health care system. Spinal injuries place the patient at risk for lasting neurologic impairment. Coordinated injury prevention efforts directed at reducing the risk of falls from building sites are warranted to reduce these preventable injuries.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):9.

Undertriage of major trauma: a population-based analysis

B Haas *, D Gomez *, B Zagorski †, TA Stukel †,‡, GD Rubenfeld †,§, AB Nathens *,†

Background

Undertriage of severely injured patients to non-trauma centres (NTC) leads to the potential for delays to definitive care, with estimates of excess mortality in the range of 40%. Accurate estimates of rates of undertriage are an essential component of ongoing quality assurance within a trauma system. In this study, we produced population-based estimates of undertriage in Ontario’s trauma system.

Methods

We performed a retrospective cohort study of severely injured adults presenting to an emergency department (ED) in Ontario (2002–2007). Severe injury was defined as ISS greater than 15 or death within 24 hours of presentation. Patient and injury characteristics, undertriage to NTC and subsequent transfer to a trauma centre were recorded.

Results

There were 19 541 patients who met the inclusion criteria, 3125 (16%) of whom died within 30 days of injury. Over half (56%) of the severely injured patients were initially undertriaged to NTC. Undertriaged patients were likely to be older, female, to have blunt injuries and to have a lower ISS. Seventy-one percent of undertriaged patients were never transferred to the NTC; 448 (4%) of undertriaged patients died in the ED of the NTC. Overall, 48% of deaths in the study period occurred at the NTC.

Conclusion

Undertriage rates in Ontario’s trauma system are significant. Factors that contribute to the high rates of primary and secondary undertriage in Ontario’s trauma system must be identified to improve access to trauma centre care.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):9.

Innovative assessment of injury burden in remote settings where there is no trauma registry

M Aboutanos 1, F Mora 1, L Wolfe 1, M Duong 1, R Ivatury 1

Background

To evaluate the usefulness of local aerial transport data to assess the burden of trauma and its appropriate management in remote settings where there is no formal injury surveillance system or trauma registry.

Methods

Aerial data were analyzed from 2 humanitarian flight companies servicing a remote region in the Amazon jungles of Ecuador (population of 11 000 inhabitants). The incidence of traumatic injuries warranting aerial transfer to traumatic centres, patient demographics, diagnosis, appropriateness and timeliness of transfer were assessed.

Results

Between January 2003 and December 2005, 12 510 fixed-wing flights were carried out in the region. There were 5716 aeromedical transfers. The average patient age was 20. The male to female ratio was 2:1. Trauma was the third highest reason for aeromedical transfer (1176 patients, 20%), after infection (1341, 23%) and respiratory disease (1229, 21%). Snake bites (356 cases, 30%) were the main reason for transfer of traumatic injuries. Other causes included fractures, burns and multiple injuries. In total, 50% and 26% of patients were under the age of 20 and 10, respectively. Flight time ranged between 36 minutes and 6 hours and differed by mechanism and site of injury, with head and neck, trunk, upper extremities and lower extremities averaging 101, 111, 72 and 68 minutes, respectively. Less than 50% of transfers were appropriate.

Conclusion

In remote settings where there is no effective injury surveillance system, innovative means to assess the burden of injury and promote basic health initiatives are feasible and may serve as the sentinel step for improved injury surveillance in remote areas.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):9.

Hypertonic resuscitation of traumatic brain injury attenuates cellular and molecular inflammatory and coagulation responses: a randomized controlled trial

J Ng *, NT Crnko *, AJ Baker †, LJ Morrison ‡, SB Rizoli *

Background

Traumatic brain injury (TBI) triggers widespread activation of leukocyte and endothelial cell–adhesion molecules and release of inflammatory mediators. Current TBI prehospital resuscitation focuses on optimizing cerebral perfusion and reducing secondary neuroinsults. Research suggests that hypertonic saline (HS), an effective osmotherapeutic agent in the management of intracranial hypertension, may confer neuroprotection through its immunomodulatory properties. We investigated the impact of prehospital HS on cellular and soluble inflammatory markers in severe isolated TBI.

Methods

A prospective randomized controlled trial of 65 adult patients with severe isolated TBI (Glasgow Coma Scale score ≤ 8), receiving prehospital 250 mL of 7.5% NaCl in 6% dextran 70 (hypertonic saline–dextran [HSD]) or normal saline (0.9% NaCl). Blood samples were drawn at 0, 12, 24 and 48 hours following fluid administration. Flow cytometry was used to analyze leukocyte cell surface adhesion (CD62L, CD11b) and degranulation molecules (CD63, CD66b). Enzyme-linked immunosorbent assays compared soluble L- and E-selectins, vascular and intercellular adhesion molecules (sVCAM-1, sICAM-1) and pro/anti-inflammatory cytokines (TNF-α, IL-10). Twenty-five healthy participants were controls. Neurological outcome was evaluated using the Glasgow Outcome Score (GOS).

Results

Patients treated with normal saline had a 2-fold higher surface expression of CD62L, CD11b and CD66b on both neutrophils and monocytes up to 48 hours. HSD blunted activation of adhesion molecules, degranulation, TNF-α and IL-10 levels at all time points, approaching control values. sVCAM-1, sICAM-1 and sE-selectin were reduced, whereas sL-selectin, initially lower, exhibited a delayed rise with HSD. HSD-reduced molecular marker expression was associated with better outcome (GOS).

Conclusion

This study suggests prehospital HS resuscitation of patients with severe isolated TBI has a potent anti-inflammatory effect and may confer neurologic protection.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):9–10.

Penetrating trauma in Nova Scotia: a 5-year review

A Beckett *, S Minor *, R Green †, J Tallon *,†

Background

Firearm injury in Canada has been called the “new public health issue.” In 1990, firearm-related deaths in young adults aged 15–24 years were the third leading cause of death in Canada. The epidemiology and demographics of penetrating trauma in Nova Scotia has not been studied.

Methods

Data were obtained by retrospective database review using the Nova Scotia Trauma Registry (NSTR) to identify all adults over age 16 who sustained penetrating trauma (ISS > 9) from Apr. 1, 2001, to Mar. 31, 2007. Demographic variables, temporal variables, injury characteristics, anatomic location of injury and type of weapon, initial vital signs, ISS, length of stay (LOS), number of days in the intensive care unit (ICU) and discharge status were evaluated. Volume, type of resuscitation fluid, type of imaging done and time to operating room were examined.

Results

In total, 350 penetrating trauma patients were reviewed; there were 176 deaths at the scene, 15 deaths in the emergency department (ED), 3 deaths in the operating room, 5 deaths in ICU and 1 on the ward. Predictors of prehospital mortality were age (OR 1.035, CI 1.016–1.054), rural location (OR 5.255, CI 2.645–10.444), gunshot wound (OR 14.837, CI 7.169–30.704) and intentionality (OR 37.819, CI 4.202–340.412). Predictors of inhospital mortality were age (p = 0.0226), gunshot wound (p = 0.0005), systolic blood pressure less than 100 (p = 0.0008), ISS (p = 0.001) and blood products given in the ED (p = 0.0001).

Conclusion

Penetrating trauma is major cause of mortality and morbidity in Nova Scotia, especially in rural areas. Predictors of prehospital mortality are age, rural location, gunshot wound and intentionality. Predictors of inhospital mortality are age, initial systolic blood pressure, ISS and blood products given in the ED.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):10.

Alcohol levels in pediatric trauma patients: a retrospective study

J Mckee *, H Austin †, S Widder †, I Bratu †

Background

In Canada, $3.3 billion in health care costs are associated with alcohol use each year, and 27% of patients admitted for alcohol-related injuries are between the ages of 10 and 24 years. Sixty-two percent of trauma deaths involving alcohol are related to motor vehicle collisions, and 30% of these involve minors. Sixty-two percent of 7–12th graders report drinking, 23% binge monthly, 16% drink weekly and 16% drink to hazardous levels. Global screening and brief intervention can decrease injury and alcohol recidivism in pediatric trauma.

Methods

Information was retrieved from the Alberta Trauma Registry on all pediatric (age 10–17 yr) major trauma (ISS ≥ 12) patients admitted to an Alberta trauma centre from January 2000 to December 2008. Data were analyzed to determine alcohol-level screening rate, prevalence of alcohol use in those screened, mechanism of injury and outcomes following trauma in Alberta.

Results

Of the 1672 patients who met the inclusion criteria, only 607 (36.3%) were screened for alcohol. Of those tested, 27.3% (n = 166) tested positive for alcohol use, with 70% (n = 116) being over the legal limit and 3% (n = 5) at lethal levels. There was no difference in age, sex, ISS or length of stay (LOS) between those who tested positive or negative for alcohol consumption. Of those tested, the median age was 16 years, median ISS was 25 and median LOS was 7 days.

Conclusion

The known risks associated with alcohol consumption such as violence, suicide and alcohol issues continuing into adulthood should be an impetus for standardized alcohol screening for pediatric trauma. Global screening and immediate focused education may decrease injury and alcohol recidivism in pediatric trauma.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):10.

Early traumatic coagulopathy is associated with coagulation factor deficiency and may not be detected by prothrombin time measurement

J Jansen *, S Scarpelini †, H Tien †, J Callum ‡, S Rizoli *,†

Background

Early traumatic coagulopathy, defined by prothrombin time (PT/international normalized ratio [INR]) greater than 1.4, is present in 25% of trauma patients and is associated with increased mortality. Recent studies suggest it is triggered by hypoperfusion and/or mediated by protein C, rather than coagulation-factor depletion. This study (1) examined changes in clotting factor activity, (2) determined the effects of critical deficiencies on transfusion requirements and mortality, and (3) compared the performance of PT/INR with coagulation factor activity.

Methods

We measured PT/INR and coagulation factors II, V, VII, VIII, IX, X, XI and XII activity in 151 trauma patients admitted to Sunnybrook within 2 hours of injury between February and October 2007. Differences in proportions were evaluated (χ2 tests). Associations were analyzed using product moment correlation coefficients.

Results

Factor activity correlated inversely with hypoperfusion (base deficit) but only weakly with injury severity. Stratification by adequacy of perfusion revealed significant differences for factors II, VII, IX, X, XI and XII, but not V or VIII. Reductions in factor activity below critical levels occurred in 27 patients (18%) and were associated with increased red blood cell (16.4 v. 5.7 units), frozen plasma (11.8 v. 5.4 units) and platelet (20.4 v. 9.3 pools) transfusions and mortality (26% v. 7%, p = 0.04). The sensitivity of INR greater than 1.4 in detecting factor deficiency was only 37%.

