(RSS) Karim's Weblog
Random snippets and thoughts - hopefully mostly trauma related!
Authors
- Karim Brohi
- trauma.org; London
(RSS) Trauma Research Blog
Selected new & juicy research papers, with editorial comment.
Authors
- Karim Brohi
- trauma.org; London
Recent Posts:
The National Audit Office has just released a report on the provision of major trauma services in the UK. The report contains no new surprises - similar reports from independent bodies have been released regularly since the Ormond-Clarke report in 1961. The NAO report does mandate a hearing in the parliament Public Accounts Committee however and it is expected that some action must follow.
Some snippets from the report:
"We estimate that there are at least 20,000 cases of major trauma each year in England resulting in 5,400 deaths and many others resulting in permanent disabilities requiring long-term care. There are around a further 28,000 cases which, although not meeting the precise definition of major trauma, would be cared for in the same way. [...] We estimate that major trauma costs the NHS between £0.3 and £0.4 billion a year in immediate treatment. The cost of any subsequent hospital treatments, rehabilitation, home care support, or informal carer costs are unknown. We estimate that the annual lost economic output as a result of major trauma is between £3.3 billion and £3.7 billion."
"Despite repeated reports identifying poor practice, the Department and NHS trusts have taken very little action to improve major trauma care. Deficiencies in major trauma care were identified by the Royal College of Surgeons in 1988, but there has been little progress since. In 2007, a report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) concluded that 60 per cent of major trauma patients received a standard of care that was ‘less than good practice’.
"As major trauma is a relatively small part of the work of an emergency department, optimal care cannot be delivered cost-effectively by all hospitals. People who have suffered major trauma often have multiple injuries which need to be treated by different surgical specialties. [...] The delivery of major trauma care lacks coordination and can lead to 11 unnecessary delays in diagnosis, treatment and surgery. There are currently no formal protocols for determining where people should be taken for treatment, nor a formal system for transferring patients between hospitals."
"The availability of rehabilitation varies widely across the country, and 14 services have not developed on the basis of geographical need. Although rehabilitation may help to reduce length of stay, minimise hospital readmissions, and reduce the use of NHS resources following the initial period of hospitalisation, it has not been considered to any great degree by strategic health authorities in their reviews of major trauma services. There is a widely perceived lack of capacity for the specialist rehabilitation of major trauma patients, but with little hard evidence about what services are currently available and how well they are arranged to meet patient needs, it is difficult to reach a conclusion on this."
The London Trauma System goes live on 1st April 2010. There is a national process in place at the moment, although there are no deadlines or deliverables for this yet. While the London system is probably secure politically, the national process is at the mercy of a change in government and policy. Both systems are at risk if some key elements of the system are not addressed, especially the financial structure for trauma and the woeful state of rehabilitation services.
The full report and executive summary are available from the National Audit Office website. The BBC has radio and TV coverage of the release, including some footage filmed with us at the Royal London Hospital.
PubMed ID: 20068485
J Trauma. 2010 Jan 9. [Epub ahead of print]
Authors: Glance LG, Osler TM, Dick AW, Mukamel DB, Meredith W.
Abstract:
BACKGROUND:: This report describes a project funded by the Agency for Healthcare Research and Quality to evaluate the impact of providing hospitals with nonpublic report cards on trauma outcomes. The Survival Measurement and Reporting Trial for Trauma explores the feasibility of using the National Trauma Data Bank as a platform for measuring and improving trauma outcomes. METHODS:: We identified a cohort of 125 hospitals in the National Trauma Data Bank with annual hospital volumes of 250 or more trauma cases meeting specific minimum criteria for data quality. The performance of hospitals in this cohort was evaluated using hierarchical logistic regression model. The effect of each hospital on trauma mortality was captured by a shrinkage coefficient, which is exponentiated to yield an adjusted odds ratio. This adjusted odds ratio represents the likelihood that a trauma patient treated at a specific hospital is more or less likely to die compared with a patient treated at an "average" hospital. RESULTS:: The initial hospital cohort includes 125 hospitals and 157,045 patients admitted in 2006. Most hospitals are either level I (36%) or level II (34%) trauma centers. Patients admitted to the worst-performing hospitals were at least 50% more likely to die than patients admitted to the average hospital, after adjusting for injury severity. CONCLUSION: The initial findings of this trial suggest that there is significant variability in trauma mortality across centers caring for injured patients after adjusting for differences in patient casemix. This variation in risk-adjusted mortality presents an opportunity for improvement. The Survival Measurement and Reporting Trial for Trauma study is designed to test the hypothesis that nonpublic report cards can lead to improved population mortality for injured patients. The results of this study may have substantial implications in the future design and implementation of a national effort to report and improve trauma outcomes in the United States.Notes & Commentary:
This wide variability in outcomes at different hospitals is mirrored by other studies of injury care at individual institutions. The Trauma Audit & Research Network iregularly collates this data for hospitals in England & Wales:
(Source)
What is more concerning is that, unlike the UK figures, the hospitals in this study are mainly trauma centres and therefore should be meeting designated performance standards in order to maintain their trauma centre status. It'd be interesting to see if there is similar variability between hospitals accredited under American College of Surgeons criteria for designation, rather than state or local criteria.