Conclusion

Most trauma patients have normal coagulation factors after trauma. Deficiencies relate to degree of hypoperfusion rather than injury severity, increased transfusion requirements and mortality. PT/INR is not sensitive in measuring clinically significant factor deficiency. Previous studies may have underestimated the prevalence of early traumatic coagulopathy.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):10–11.

Preliminary data from a new trauma registry in Colombia

CA Clarkson *, AM Rubiano †

Background

The global burden of trauma is high, and injuries are expected to continue increasing within low- and middle-income countries. Trauma registries are one tool used to help design injury-prevention strategies. At present there is no organized system of hospital-based trauma registries in Colombia.

Methods

Preliminary data are presented from a newly implemented trauma registry in Colombia.

Results

Data are provided on 2220 trauma patients. Average age was 30 years. Men accounted for 76% of trauma patients. Eighty-three percent of patients arrived by ambulance, with an average prehospital delay of 12 hours. Road traffic accounted for 26% of injuries. Fifty-nine percent of patients had extremity injuries, and 41% had head injuries. Interventions were carried out in 37% of patients. The overall death rate was 2%. Length of hospital stay averaged 2 days, with a maximum length of stay of 40 days.

Conclusion

Using the data from a newly developed trauma registry in Colombia, a number of areas have been identified to allow for targeted injury prevention strategies.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):11.

Missed injury in trauma patients: the utility of the tertiary survey in Alberta

K Haugrud *, J McKee †, K Fathimani *, S Widder *

Background

Technological and medical advancements have enhanced the care and survival of trauma patients. However, missed injuries still occur, increasing the morbidity and mortality from trauma. The tertiary survey examination that is performed within 24–48 hours of admission in an awake, alert patient includes: a head-to-toe physical examination, a review of laboratory work and radiology. As per the new Advanced Trauma Life Support guidelines, the tertiary survey should be used as “standard of care” in trauma. However, it has not yet been implemented in all major Canadian trauma centres. The purpose of this study was to determine the frequency and type of injuries that are missed on initial evaluation but are later picked up by the tertiary survey.

Methods

A retrospective chart review was performed for all major trauma adult patients who presented to the University of Alberta Hospital in Edmonton in 2009. The study compares the summary of injuries initially documented at the time of admission to those recorded on the tertiary survey assessment form.

Results

Data collection and analysis are currently underway. Preliminary results show a 30% rate of missed injuries, several of which are clinically significant, including a brachial plexus injury, aortic arch injury and cervical spine fractures.

Conclusion

Given the rate of missed injuries detected by the tertiary survey, the tertiary survey is important in preventing unnecessary morbidity to the trauma patient. Our data suggest that the tertiary survey be used at all major trauma centres, including Canadian sites.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):11.

Does screw orientation play a role in fracture fixation? A sawbone study using a transverse patella fracture model

M Boitano *, D Sherman †, C Bir ‡, F Baillie *

Background

The most common and challenging fracture of the patella for fixation is the transverse fracture. Recently, momentum is shifting from the traditional modified tension band technique using parallel K wires to parallel screw fixation using cannulated cancellous screws with a tension band construct (wire or suture). It is theorized that the orientation of the screws could directly affect the failure rate of the fixation technique. The objective of this study was to compare the traditional 0° parallel screw orientation to a 180° screw orientation.

Methods

The 4.5-mm cannulated cancellous screw was selected for testing from 3 manufacturers demonstrating 3 different designs. Homogenous polyurethane foam with a density compatible with the cancellous bone of the patella was cut into blocks, and a transverse fracture was created. The blocks were tested in tension and 3-point bending.

Results

The TriMed screw had the highest load to failure with a mean tensile load of 1465 (SD 161) N at 0° and 1435 (SD 155) N at 180°. Regarding 3-point bending, the Acutrak screw had the highest mean compressive load for crack initiation of 670 (SD 139) N at 0° and 715 (SD 157) N at 180° (see Table).

Table.

Strength of 3 different 4.5-mm cannulated cancellous screws in tension and 3-point bending

Screw manufacturer Load; mean (SD) N
0° Tension 180° Tension 0° Bending 180° Bending
Acutrak 1341 (263) 1392 (83) 670 (139)* 715 (157)*
Synthes 1037 (52)* 917 (115)* 529 (87) 432 (133)
TriMed 1465 (161) 1435 (155) 613 (92) 460 (144)
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*

p < 0.05 between 0° and 180° orientation.

Conclusion

The data relflect screw design, as screw fixation depends on the purchase of threads in the cancellous bone of the patella.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):11.

Evaluating the impact of AIS 2005 on the population of the Ontario Trauma Registry comprehensive dataset

M Brennan-Barnes *, A Nathens †, A Moses McKeag ‡, S Chandra ‡

Background

Since its inception, the Ontario Trauma Registry (OTR) has been using the Abbreviated Injury Scale (AIS) 1990 to code injury severity. The AIS 2005 is the most recent version. The purpose of this study was to evaluate the impact of the AIS 2005 on the population of the OTR Comprehensive Data Set (CDS). Inclusion into the OTR requires an Injury Severity Score (ISS) 13 or greater.

Methods

Trauma records were coded using AIS 2005 and 1990 at 11 Ontario trauma centres by trained coders using coding software by Digital Innovations Inc. A staggered implementation of the dual coding occurred beginning in April 2008. Data between April 2008 and June 2009 were analyzed.

Results

Sixty-two percent (2713) of the 4366 records were coded in both AIS 2005 and AIS 1990; 29% had an equal ISS in both systems. The concordance of cases with an ISS of 13 or greater in AIS 1990 and 2005 was 85% (417 cases with AIS 1990 ≥ 13 had AIS 2005 < 13). Cases with an AIS 2005 of 13 or greater were more likely to require a special care unit stay (p = 0.0003), have a longer hospital stay (p = 0.0959) and a higher mean ISS score (p < 0.0001) than those in the group with an AIS 1990 of 13 or greater.

Conclusion

The AIS 2005 appears to more accurately reflect the severity of the injured patient. The adoption of the AIS 2005 coding in the OTR CDS will exclude 15% of trauma patients presently included in the registry. Decreasing or eliminating the ISS value as criteria for inclusion in the OTR CDS should be considered.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):11–12.

Medicine versus surgeons/anesthesia intensivists: a comparison of outcome in trauma patients admitted to a mixed medical–surgical–trauma intensive care unit

J Lee 1, S Iqbal 1, A Gursahaney 1, T Nouh 1, T Razek 1, K Khwaja 1

Background

In a tertiary-level intensive care unit (ICU), it is common to have intensivists with core training in internal medicine, surgery or anesthesia. In a mixed medical–surgical–trauma ICU at the Montreal General Hospital, trauma patients are cared for by intensivists with different core background training, all with critical care fellowships. We hypothesized that there should be no difference in patient mortality with respect to the core training of the intensivist.

Methods

Using an electronic database, we conducted a retrospective study of all trauma patients admitted during a 1-year period to a 22-bed mixed ICU. Patients were assigned to 1 of 2 treatment groups based on the treating intensivist’s training background, group A being internal medicine and group B being surgery/anesthesia. Allocation was conducted in 2 ways: intensivist treating the patient over 50% of the ICU length of stay (LOS) and over 50% of the first 72 hours in ICU.

Results

In total, 395 trauma patients were admitted from Jan. 1 to Dec. 31, 2007, with 34 deaths. We found no significant difference in mortality between groups when allocating patients to group based on the treating intensivist’s background over 50% of LOS (HR 1.59, 95% CI 0.73–3.49, p = 0.2469) or over 50% of the first 72 hours in ICU (HR 1.39, 95% CI 0.66–2.94, p = 0.3861).

Conclusion

In a large university trauma centre that operates a mixed medicine–surgical–trauma intensive care unit, there was no significant difference in mortality rates for trauma patients managed by either intensivists with core training backgrounds in internal medicine or in surgery/anesthesia.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):12.

Complete reversal of anuric renal failure after operative evacuation of extraperitoneal hematoma induced abdominal compartment syndrome

PB McBeth *, AW Kirkpatrick *,†

Background

With the growing use of anticoagulation therapies, spontaneous hematoma formation within the extraperitoneal abdominal spaces are increasingly being recognized from the entities of both retroperitoneal and rectus sheath bleeding. Overt abdominal compartment syndrome (ACS) is a rare but devastating complication of extraperitoneal compression of the intra-abdominal space in such cases as retroperitoneal hematoma (RH) or rectus sheath hematoma (RSH). Classically, both RH and RSH are managed conservatively, with operative intervention discouraged.

Methods

A retrospective review of 2 cases involving the operative evacuation of the extraperitoneal compression on the intra-abdominal space resulting in an ACS with overt renal failure are presented. A comprehensive review of the literature using PubMed was conducted.

Results

Despite the rarity of recognized ACS from extraperitoneal hematoma, limited precedents exist to support both operative intervention after correction of the coagulopathy. Two cases of extraperitoneal hematoma–induced ACS responded dramatically and completely to operative decompression and evacuation of the extraperitoneal space. Both patients were anuric, requiring renal replacement therapy pre-operatively, but had complete reversal of renal function post-operatively, as well as significantly improved pulmonary functions (see Figure).

Figure.

Figure

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Intra-abdominal pressure and renal function response to abdominal decompression.

Conclusion

Abdominal compartment syndrome is a rare but completely reversible complication of both RH and RSH. Organ failure such as anuria should not be accepted as inevitable, however. Patients with large RH or RSH should have intra-abdominal pressure monitoring and aggressive operative drainage after correction of the coagulopathy.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):12–13.

All-terrain vehicle injuries in Alberta

JS Pelletier *, J McKee †, D Paton-Gay *, S Widder *

Background

The growing popularity of all-terrain vehicles (ATVs) is a serious risk to our society. It has been argued that because of their inherent instability, increasing speed and power and complexity of operation, ATVs are more difficult to operate than automobiles. In spite of this and the numerous papers published advocating further legislation, there is a lack of regulations regarding their use.

Methods

The objective of this research project was to study the frequency, severity and nature of injuries sustained on ATVs in Alberta. Secondary objectives include correlation between helmet use and injury pattern/severity, and injury, mortality and helmet use in the pediatric population.

Results

In total, 435 patients met our inclusion criteria: 81.6% were male (average age 33.2 yr, average ISS 22.8). Overall mortality was 4.6%, and 54.6% of the patients were not wearing helmets. The primary reason for death was closed head injury (85%). Helmet use was also associated with a lower risk of intubation (15.9% v. 26.0%) and injury to the head and/or c-spine (45.5% v. 72.1%). The pediatric population accounted for 18.9% of all patients as well as 15% of the deaths in this study.

Conclusion

Use of ATVs in Alberta carries a significant risk of injury and of mortality. Most of the deaths were associated with a lack of helmet use. We propose making helmet use mandatory during the use of an ATV as well as increasing the minimum age of use to at least 16 years of age.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):13.

Ten years of all-terrain vehicle injury, mortality, and healthcare costs in Alberta

EM Krauss *, R Buckley †, DM Dyer §, K Laupland ‡

Background

All-terrain vehicles (ATVs) have increased in popularity in Canada over the past 10 years. The province of Alberta accounts for 25% of all ATV sales in the country. The popularity of ATVs is accompanied by a pattern of significant injury and mortality. This study describes a decade of ATV injury and mortality in the province of Alberta.

Methods

Data were obtained from the Alberta Trauma Registry and the Office of the Chief Medical Examiner of Alberta. Individuals aged 18 years and older who suffered injuries with an injury severity score (ISS) 12 and over or died in ATV incidents in Alberta between Apr. 1, 1998, and Mar. 31, 2008, were included in the analysis. Descriptive statistics included individual, injury and incident demographics. Costs were extrapolated from figures for the Foothills Medical Centre, Calgary, a subset of the total population.

Results

ATV trauma primarily affects males aged 18–55. Twelve percent of patients wore helmets, and 23% were intoxicated at the time of injury. Incidents commonly occurred on weekends during summer months. Alcohol use, riding without helmets and travel on unfamiliar terrain were common factors in fatal ATV incidents. Injuries or cause of death were primarily head, c-spine and thoracic injuries. The estimated 10-year cost of ATV injury exceeded Can$5 million.

Conclusion

ATV trauma is a disease of young people. Despite recent publicity on the dangers of ATVs, people continue to ride without protective equipment and under the influence of alcohol. ATV injury and mortality represent significant and preventable health care costs and years of life lost.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):13.

Does the presence of a dedicated trauma surgeon as trauma team leader influence the time to CT scan for serious head injuries?

A Rados *, K Stevenson *,†,‡, K Musselwhite *, C Vis *, D Zygun ‡, VA Ciura §, B Matiakis *, AW Kirkpatrick *,†,‡

Background

Serious head injuries constitute the leading cause of posttraumatic mortality. Practically, the major interventions required to treat serious head injuries require expedited transfer for computed tomography (CT) scanning after ruling out other immediately life-threatening conditions. At our centre, trauma responses variably consist of either full activation (FA) with trauma attendings or a nonsurgical surgical response (NSR). With continuing human resource restrictions, we sought to clarify whether FAs expedited the time to CT head (TTCTH).

Methods

Chart review augmented demographics of 88 serious head injuries identified from a regional trauma database.

Results

There were 58 FAs and 30 NSRs; 91% of FAs and 17% of NSR were intubated before hospital admission. Although FAs were more seriously injured (mean ISS 32), NRSs were still severely injured (mean ISS 25, Abbreviated Injury Scale [AIS] head score 20) and older (median 54 v. 26 yr). Median TTCTH was double without dedicated FA (median 26 v. 53 min, p < 0.001), despite similar justifiable delays (48% FA, 53% NSR). Without FA, most delays (69%) were for emergency room intubation after which TTCTH was longer (median 33 v. 16 min). After definitive airway control, TTCTH were 25 versus 33 minutes for FA. With FA, delays were for chest tubes (32%), intubation (21%) and administration of blood products or pressors (7%).

Conclusion

Full trauma activations involving attending surgeons were quicker at transferring serious head injuries to CT. Patients with FA were younger and more seriously injured. Discerning the reasons for delays to CT should be used to refine protocols aimed at minimizing unnecessary delays and maximizing workforce efficiency.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):13–14.

A tertiary hospital alcohol screening/intervention program: preliminary results

R Saybel 1, J Mckee 1, G Hickey 1, K Kostiuk 1, I Brown 1, M Stephens 1

Background

Our tertiary hospital commenced an alcohol screening/intervention program in 2008. Severely injured patients were to have alcohol (ETOH) levels measured on admission. All patients were asked to participate in a screening process. The AUDIT tool, created by the World Health Organization, was used as a screening tool for alcohol abuse/addiction. Based on AUDIT scores, patients were informed of their alcohol risk and provided with an interventional pamphlet.

Methods

Over 9 months, 1032 patients were screened; 376 surveys were completed (36%). Patients were not captured for the following reasons: discharged 50% (329), no ETOH drawn 10% (65), transferred 11% (74), missed 9% (60), deceased 7% (49), low Glasgow Coma Scale score 4% (24), refused 4% (23) and miscellaneous 5% (32).

Results

Audit screening results were completed for 36% of (376) patients. Of these, 119 (32%) had no ETOH drawn. Of the remaining 257 where ETOH was drawn, 162 (63%) had an ETOH level of 0. ISS was only captured if greater than 12 (see Tables).

Conclusion

Population-based studies suggest a mean AUDIT score in alcoholic patients of 26.68 (SD 8.39) and 3.79 (SD 3.60) in controls. For our severely injured patients, those whose ETOH was positive had a higher AUDIT score than those whose ETOH was negative on presentation. There was a trend to higher presenting ETOH levels among those with higher AUDIT scores.

Table 1.

AUDIT completed

Characteristic ETOH positive (n = 95) ETOH negative (n = 162) p value
Age, mean yr 35.2 39.4 0.02
ISS 21.3 (66/98) 20.9 (78/162) NS
Male 86 (89) 127 (78) 0.02
ETOH level, mean 37.9 0
AUDIT score, mean 16 5.9 < 0.001
Open in a new tab

ETOH = alcohol; NS = not significant.

Table 2.

AUDIT score

Level of risk No. No. (%) Mean ETOH
ETOH drawn ETOH positive
Severe risk (20–40) 46 36 (78) 28 (78) 44
High risk (16–29) 28 19 (68) 14 (74) 43
At risk (8–15) 105 72 (69) 38 (53) 37
Low risk (1–7) 150 103 (69) 14 (14) 24.2
No risk (0) 47 27 (57) 0 0
Open in a new tab

ETOH = alcohol.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):14.

Maximizing resources in a trauma research environment

V Speers 1, SB Rizoli 1

Background

Trauma research is challenging for study teams, as patients present at anytime of the day, often when resources do not match the needs of studies. Our previous work has shown challenges with off-hour admissions, peak admissions over summer holidays and decreased level of consciousness in patients, which impacts the informed consent process. To further address research challenges, this study investigates weekday versus weekend admissions and Injury Severity Score (ISS), which might ultimately impact appropriateness for enrollment.

Methods

Information from the Sunnybrook Trauma Databank was retrospectively reviewed from Jan. 1, 2007, to Dec. 31, 2007, for the number of trauma admissions on each day of the week and the ISS of each patient according to time of admission. The mean number of admissions was used for each day of the week. The mean ISS was used to describe the severity of injury across 3 time periods of the day: daytime (08:00–15:59), evenings (16:00–23:59) and nights (24:00–7:59).

Results

Retrospective analyses of 1115 patients established that trauma admissions tend to be uniform throughout the week (Monday–Friday), with an increased number of cases on weekends (Saturday–Sunday). ISS confirmed that all patients had an ISS of 16 or greater, meeting the established medical score of polytrauma.

Conclusion

Resource allocation and availability should be focused during the afternoon and evening period for both weekday and weekend cases. In addition, all trauma admissions met the established medical score of ISS of 16 or greater, making them a polytrauma, and thus suitable to evaluate for enrollment into trauma research investigations.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):14.

Irrespective of mechanism or time of day, most severe traumas occur close to home

CD Rogers *, A Phillips *, FD Brenneman *,†, LN Tremblay *,†

Background

Most trauma centres were designated decades before recent epidemiologic shifts (e.g., increasing numbers of penetrating trauma and elderly patients). Although insurance companies state that most car collisions occur close to home, we found no reports as to whether this applies to severe trauma and all other mechanisms of injury (MOI). Given the important implications for injury prevention programs/trauma systems, we explored whether most urban severe injuries occur near home irrespective of time of day or MOI.

Methods

We performed a retrospective study of patients from the greater Toronto area (6157 km2) seen by Sunnybrook Trauma from April 2008 to March 2009 for whom the registry contained scene and residence data. Data analyzed included patient demographics, MOI, day/time of injury, daylight or darkness (from National Research Council of Canada), injuries sustained and outcomes. Data are presented as mean (SD) or median (25th, 75th percentiles).

Results

578 patients (41 [SD 21] yr, 26% female, 29% penetrating trauma, 16% pedestrians, 19% falls, ISS 20 [SD 14], 11% mortality) met the inclusion criteria. Interestingly, most traumas occurred close to home with an exponential decrease in trauma with greater distances, irrespective of time of day, day, month, presence/absence of daylight or MOI. This pattern was most pronounced for burns and falls. Women were also injured closer to home than men (median 1.4 v. 3.2 km, p < 0.05). Overall, the median distance of injury from home was 3 km (0, 11), one fourth the distance from scene to Sunnybrook.

Conclusion

Trauma systems and prevention programs must consider population shifts, particularly for injuries that are rapidly fatal, as most severe traumas occur close to home.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):14.

Outcomes of elderly trauma patients admitted to the intensive care unit

KN Vogt *, M Swart *, T Charyk Stewart *,†, M Girotti *,†, D Gray *,†, N Parry *,†,‡

Background

To determine the mortality in elderly trauma patients admitted to the intensive care unit (ICU) and explore factors associated with mortality. Particular attention was paid to the relation between preinjury anticoagulation and mortality.

Methods

A retrospective cohort of all elderly (age ≥ 70) trauma patients admitted to the ICU from 1997 to 2008 was identified. Data were obtained from the London Health Sciences Centre trauma database. Therapeutic international normalized ratio (INR) levels on admission (INR ≥ 2.0) were used to identify preinjury therapeutic warfarin use.

Results

Of the 906 elderly patients admitted after trauma, 248 were admitted directly to the ICU. Patients had a mean age of 79 years (SD 5.6) and a mean ISS of 26 (SD 11.2). Overall mortality was 50% (124 patients), with a mean time to death of 8 days. Univariate analysis identified increased mortality among patients with therapeutic INR (49% v. 69%, p = 0.04). Logistic regression identified the following factors associated with mortality: age (OR 1.08, 95% CI 1.02–1.14), ISS (OR 1.06, 95% CI 1.03–1.09), INR (OR 5.13, 95% CI 3.86–6.40) and need for operative intervention (OR 2.37, 95% CI 1.72–3.02). Among patients who survived, only 27 (10.9%) were discharged home.

Conclusion

In contrast to the overall elderly population, elderly patients requiring admission to the ICU after trauma have high mortality and morbidity rates, with very few patients returning home. This study highlights the importance of therapeutic anticoagulation as a predictor of mortality. With the rising proportion of elderly patients, strategies will be required to manage the burden of injury in this population.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):15.

Determinants of inferior vena cava filter insertion in trauma: retrospective cohort study

J Yan *,†, A Karamaoun *,†, E Villeneuve *, T Razek ‡, MM Perreault *,†

Background

The trauma population is at high risk of thromboembolism and bleeding. Availability of retrievable inferior vena cava (IVC) filter and lack of evidence-based guidelines leads to variable practice. This study aimed to describe such variability and investigate determinants of their insertion.

Methods

Trauma patients admitted over 3.5 years who satisfied our inclusion criteria (age ≥ 18, ISS ≥ 15, head injury and/or spinal cord injury and/or pelvic fracture and/or multiple long bone injuries and/or thoracic injury) comprised 1595 patients. Patients with an IVC filter were selected (IVC group) and a comparative cohort was randomly selected (2:1 ratio of controls:IVC). Data collected underwent univariate analysis followed by multivariate logistic regression to determine predictors of filter insertion.

Results

Demographics of the IVC group (n = 103) and control group (n = 192) were compared. The IVC group was significantly younger (42.8 yr), had a greater number of injuries, greater maximum Abbreviated Injury Scale (AIS) score of 5 and over (60.2%), more shock on admission (8.7%), required intensive care unit (ICU) admission (98.1%), intubation (88.4%) and 4 or more transfusions of packed red blood cells (27.2%) over the first day more frequently than controls. Nine variables from univariate analysis were selected for identifying determinants of filter insertion. Multivariate regression analysis revealed that the number of injuries, maximum AIS score, type of injury with maximal AIS score, number of transfusions over 3 in the first day, admission to ICU and need for intubation were such determinants.

Conclusion

The number and severity of injuries, the need for transfusions, intubation and ICU admission were significantly associated with filter placement.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):15.

Hypertonic resuscitation reduces catecholamine and troponin release after severe traumatic brain injury

AN Capone *, SG Rhind †, AJ Baker ‡, PN Shek †, LJ Morrison §, SB Rizoli *

Background

Severe traumatic brain injury (TBI) elicits profound sympathetic nervous system activation with enhanced release of catecholamines, which can impact upon cardiovascular and inflammatory responses and patient outcome. Hypertonic fluids improve cerebral hemodynamics and may blunt catecholamine release following TBI. We examined the effects of prehospital resuscitation with hypertonic saline of severe TBI on catecholamine and cardiac troponin-T (cardiac TnT) release, within a larger prehospital randomized controlled trial.

Methods

Sixty-five adult severe TBI patients were randomized to a 250-mL infusion of 7.5% hypertonic saline in dextran-70 (HSD) or normal saline (NS). Plasma epinephrine (E), norepinephrine (NE) and dopamine (DA) concentrations (pg/mL) were measured on admission, at 12 hours and at 24 hours. Cardiac TnT was also measured on admission. Twenty-five healthy volunteers served as controls.

Results

On arrival, mean E (665.3, SD 188.2) and NE (671.6, SD 85.2) were significantly higher in all patients compared with controls. NS patients massively released E (1082.7, SD 291.3, up to 30 times more than controls) and NE (823.7, SD 124.8). HSD patients had slightly elevated E (195.8, SD 60.1) and NE (500.5, SD 85.9), which normalized by 12 hours. In NS-treated patients, catecholamines remained elevated. cardiac TnT concentrations significantly correlated (p = 0.0002) with the injury severity. Those who died had significantly higher concentrations of catecholamines and cardiac TnT than those who lived. The NS-resuscitated patients who died had the highest cardiac TnT concentrations, whereas the lowest concentrations were evident in surviving HSD patients.

Conclusion

Our study confirms that catecholamine levels can be used as prognostic biomarkers in severe TBI and suggests that HSD may be a better resuscitation fluid for TBI, in part because of its significant attenuation of injury-induced catecholamine release. Funded by Defence R&D Canada.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):15.

Fragility fractures: an audit of posttraumatic osteoporosis management

SS Goonewardene 1, K Mangat 1, ID Sargeant 1, K Porter 1

Background

Fragility fractures are an increasingly common problem, especially in the elderly population, and may indicate underlying pathological processes (e.g., osteoporosis). It is estimated that 1.2 million women in the United Kingdom have osteoporosis. National Institute for Health and Clinical Excellence (NICE) guidelines recommend specific investigation and treatment options for the secondary prevention of osteoporotic fragility fractures. However, these guidelines, even though present, are not closely followed. We wished to investigate our compliance level with these recommendations and if necessary propose changes to increase compliance.

Methods

We conducted a retrospective audit collecting data on patient demographics; prior osteoporosis history and treatment; investigations, diagnosis and treatment of osteoporosis during hospital admission, communication of information to general practitioners (GPs) and refracture rate to see whether we are complying with these guidelines.

Results

We demonstrated that the majority of patients are admitted without a history of osteoporosis or treatment regardless of primary osteoporosis guidelines, yet we are not properly investigating or treating patients for secondary prevention of osteoporotic fractures or adequately informing GPs to do so, with refractures occurring.

Conclusion

We discuss these results and develop recommendations based on the results including changes to the patient information computer system that would increase medical professionals’ compliance with guidelines and reduce the risk of refracturing, reducing strain on resources.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):15–16.

Hip fracture surgery: an audit of blood product use

SS Goonewardene 1, K Mangat 1, ID Sargeant 1, K Porter 1

Background

Hip fragility fractures are common, with over 364 admitted over the past year to University Hospital Birmingham, NHS Foundation Trust. Different types of implants are use to correct this injury (e.g., dynamic hip screws, hemiarthroplasties and AO screws). There are mixed guidelines available nationally for blood product order for these procedures, resulting in wastage of resources, delays to surgery and increased morbidity and mortality. We aimed to determine current practice of blood product ordering and usage in hip fracture surgery and to develop guidelines for preoperative blood product ordering according to type of hip implant used and preoperative hemoglobin.

Methods

A retrospective review of 84 cases was carried out after gaining audit registration within the trust. Information on demographics, surgical procedure, pre- and postoperative hematology, blood product ordering and usage was collected.

Results

We demonstrated that the most common fixation method is with dynamic hip screws. Over-ordering of blood for both dynamic hip screws and hemiarthorplasties occurred (cross-match to transfusion ratio 1.74). These 2 types of hip replacement also had the highest rate of blood loss. The majority of patients in each category of hip implant were grouped and saved preoperatively with a large proportion requiring conversion to cross-matching.

Conclusion

We discuss these results, comparing them to other studies and with the results available, develop new guidelines for blood product ordering based on preoperative hemoglobin and type of hip implant used, that can be used on a national basis.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):16.

Causes of death in Canadian Forces members deployed to Afghanistan

D Pannell *,†, HC Tien †,‡

Background

In January 2006, the Canadian Forces (CF) initiated its combat operations in Kandahar, Afghanistan. We studied the causes of deaths sustained by the CF during a 28-month period. The purpose of this study was to identify potential areas for improving tactical combat casualty care (TCCC).

Methods

We analyzed autopsy reports of Canadian soldiers killed in Afghanistan between January 2006 and April 2008. Demographic characteristics, ISS, location of death within the chain of evacuation and cause of death were determined. We also determined whether the death was potentially preventable using both explicit review and implicit review by a panel of trauma surgeons.

Results

During the study period, 73 Canadian Forces members died as a result of service in Afghanistan. Their mean age was 29 (SD 7) years, and 98% were male. The predominant mechanism of injury causing death was blast injury, resulting in 81% of overall deaths during the study period. Gunshot wounds and non–improvised explosive device–related motor vehicle collisions were the second and third leading mechanisms of injury causing death. The mean ISS was 57 (SD 24) for the 63 autopsy reports analyzed. The most common cause of death was hemorrhage, followed closely by neurologic injury and then by blast injuries. Panel review identified several interventions that are not currently part of TCCC that may prevent future battlefield deaths.

Conclusion

The majority of combat-related deaths occurred in the field. Comparatively few deaths were preventable with current TCCC interventions. We propose novel TCCC interventions to prevent deaths of soldiers engaged in Afghanistan.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):16.

Taking the fall: a population-based study of children falling from buildings

DA Davies *, A Mikrogianakis †, Y Lyratzopoulos ‡, P W Wales §

Background

During the summer of 2007, much media attention was paid to events of children falling from buildings. Unintentional falls from windows or balconies have not previously been investigated in Canada. Our purpose was to determine their incidence in Ontario children and identify high-risk populations.

Methods

A population-based, retrospective cohort study was conducted using the Ontario Trauma Registry. The records of all children (1–16 years old) admitted to hospital with injuries resulting from falling from buildings between 1994 and 2004 were analyzed. Poisson regression analysis was used to determine trends in incidence and the incidence rate ratios of independent risk factors.

Results

In total, 1007 children were admitted to hospital after falling from a building during the 11-year study period (mean age 7.6, SD 4.7 yr). Most were boys (n = 702/1007, 69.71%) and the majority of falls occurred in urban communities (823/983, 84.00%). Children of low socio-economic status (SES) were found to be at higher risk (IRR 1.85, 95% CI 1.61–2.17, p < 0.001). The age-standardized, mean-annual incidence was 3.93 per 100 000 person years (95%CI 3.70–4.17). This decreased throughout the study period from 4.9 to 2.4 per 100 000 person years (p < 0.001, 95% CI 3.24–7.30 and 1.18–4.90, respectively). Urban children and those of low SES did not experience as great a reduction.

Conclusion

Building falls in Ontario children remain a substantial cause of preventable morbidity and mortality. This is especially true among children of low SES, who should be the focus of future prevention programs.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):16–17.

Reducing response times to major trauma: Autolaunch of helicopter emergency medical services in British Columbia

S Wheeler *, R L’Heureux †, K Danielson ‡, N Lhaka §, R Simons

Background

Autolaunch of helicopter emergency medical services (HEMS) before the arrival of ground ambulances based on information provided by 911 callers is an innovative way of reducing response times to major trauma. This study sought to determine the changes in response times to major traumas in southwestern British Columbia since the inception of the Autolaunch dispatch strategy in 2004.

Methods

This is a retrospective trauma database review involving all adult (> 18) major trauma patients (ISS > 15) who were transported by BC HEMS within the Autolaunch response area during the study time periods. Two cohorts were compared: one from July 1, 2003, to June 15, 2006, when the traditional HEMS dispatch strategy was used, and one from June 15, 2006, to June 15, 2008, when Autolaunch came into effect. Data were obtained from the BC Trauma Regis try and the BC Ambulance Service. The mean activation time and total response time was calculated for each cohort and then compared. The Student t test was used for significance testing. For all tests, statistical significance was set at p ≤ 0.05.

Results

Mean response time from injury to definitive care using the Autolaunch method was 128 minutes (SD 79 min) versus 240 minutes using the traditional dispatch method (SD 157 min, p < 0.001). The mean activation time using Autolaunch was 26 minutes (SD 46 min) versus 112 minutes (SD 109 min, p < 0.001) using the traditional dispatch method.

Conclusion

This study demonstrated significant reductions in response times to major trauma when Autolaunch was used.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):17.

Outcomes of homeless people who sustain injury in trauma

E Simoneau 1, S Iqbal 1, T Razek 1, K Khwaja 1

Background

Patients with no fixed address who sustain injury can be a challenging population to manage, especially with respect to recidivism, disposition and follow-up. The objective of this study was to identify risk factors associated with this population in trauma and to determine clinical outcomes.

Methods

A retrospective study of 63 homeless patients admitted with trauma from 2003 to 2008 was conducted using our trauma registry and chart review. Descriptive and logistic regression analysis was performed.

Results

Alcohol abuse was present in 54.8% of patients and hepatitis C, intravenous drug use and HIV were found in 28.6%, 14.3% and 14.3%, respectively. The median Glasgow Coma Scale scores on arrival and ISS were 14 (range 3–15) and 14 (range 1–66). The most common mechanisms of injury were falls (38.1%), blunt assault (25.4%) and pedestrian versus car injuries (20.6%). Traumatic brain injury represented 53.9% of injuries. Trauma recidivism was present in 42.9% of patients. The median hospital stay was 8 days (1–254), median intensive care unit stay was 1 day (0–8), and the overall mortality was 3.2%. Factors associated with a prolonged length of stay (≥ 14 d) were pedestrians versus car injuries (OR 16.7, p = 0.0002), respiratory infections (OR 25, p = 0.0018) or having delirium (OR 12.5, p = 0.0103) as complications. A majority of patients (71.7%) was lost to follow-up.

Conclusion

Homeless trauma patients make up an important and understudied population. They commonly present with falls, assault or pedestrian versus car injuries contributing to prolonged hospital stay. They are at high risk for trauma recidivism and being lost to follow-up. Strategies focused on the homeless population are needed to improve patient outcomes in this challenging group of trauma patients.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):17.

In-hospital triage of a mass casualty incident following a school shooting in a Canadian regional trauma system

J Spicer 1, T Razek 1, P Fata 1, B Bernardin 1, A Gursahaney 1, D Mulder 1, K Khwaja 1

Background

Mass casualty incidents (MCI) such as school shootings cause major stress on regional trauma systems. This study focuses on the in-hospital triage and trauma centre response following a MCI resulting from a school shooting in a large Canadian city.

Methods

A retrospective review was conducted with McGill University Health Centre’s institutional review board approval. Clinical data were extracted. Interdisciplinary debriefings elucidated system successes and failures.

Results

Eleven gunshot wound (GSW) victims arrived at the emergency department within 50 minutes of the shooting and were triaged using a physiologic- and anatomic-based colour classification (red, yellow, green, black). The mean Injury Severity Score was 12.5. An intervention (operation or angiography) was required in 7 of 11 patients. Mean time from admission to intervention was 103 minutes. Those triaged with highest priority had the shortest time to imaging and surgical intervention. Resources were available in a timely fashion with sufficient capacity to accommodate 5 more urgent cases to the operating room and 10 additional admissions to the intensive care unit. The telecommunication system failed because of 100% use for a 2-hour period after the event. All 11 patients are alive at 3 years of follow-up.

Conclusion

A regionalized trauma system with a defined external disaster protocol contributes to successful outcomes. A robust telecommunication system with large capacity is essential for coordination of the trauma system response. In our hands, a novel triage system based on physiology and anatomic location of GSWs was effective to assign patients rapidly to appropriate care.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):17.

Hip fracture in the elderly: identifying vulnerable populations to target intervention

DA Tanner *,†, RG Crilly ‡, M Kloseck *, BM Chesworth *, J Gilliland §,, T Charyk Stewart †,**

Background

Hip fractures increase with age and are associated with adverse outcomes for older adults. This study examined the relation between hip fracture and place of residence (community dwelling v. institutionalized) in a cohort of older adults.

Methods

Hip fracture events from discharge abstract records (2002–2006) for residents of London, Ontario, were obtained from 2 acute care hospitals. Data on patients 65 years and older were analyzed by age, sex and residence type, and were integrated into a geographic information system for mapping.

Results

A total of 1209 fracture events (mean age 83.5, SD 7.09 yr; 75% female; 69% community dwelling) were analyzed. Eighty-eight (7.3%) patients died in hospital and 11% (n = 94) of those living in the community before fracture were transferred to long-term care at discharge. Crude fracture rates were elevated in the institutionalized population (23.3/1000, n = 373) compared with the community population (4.0/1000, n = 836) and remained 1.8 times greater after correcting for age and sex. In-hospital mortality rates among institutionalized patients were almost 2 times higher than community dwellers and were elevated in older male community dwellers. Consistent with this, mapping analysis identified fracture “hot spots” in the city which coincided with the distribution of residential institutions and senior-dense neighbourhoods.

Conclusion

Hip fractures are a significant injury for older adults and rise markedly with age. They are most common in women but are more likely to be fatal in men and the institutionalized population. They are a major cause of loss of independence in all. The use of descriptive and geographic methods isolated high-risk populations and locales that may benefit from targeted preventive interventions.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):18.

Intensive care unit intensive glucose control is associated with in-hospital mortality in patients with severe trauma

LF Ferri *, MB Ferri †, B Shah ‡, S Rizoli †,§

Background

Hyperglycemia is common in critically ill trauma patients and has been independently associated with increased mortality. Intensive glucose control (IGC) has become the standard of care in intensive care unit (ICU) patients, including trauma patients. However, the role of IGC in severe trauma has not been established and often causes hypoglycemia, which may adversely affect outcome. We hypothesized that the IGC protocol in ICU trauma patients leads to large blood glucose variations and worsens outcomes.

Methods

We conducted a retrospective cohort study of all adult trauma patients admitted to Sunnybrook ICU between 2005 and 2007. The IGC protocol was introduced in 2005. The IGC was nurse-driven and automatically initiated after 2 measurements greater than 8 mmol/L, to a target of 4.1–8 mmol/L. Hyperglycemia (> 7 mmol/L) and hypoglycemia (< 4 mmol/L) were measured. Our primary outcome was in-hospital all-cause mortality. A conservative approach for logistic regression model was performed for in-hospital mortality.

Results

In total, 1150 trauma patients were admitted to Sunnybrook ICU between 2005 and 2007. Their mean age was 42 years, ISS was 29.75 (SD 12.37) and Abbreviated Injury Scale head score was 2.72 (SD 1.8). The primary outcome initially was investigated using a χ2 test (hyperglycemia, p = 0.00021; hypoglycemia, p = 0.0101). Our logistic regression model included the main confounders associated with mortality: severity (ISS), age, sex, trauma mechanism and presence of head injury. Hypoglycemia, minimal and maximal glucose level, age, ISS and head injury were independently associated with mortality. The hypoglycemia odds ratio for mortality was 4.51 (95% CI 2.12–9.64).

Conclusion

This study demonstrates that hypoglycemia but not hyperglycemia is independently associated with in-hospital mortality in severe trauma patients.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):18.

Evaluation of an injury severity crosswalk tool: ICD-10-CA to AIS 2005

A Moses McKeag *, M Brennan-Barnes †, S Chandra *

Background

The Canadian Institute for Health Information (CIHI) contracted Digital Innovations Inc. and an expert coding consultant to develop a crosswalk tool that applies an Abbreviated Injury Scale (AIS) 2005 injury severity code to each ICD-10-CA injury code. CIHI is the custodian of the Ontario Trauma Registry Comprehensive Data Set (OTR CDS), a database that contains both ICD-10-CA and AIS 2005 codes.

Methods

The Injury Severity Crosswalk (using lowest and highest possible severity values) was applied to the ICD-10-CA injury codes in 2411 records in the OTR CDS, generating “derived AIS” codes. “Derived ISS” was then calculated using the “derived AIS” codes. Derived ISS was compared with the ISS calculated from codes in the OTR CDS record, assigned by trained coders.

Results

When compared with the coder ISS (using a paired t test), derived ISS (low) results in a significantly lower ISS assignment (p < 0.0001) and derived ISS (high) results in a significantly higher ISS (p < 0.0001). Notable differences were seen in the ISS 9–12 range: 11% coder ISS, 40% derived ISS (low) and 1% derived ISS (high); and in the ISS 41+ range: 4% coder ISS, 1% derived ISS (low) and 35% derived ISS (high). The best estimate of ISS was in the ISS 13–15 range: 12% coder ISS, 15% derived ISS (low), 2% derived ISS (high).

Conclusion

The crosswalk applied to the OTR CDS has generated an underestimate (derived ISS low) and an overestimate (derived ISS high). Future work is necessary to find a way to use this tool to best estimate ISS.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):18.

Institution of a 5-day prethawed plasma program reduces waste and cost

T Nouh *, A Wilson †, G Spurll †, K Khwaja *, P Fata *, T Razek *

Background

The increasing demand for timely access to sufficient amounts of plasma for massively transfused patients has underscored the need for maintaining a constant supply of readily available prethawed plasma. This has been tempered by the concern of increasing the waste of plasma units not used within the normal 24-hour window for thawed plasma and/or an increase in the use of AB plasma.

Methods

We compared plasma wastage during the 6 periods before and the 6 periods after the institution of a 5-day prethawed plasma program across the McGill University Health Centre (MUHC).

Results

The introduction of the 5-day prethawed plasma program across the MUHC hospitals led to a 63.78% reduction in wasted plasma during the 6 periods after program implementation (67 units compared with 185 units in the previous 6 periods). This translates to a cost saving of $29 044.52. About 92% of the plasma units were transfused within 48 hours of thawing. The use of AB plasma as a universal donor decreased from 35.2% to 30%.

Conclusion

The implementation of the 5-day prethawed plasma program across the MUHC reduced wasted plasma units and saved thousands of dollars. This was achieved without an increase in the use of universal AB plasma donor units.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):18–19.

Prehospital care pathways for major head injury

G Thibault-Halman *, JM Tallon †, S Ackroyd-Stolarz †, L Fenerty *, B Sealy ‡, S Karim ‡, DB Clarke *

Background

Timely access to tertiary care is vital following major traumatic brain injury. A head injury guideline was implemented in Nova Scotia to streamline prehospital management of these patients. The guideline advises use of the provincial transport and trauma hotline for arranging expeditious transport to tertiary care for patients with major head injury, following intubation or oxygen mask, spine immobilization and 2-minute neurologic exam. The impact of the guideline on timely access to care has been evaluated.

Methods

Data from the Nova Scotia Trauma Registry and the Emergency Health Service Communications and Dispatch Centre database were analyzed for patients with an Abbreviated Injury Scale (AIS) head score of 3 or greater. Time elapsed before calling the trauma hotline and time required to gain access to tertiary care were determined. Time elapsed was compared for the period before guideline implementation, the implementation phase and after implementation.

Results

The time elapsed before the call to the trauma hotline was not statistically different following guideline implementation. This was true for the cohort which included all patients with an AIS head score of 3 or greater (including polytrauma, n = 388) and for the subset cohort (n = 99) with isolated head injuries (Kruskal–Wallis test, p = 0.247 and p = 0.874, respectively). Similarly, time elapsed before accessing tertiary care was not influenced by the guideline for both cohorts (Kruskal–Wallis test, p = 0.297 and 0.229, respectively).

Conclusion

Times to tertiary care have not been reduced by guideline implementation. System changes beyond guideline implementation may be required to provide timely access to tertiary care.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):19.

Computed tomography and not chest radiography should be used to screen for blunt thoracic aorta injury

S Tacci 1, H Shulman 1, S Rizoli 1, J Ng 1, F Spencer 1

Background

In blunt trauma, chest radiograph (CXR) findings such as widened mediastinum are commonly used to screen for thoracic aorta injuries (TAI). However, normal CXR findings do not exclude TAI, and chest computed tomography (CT) scans are superior in detecting TAI. Despite wide availability, CT scans are not used to screen for TAI. We hypothesized that CT scans, and not CXR, should be recommended to screen for TAI.

Methods

We conducted a retrospective study at Sunnybrook Trauma Centre, where multislice 64-slice CT scans have been used since 2003. We included all adult patients with blunt chest trauma admitted between July 2003 and June 2005 who underwent both CXR and chest CT scan–angiography on arrival. A senior radiologist dedicated to the chest reviewed all CXR images for widened mediastinum, which he subsequently compared with CT scans that were performed simultaneously. TAI was defined by conventional angiography, surgery or autopsy.

Results

A total of 847 patients were included. Of the 11 patients with TAI, CXR showed widened mediastinum in 7, whereas CT detected the aortic injury in all 11. Even after meticulous review, 4 CXR scans showed a normal mediastinum, thus failing to identify TAI. CXR sensitivity was 63%, whereas CT scan sensitivity was 100%. Both had a specificity of 100%.

Conclusion

In our trauma centre, 37% of all patients with blunt TAI would be missed and not submitted to further investigation had plane supine CXR been used as the sole screening tool. In contrast, CT scans correctly identified all TAI, suggesting that CT should be used to screen and identify blunt thoracic aorta injuries wherever available and not chest radiography.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):19.

Evaluation of a massive transfusion protocol

AW McFarlan *,†, S Canzian *,†, K Pavenski †,‡, AB Nathens *,†,‡

Background

In 2008, a massive transfusion protocol (MTP) was introduced at our hospital for use in trauma patients with significant anticipated blood loss. The MTP goal was to provide timelines, transfusion thresholds and essential monitoring parameters for the management of patients requiring large blood volume replacement. Desired outcomes of the MTP included reducing the incidence of intractable coagulopathy, decreasing time to transfusion, avoiding wastage of blood and improving team communication.

Methods

We conducted a retrospective chart review of patients from December 2008 to October 2009 who had an MTP called (n = 18) and also those (n = 14) who received 5 or more units of packed red blood cells (PBRC) in a 2-hour period and met the MTP inclusion criteria (but MTP not called).

Results

Of the MTP-called cases, 13 (72%) were appropriate; 5 patients did not meet MTP inclusion criteria and were deemed inappropriate. Average time to issue of the first unit of plasma (MTP-called group) was 60 minutes compared with 75 minutes in the not-called group. Average time to issue of the first unit of platelets was 120 minutes compared with 198 minutes in the MTP not-called group.

Conclusion

Average time to issue of the 7th unit of PRBCs in the MTP-called group was 107 minutes compared with 101 minutes in the not-called group. Pretransfusion laboratory work was completed on 14 (77%) MTP-called patients and 100% of the not-called group. Sixty-one percent of the MTP-called group were coagulopathic on arrival compared with 46% in the not-called group. Use of the MTP improved transfusion times and team communication.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):19–20.

Penetrating injuries in eastern Ontario: The Ottawa Hospital experience

L Perron *, D Kim *, A Lester *, J Trickett †, N Shore *, M Martin ‡, H Knight *, G Pagliarello *, J-D Yelle *

Background

Recent media reports have suggested there is an increasing prevalence of street violence in urban metropolitan centres in Canada, specifically with respect to violence involving penetrating injuries. The present study approximates a population study, insofar as the majority of adult patients from eastern Ontario with penetrating injuries are transferred to Ottawa.

Objective

The overall purpose of the current study was to evaluate and describe our experience with patients who had penetrating injuries treated at The Ottawa Hospital’s tertiary trauma centre. More specifically, we performed both a descriptive and quantitative analysis of patients with penetrating injuries while reporting the demographics of the patient population. Furthermore, mortality rates and factors influencing mortality are analyzed and reported.

Methods

A retrospective review of the period from 1998 to 2008 was performed using locally collected data on patients with penetrating injuries at The Ottawa Hospital. Our primary outcome was all-cause mortality. Several system enhancements were initiated in 2002, therefore a preplanned analysis of 2 distinct periods was also performed: period 1 (1998–2002) and period 2 (2003–2008). We performed Student t and Fisher exact tests and logistic regression for secondary analysis.

Results

Most patients were male (89%) with a mean age of 33 years. The mechanism of penetrating trauma included 54 gunshot wounds (GSW), 183 stab wounds, 93 self-inflicted wounds and 32 other incidental penetrating injuries not resulting from violence or self infliction. There were 142 (39%) patients who required surgical intervention. The average Injury Severity Score (ISS) was 14. The mortality rate observed for the time period from 1998 to 2008 was 13% (49/362) with 6% (21) of the deaths occurring in the emergency department (ED). Variables affecting mortality were analyzed. ISS odds ratio 0.9 (95% CI 0.87–0.94) and Modified Abbreviated Injury Score (MAIS) head and neck 0.8 (95% CI 0.64–0.94) were found to be statistically significant (p < 0.001). No significant increase in the number of patients treated for penetrating injuries was observed when comparing the 2 study periods. The observed mortality rate decreased from 19% (31/162) in period 1 to 11% (18/169) period 2. This was statistically significant (p < 0.05). For both periods, mortality was associated with a statistically significant higher ISS and MAIS scores (p < 0.001). In period 1, the ISS odds ratio was 0.9 (95% CI 0.85–0.95) and MAIS head and neck was 0.85 (95% CI 0.7–1). Similar results were observed from period 2, with ISS odds ratio 0.9 (95% CI 0.88–0.98) and MAIS head and neck 0.7 (95% CI 0.5–0.91). The reduced mortality for period 2 is most likely attributed to the trauma system enhancements implemented in 2002 that provided an opportunity for improved responsiveness, organization and coordination of care for the patients with penetrating injuries in eastern Ontario.

Conclusion

We are not seeing an increased number of patients presenting with penetrating injuries at The Ottawa Hospital. We have observed significantly improved mortality rates in the cohort of patients with penetrating injuries, which we attribute to improvements and enhancements to the trauma system in eastern Ontario.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):20.

Outcome analysis of 160 trauma patients with flail chest

M Ellabib 1, S Faidi 1, N Sne 1, M Ben-Ibrahim 1, F Baillie 1, M Sagar 1

Background

Flail chest is the most serious form of blunt thoracic trauma that occurs as a result of fracture of 3 or more ribs from at least 2 places resulting in a paradoxical movement of the chest wall, and it carries a high morbidity and mortality rate. The outcome of flail chest injury is a function of associated injuries. Early intubation and mechanical ventilation is vital in patients with refractory respiratory failure. Prolonged mechanical ventilation is associated with the development of pneumonia and a poor outcome.

Methods

All patients who presented with blunt chest trauma from January 2000 to December 2006 were identified from the trauma registry at Hamilton General Hospital. Patients who had flail chest served as the study population. Mechanism of injury, site of injury, complication of injury and mortality were analyzed.

Results

Out of 3369 patients admitted with thoracic injury, 160 (5%) patients had flail chest injuries. Seventy-seven percent of the patients were male with mean age of 54 years. Eighty-one percent of the flail chest injuries were due to motor vehicle accidents, 14% due to falling down and 5% due to other causes. Sixty percent of the injuries were on the left side, 26% were on the right side and 14% on both sides of the chest wall. Twenty-four percent of patients had hemopneumothorax, 20% had pneumothorax and 8% had hemothorax. Eighty-two percent of patients were intubated and admitted in the intensive care unit (ICU). The mortality rate was 25%, and most of the deaths occurred in the ICU because of pneumonia.

Conclusion

The most common cause of injury is motor vehicle collision, and the most common site of injury is left side. Most of the deaths occurred because of pneumonia as a complication of prolonged intubation and mechanical ventilation.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):20.

Long-term functional outcomes following major traumatic brain injury

G Thibault-Halman *, JM Tallon †, S Walling *, S Ackroyd-Stolarz †, L Fenerty *, P Taylor *, DB Clarke *

Background

Patients who suffer brain trauma can have significant and long-lasting cognitive, psychosocial, physical and functional sequelae. Despite this, few Canadian studies have prospectively examined long-term functional outcomes following major traumatic brain injury (TBI).

Methods

Fifty-one patients with major head injury (Glasgow Coma Scale score 3–12) were recruited. These patients were evaluated at 6, 12 and 24 months after injury and were subjected to a clinical assessment, imaging studies and a battery of testing that included a Glasgow Outcome Scale (GOS) score.

Results

In all, 28 follow-ups were completed; 23 patients withdrew before their 24-month follow-up. Among those who completed the study, 50% had a GOS of 5 at 6 months; by 24 months, 75% had reached a GOS of 5. Age appears to play a role in the rate of recovery: 59% (10/17) of patients younger than 25 had a 6-month GOS of 5, whereas only 24% (5/21) of those older than 25 had a score of 5, despite similar injury severity. By 24 months, however, 75% of both groups had achieved a GOS of 5. All (8/8) moderate TBIs, but only 65% (13/20) of severe TBIs, had achieved GOS of 5 at 24 months.

Conclusion

A significant segment of this population remains unable to return to work or school, or is unable to live independently in the long term. However, important gains in functional independence can be achieved during the first 2 years after injury. The rate of recovery appears to be influenced by age. At 2 years, most patients in our cohort had a good recovery.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):20–21.

A new device for percutaneous tracheostomy

JB Rezende-Neto *, SB Rizoli †

Background

Percutaneous tracheostomy (PT) has become an alternative procedure to conventional surgical tracheostomy. Percutaneous dilatational tracheostomy, Ciaglia technique, is the most popular. Griggs’ technique uses a Howard–Kelly forceps for blunt dilation of the trachea; we describe a similar procedure.

Methods

We designed a curved, self retaining retractor with an opening for a J-tipped guidewire, a short metal dilator and a blunt-tipped flexible metal introducer. The procedure consists of midline incision and a 16-gauge (Jelco) intravenous catheter introduced into the trachea, confirmed by aspiration of air. A J-wire is threaded through the catheter and the tip of the metal dilator is slid over the J-wire 2–3 mm into the trachea and removed. The self retaining retractor is slid over the J-wire to maintain the trachea open. A tracheostomy tube, slid over a flexible metal introducer, is placed inside the trachea under direct vision.

Results

From July 2009 to October, 65 trauma patients underwent PT at the bedside (89% in the intensive care unit). Sixty-one percent had sustained a head trauma and 20% a thoracic trauma. The average time for the procedure was 5 minutes; no fibreoptic bronchoscopy was used. More than 2 attempts to insert the intravenous catheter into the trachea were necessary in 6 patients; this was solved by pulling back the endotracheal tube. There were no cases of tracheostomy tube misplacement. There were 2 com plications (3%); both were incision bleeding that resolved with pressure. There were no conversions to open tracheostomy.

Conclusion

The device provides a safe and quick means for PT, with the advantage of tracheostomy tube placement under direct vision.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):21.

Assessment of regional blood flow with fluorescent microspheres during permissive hypotension in hemorrhagic shock

B Rezende-Neto *, B Schmit *, MV Andrade *, JR Cunha-Melo *, SB Rizoli †

Background

Severe hemorrhage is the second most common cause of death in trauma patients and the leading cause of preventable death. We have previously shown that permissive hypotension (PH) enhances clot formation and decreases blood loss in hemorrhagic shock (HS). However, concerns of possible harm caused by tissue under perfusion with that strategy exist. The purpose of this study was to investigate regional perfusion with fluorescent microspheres in HS during PH.

Methods

Thirty rats were randomized to 3 groups: sham, PH and normotensive resuscitation (NR) with Ringers’ lactate. PH was defined as 60% of baseline mean arterial pressure. HS was provoked by injury to the abdominal aorta; mean arterial pressure was monitored continuously. Fluorescent microspheres were injected in the left ventricle. The assessment of regional blood flow (RBF) by fluorescent microsphere concentration was done in the brain, kidney, lung and liver by spectrophotometry 85 minutes after the beginning of shock. Analysis of variance analysis was performed; significance was set at p ≤ 0.05.

Results

Compared with sham, RBF to the brain was 73.8% with PH and 88% with NR (p ≥ 0.05); RBF to the kidney was 64.8% with PH and 63.4% with NR (p ≥ 0.05); RBF to the lung was 48.3% with PH and 41% with NR (p ≥ 0.05); RBF was 48.9% with PH and 50.2% in the NR liver (p ≥ 0.05).

Conclusion

Our study showed that despite concerns about under perfusion with PH, RBF was not statistically different from NR.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):21.

The effects of helmet use before and after mandatory helmets for skating: the Halifax experience

L Fenerty *, DB Clarke *, G Thibault-Halman *, K Wheadon-Hore †, L Sangster ‡, J Heaton ‡

Background

In Nova Scotia each year, 434 people die, 89 979 visit emergency departments and 5518 are hospitalized due to injury. Falls account for $175 million of the total $518 million per year price tag for injury in Nova Scotia. The human costs of injury are incalculable, leaving many health professionals in trauma care at the forefront of innovative injury prevention programs. As part of our strategy to develop initiatives that will prevent head trauma through promotion of helmets, we have developed a collaborative research project with Dalhousie University to examine the effects of introducing mandatory helmet use for skating.

Methods

Mandatory helmets go into effect on Jan. 1, 2010, at Dalhousie Memorial Arena. Observational studies for falls and helmet use, qualitative surveys as well as educational programs leading up to the helmet rules have been completed. Enforcement consists of all skaters wearing Canadian Standards Association–approved hockey helmets to enter the ice surface for skating.

Results

We are now completing observational studies before implementation of mandatory helmets. Of the 361 skaters observed (51.0% male), 46.2% wore helmets.

Conclusion

We are in the process of implementing mandatory helmet use for skating at Dalhousie. Observational studies indicate that fewer than half of skaters wear helmets. We look forward to reporting the postimplementation data.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):21.

The walk-in clinic that never closes: primary care delivered by a dedicated trauma nurse practitioner embedded into a regional trauma service

N Biegler *, PB McBeth †, AW Kirkpatrick *,†,‡

Background

Obtaining consistent primary medical care is ever more challenging in Canada. Thus, infrequent primary care coupled with an increasing rate and scope of anatomic diagnostic imaging after injury and more diligent clinical examinations (tertiary surveys) has resulted in increased rates of new and unexpected diagnoses unrelated to the injury, known as incidental findings (IF). Although appropriately managing IFs poses risks and demands, there is also an opportunity to improve the overall health of all managed by the regional trauma service (RTS). We thus sought to characterize the volume and nature of primary care delivered by an embedded trauma nurse practitioner (TNP).

Methods

A prospective log of IFs and follow-up details was maintained by the TNP. This was supplemented by demographic details obtained from both hospital administrative databases and a regional trauma database.

Results

From September 2008 through March 2009, 425 RTS patients were cared for on the RTS ward. A minimum of 57 patients had IFs recorded. Of these, 3% required urgent intervention, 6.8% required specific follow-up consultations or investigations, and 3.5% required communication and education of the patient. Thirty percent of this group had no primary care physician.

Conclusion

IFs are frequent in modern trauma care. The appropriate management and follow-up required is a major undertaking that can be well managed by a TNP. This service to the community, often involving those without any other primary care, is an underrecognized consequence of an organized RTS and needs consideration when assessing human resources and program support.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):21–22.

Injury and spatial epidemiology of severe adult trauma: implications for prevention

T Charyk Stewart *,†, D Tanner *, J Gilliland ‡,§, M Healy ‡, J Williamson *, S McKenzie , MJ Girotti *,†, DD Fraser §,**

Background

Identifying who is injured within a geographic region and by what mechanism is essential for injury prevention (IP). Our objective was to define the injury and spatial epidemiology of severe adult traumas to prioritize and target IP initiatives.

Methods

Epidemiologic profiles were generated for severely injured (ISS ≥ 12) adult (≥ 18 years) patients treated at lead trauma hospitals (LTH) in southwestern Ontario, from 2004 to 2009. Subanalysis was undertaken by age groups (18–24, 25–64, ≥ 65 yr). Injury cases were mapped by patient residence and place of injury to examine spatial relations.

Results

LTHs resuscitated 2804 severely injured adults (15% young adult, 55% adult, 30% senior; 72% male). Patient residences were dispersed throughout southwestern Ontario, with clusters in cities and lower-income areas. Motor vehicle collisions accounted for 61% and 46% of injuries among young adults and adults, respectively. Only 60% of injured occupants wore a seatbelt; 24% of drivers had a blood-alcohol concentration above the legal limit. Motor vehicle collisions were overly concentrated in high-density urban areas with highly mixed land uses. Alcohol was involved with nearly one-third of severe injuries not involving seniors (48% of assaults, 34% of crashes). Falls were the leading injury mechanism for seniors (68%); 67% occurred at home. Only 6% of patients were injured at work, and half involved falls. The mortality rate was 15%, with 42% fall-related deaths.

Conclusion

Integrating injury epidemiology with geographic data on patients’ daily surroundings allowed for the identification of socio-spatial variations in injury patterns among vulnerable groups. This approach identified motor vehicle collisions, falls and alcohol use as adult IP priorities to be targeted to the populations and regions of greatest need.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):22.

Embolization of a carotid cavernous fistula caused by facial trauma

JB Rezende-Neto *,†, AC Marques †, SB Rizoli ‡

Background

Aside from airway obstruction, facial injuries are seldom life-threatening, although considerable morbidity can occur.

Methods

A 26-year-old man was in a motorcycle crash. He was hemodynamically stable and had a Glasgow Coma Scale score of 14, a left zygomatic fracture and a right tibial fracture. A head computed tomography scan showed a small subdural hematoma, fracture of the frontal sinus and a left zygomatic arch fracture; the subdural hematoma did not require surgery. On the 13th day after injury, he presented with left eye proptosis, herniation of the conjunctiva and impairment of eye movement. An arteriogram revealed a carotid-carvenous fistula (CCF) that was treated by embolization of the left internal carotid artery with micro coils (see Figure).

Figure.

Figure

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Arteriogram showing a carotid-carvenous fistula in a young man who was in a motorcycle crash 13 days previously.

Results

There was complete resolution of the proptosis with residual eye movement compromise.

Conclusion

Traumatic CCF is more common in middle fossa basilar fracture. It is best treated by embolization; loss of vision occurs in 90% of patients if not treated.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):22.

Calcium management during massive transfusion in trauma: reassessing medical practice

B Nascimento *,†,‡, S Rizoli *,†, E Passos *, L Tremblay *,†, M Reis ‡, A Capone *,†, J Callum ‡

Background

There is no agreement among guidelines on whether or how calcium should be replaced during massive transfusion. The goal of this study is to review the medical practice on calcium management and to assess the need for calcium replacement during massive transfusion in trauma.

Methods

We looked at trauma patients who received transfusions of 8 or more units of red cells (RCs) within 12 hours of hospitalization between January 2000 and November 2006. The rate of transfusion (RCs/h) was calculated for the first 6 hours of hospitalization. Serum calcium levels, time to first calcium level, and dose, type and time to calcium replacement were recorded. Parametric tests were used to analyze differences between groups.

Results

In total, 43 massively transfused trauma patients (≥ 3.5 units of RCs/h) were included. Calcium was replaced in 84% of the cases at 2.5 hours of hospitalization. The first corrected calcium level was 2.6 mmol/L and obtained only at 4.1 hours after admission (see Table).

Table.

Characteristics of transfusion and calcium replacement among trauma patients

Characteristic Calcium group (n = 32) No calcium group (n = 11)
Rate of RC transfusion, RC/h 4.6 4.0
Serum calcium, mmol/L 2.7 2.2
Time to serum calcium, h 4.1 3.4
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RC = red cells.

Conclusion

Calcium is empirically replaced during massive transfusion in trauma. Massive transfusion does not deplete calcium to critical levels, and its replacement might not be necessary in most cases.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):22–23.

Futility of activated recombinant FVII use in trauma

B Nascimento *,†,‡, H Tien *, J Callum ‡, Y Lin ‡, M Reis ‡, S Rizoli *,†

Background

The use of recombinant factor VII activated (rFVIIa) in trauma is controversial, particularly in the context of severe metabolic acidosis. The goal of this study is to determine critical degrees of acidosis at which the use of rFVIIa may be deemed futile.

Methods

Massively transfused trauma patients receiving rFVIIa (January 2000 to November 2006) were included. Demographics and baseline characteristics were obtained. The rate of red blood cell transfusion in the first 6 hours of hospitalization was calculated. Univariate analysis was performed to assess for differences between survivors and nonsurvivors. Receiver-operator curve analysis was performed to determine the cut-off for pH value associated with no survival.

Results

In total, 72 patients received rFVIIa. Survivors were less acidotic and coagulopathic and had higher bleeding rates. There were no survivors when the drug was used for patients with pH less than 7.03. The projected cost for each adult treatment with rFVIIa would be about US$6300 (see Table).

Table.

Characteristics and 24-hour survival of massively transfused trauma patients receiving recombinant fVIIa

Characteristic 24-hour survival; mean (SD) [range] p value
Alive (n = 48) Dead (n = 24)
pH 7.3 (0.1) 7.1 (0.2) 0.0002
INR 1.34 [1.17–1.93] 1.51 [1.35–1.93] 0.06
Total dosage 89.5 [80–146.75] 71.3 [65–117.95] 0.08
Transfusion rate 2.7 (1.6) 4.00 (1.7) 0.002
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fVIIa = factor VII activated; INR = international normalized ratio; SD = standard deviation.

Conclusion

The use of rFVIIa for the management of coagulopathy in extremis of acidosis seems to be futile. rFVIIa is expensive and should be used wisely for a selective group of patients.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):23.

The Trauma-Formula-Driven versus Lab-Guided Study (TRFL Study): preliminary results of a clinical trial

B Nascimento *,†,‡, J Callum ‡, H Tien *, V Speers *, Y Lin ‡, G Rubenfeld †, S Rizoli *,†

Background

Recent retrospective studies report impressive survival advantages of early use of fresh frozen plasma (FFP) at a 1:1 ratio with packed red blood cells (RBC) in trauma. However, these studies have innate limitations that discredit their validity. We designed a prospective clinical trial, the TRFL Study, to overcome these limitations and now report the preliminary analysis on the first 5 patients.

Methods

We conducted a feasibility randomized controlled trial including massively transfused trauma patients. The main outcomes were protocol violation, death by exsanguination at 24 hours and 28 days, cessation of bleeding, blood product usage and wastage and complications. Descriptive data are presented (see Table).

Table.

Characteristics of trauma patients who received massive transfusions according to formula-driven or laboratory-guided protocols

Characteristic Formula-driven Laboratory-guided
Patient no. 1 4 5 2 3
Protocol violation Yes Yes Yes Yes Yes
Alive at 24 h Yes Yes No Yes No
FFP:RBC 0.6 0.8 0.6 0.4 0.4
Cessation of bleeding Yes Yes No Yes No
Wastage 4 FFP 4 FFP + 1 RBC 0 0 0
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FFP = fresh frozen plasma; RBC = packed red blood cells.

Results

Protocol violations happened in all cases. The formula-driven group had higher FFP:RBC ratios; however, we were unable to reach the 1:1 ratio. The formula-driven protocol resulted in significant FFP waste.

Conclusion

Protocol compliance and fast delivery of FFP are major challenges in this study, where protocol violations are common and the current blood delivery system does not allow the implementation of 1:1 massive transfusion protocol.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):23.

Do we need to adopt early stabilization in selected groups of patients with flail chest injury to reduce morbidity and mortality?

M Ben-Ibrahim 1, M Ellabib 1, S Faidi 1, F Baillie 1, M Sagar 1

Background

Whereas many chest injuries will require no specific therapy, many reports showed early surgical stabilization might decrease mechanical ventilator days, long-term outcome and overall lower cost of hospitalization in select patients with severe flail chest.

Methods

All patients who presented with blunt chest trauma from January 2000 to December 2006 were identified from the trauma registry at Hamilton General Hospital. Patients who had flail chest without any associated injuries served as the study population.

Results

Out of 160 patients admitted with thoracic injury, 96 (62%) patients had a flail chest injury without associated injuries. Sixty-seven percent of the patients were intubated and admitted to the intensive care unit. The mean length of stay was 70 days (range 4–140 d). The most common complication was pneumonia (30%) related to prolonged mechanical ventilation and lung contusion. The mortality rate was 23%, which was almost the same as the mortality rate in patients with flail chest trauma associated with other injuries (25%).

Conclusion

In patients with flail chest injury without associated injuries, early surgical stabilization may result in shorter intensive care unit stay with lower morbidity and mortality.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):23–24.

Advanced Trauma Care for Nurses in Canada

S Canzian 1, J Ali 1, L Barratt 1, L Horton 1, M Joithe 1, A Sorvari 1

Background

The phrase “trauma is a team sport” rings true for health care providers who understand first-hand the challenges of caring for severely injured trauma patients. The Advanced Trauma Care for Nurses (ATCN) course, offered in collaboration with the Advanced Trauma Life Support (ATLS), provides the opportunity to build this team approach to care in the collaborative forum. In June 2008, the inaugural ATCN course was held in Toronto, Canada. ATCN is an internationally recognized course, and Canada is the 16th country to offer this unique approach to trauma education that intertwines the leadership and clinical skills of medicine and nursing to provide optimal care in the trauma setting.

Methods

The ATCN course structure consists of didactic sessions and skill stations. The didactic sessions are done in conjunction with the ATLS faculty. The skill stations in the ATCN course are separate from the medical skill stations and are interactive case-based scenarios that complement the content of the ATLS lectures while maintaining a focus on nursing roles and scope of practice.

Results

The process of establishing this program was rewarding and challenging. Whereas preliminary discussions were enthusiastic and promising, there were identified obstacles to be overcome.

Conclusion

The purpose of this poster is to provide an overview of the ATCN course as an option for trauma education in Canada and further describe the process used to establish this educational endeavour with a goal to assisting others in introducing the ATCN program in their institutions or provinces.

Can J Surg. 2010 Feb 1;53(2 Suppl 1):24.

The effects of enforcement and education on helmet use in rural and urban Nova Scotia

L Fenerty *, S Huybers *, S Walling *, N Boutilier †, J LeBlanc ‡

Background

In December 1996, Nova Scotia enacted mandatory helmet use for cyclists. Revisions to the legislation added all ages, all wheels (2003) and all locations (2007). This places Nova Scotia in the position of having one of, or the most, aggressive and comprehensive helmet legislations in Canada. Enforcement has been in place since September 1997. Since 2004, formalized active enforcement programs (Operation Headway) and diversion education sessions (Noggin’ Knowledge) have occurred throughout Nova Scotia, along with helmet observation studies.

Methods

This study replicated the methods used to conduct an earlier (1995–1999) longitudinal helmet observational survey that took place in Halifax. The goals of the study were to examine and compare helmet use rates in metropolitan Halifax (population 373 000) and in the town of Pictou (population 3800) as well as to determine the amount of education and enforcement taking place.

Results

Helmet use increased during and after active enforcement in Halifax from 36% (1995 before legislation) to 84% (1999 after legislation). With consistent enforcement and education programs, Halifax (urban centre) had an increase in helmet use from 82% (2006) to 92% (2008), and Pictou (rural centre), with minimal enforcement, saw gains from 69% (2006) to 77% (2008).

Conclusion

Regular, ongoing education and enforcement has led to increased rates of helmet use for Halifax. The significant increase in helmet use in Pictou indicates that enforcement may contribute to higher rates of helmet use (for children), and the continued increase in helmet use in Halifax indicates that ongoing enforcement is effective (for all age groups).

Can J Surg. 2010 Feb 1;53(2 Suppl 1):24.

Blunt carotid and vertebral artery injuries after cervical spine fracture: 10-year experience at a Canadian lead trauma hospital

L VanHouwellingen *, KN Vogt *, TC Stewart *,†, J Williamson §,†, N Parry *,†,‡, G DeRose *, D Gray *,†

Background

The impact of screening for blunt carotid and vertebral artery injuries (BCVI) after trauma in the Canadian population remains unclear. Patients with cervical spine (c-spine) fractures are at high risk of BCVI. We undertook this study to determine whether the implementation of computed tomographic angiography (CTA) in patients with c-spine fracture has changed the rate of detection of BCVI as well as whether it has improved patient outcome.

Methods

We conducted a retrospective cohort of all trauma patients who sustained a c-spine fracture from 1999 to 2008 was identified from our trauma database. Data on injury and complication rates were compared before and after the availability of CTA.

Results

Of the 5533 trauma patients admitted during the study period, 569 (10.3%) sustained c-spine fractures and 19 (3.3%) sustained BCVI. BCVI was identified in 4 of 273 (1.5%) of patients before the use of CTA and in 15 of 296 (5.1%) of patients after its implementation (p = 0.04). After the introduction of CTA, 71 of 296 (24%) of patients underwent screening. A comparison of overall stroke rate revealed no difference between the pre- and post-CTA groups (1.8% v. 3.0%, p = 0.44).

Conclusion

The availability of screening CTA significantly increased the rate of detection of BCVI in patients with c-spine fractures; however, this has not resulted in a decrease in stroke rate. Implementation of effective management strategies for patients with BCVI may be required to justify the use of screening in this population.

Articles from Canadian Journal of Surgery are provided here courtesy of Canadian Medical Association

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