There are problems with this form of modelling. Hospital's whose case mix varies from the national average may have skewed results (positively or negatively). Additionally the relationship between statistical modelling of unexpected deaths or survivors has not yet been validated against assessment of the quality of clinical care.
Interesting also is that these are non-reported data. TARN data is available to the general public, so you can see how your local hospital performs compared to the national average. Here's part of our page from the Royal London Hospital.
There's nothing like public opinion to make hospitals up their game.
Just put the programme to bed on this year's Trauma Transfusion & Haemostasis Scientific Symposium. There's a really *really* strong speaker line-up and it should be a fantastic day. Speakers have been told to bring their latest data and most current thinking on their topics and we'll be looking at current knowledge as well as looking into the near future at things like artificial platelets and stem-cell derived blood transfusions.
Full programme is here: http://www.trauma.org/index.php/main/article/951/
As always, the London Trauma Conference (of which this is a part) is at: www.londontraumaconference.com where you can book online.
Videos of last years Trauma Transfusion & Coagulopathy masterclass are online of TRAUMA.ORG: http://www.trauma.org/index.php/main/article/713/
See you there!
So, just in time for this year's London Trauma Conference, we've uploaded the presentations from the 'Trauma Massive Transfusion & Coagulopathy State of the Art Symposium' held at the London Trauma Conference in 2008. This set of lectures presents an overview of the current state of knowledge in the exploding field of Trauma Induced Coagulopathy (TIC) and transfusion practice. At this year's conference we'll be holding a complementary Scientific Symposium on Trauma Haemostasis & Transfusion. The programme is just being finalized and will be available in the next few days. Meanwhile, enjoy the presentations from last year - and TRAUMA.ORG's new video channel on Vimeo.
PubMed ID: 19680160
J Trauma. 2009 Aug 12.
Authors: Teixeira PG, Inaba K, Oncel D, Dubose J, Chan L, Rhee P, Salim A, Browder T, Brown C, Demetriades D.
Abstract:
OBJECTIVE:: Because of its rarity and high rate of mortality, traumatic blunt cardiac rupture (BCR) has been poorly studied. The objective of this study was to use the National Trauma Data Bank to review the epidemiology and outcomes associated with traumatic BCR. METHODS:: After approved by the institutional review board, the National Trauma Data Bank (version 5.0) was queried for all BCR occurring between 2000 and 2005. Demographics, clinical injury data, interventions, and outcomes were abstracted for each patient. Statistical analysis was performed using an unpaired Student's t test or Mann-Whitney U test to compare means and chi analysis to compare proportions. Stepwise logistic regression analysis was performed to identify independent predictors of inhospital mortality. RESULTS:: Of 811,531 blunt trauma patients, 366 (0.045%) had a BCR of which 334 were available for analysis, with the mean age of 45 years, 65% were men, and their mean Injury Severity Score was 58 +/- 19. The most common mechanism of injury was motor vehicle collision (73%), followed by pedestrian struck by auto (16%), and falls from height (8%). Twenty-one patients (6%) died on arrival and 140 (42%) died in the emergency room. The overall mortality for patients arriving alive to hospital was 89%. Of the patients surviving to operation, 42% survived >24 hours of which 87% were discharged. Survivors were significantly younger (39 vs. 46 years, p = 0.04), had a lower Injury Severity Score (47 vs. 56, p = 0.02), higher Glasgow Coma Scale (10 vs. 6, p < 0.001), and were more likely to present with an systolic blood pressure >/=90 mm Hg (p = 0.01). Nevertheless, none of these factors was found to be an independent risk factor for mortality. CONCLUSION:: BCR is an exceedingly rare injury, occurring in 1 of 2400 blunt trauma patients. In patients arriving alive to hospital, traumatic BCR is associated with a high mortality rate, however, is not uniformly fatal.Notes & Commentary:
Coming shortly after our description of the patient with cardiac herniation following blunt trauma is this review of the National Trauma DataBank from the LA County group. Of course this is the tip of the iceberg as most patients will die at scene, but there's a surprisingly low (42%) mortality in the emergency department, suggesting that a significant proportion of these patients should be salvageable if identified early and managed appropriately.
PubMed ID: 19627869
PM R. 2009 Jan;1(1):23-8
Authors: Sayer NA, Cifu DX, McNamee S, Chiros CE, Sigford BJ, Scott S, Lew HL.
Abstract:
OBJECTIVE: To describe the rehabilitation course of combat-injured service members who sustained polytraumatic injuries during the current wars in and around Iraq and Afghanistan. DESIGN: Retrospective descriptive analysis. SETTING: Department of Veterans Administration Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: One hundred eighty-eight consecutive, acutely combat-injured service members suffering polytraumatic injuries requiring inpatient rehabilitation and being treated at PRCs between October 2001 and January 2006. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medications prescribed, devices used, injuries and impairment information, and consultative services. RESULTS: Ninety-three percent of the patients had sustained a traumatic brain injury (TBI) and more than half of these were incurred secondary to blast explosions. Over half of the patients had infections or surgeries prior to PRC admission that required continued medical attention during their stay. Pain and mental health issues were present in 100% and 39%, respectively, of all patients admitted and added complexity to the brain injury rehabilitation process. Common treatment needs included cognitive-behavioral interventions, pain care, assistive devices, mental health interventions for both patients and their families, and specialty consultations, in particular to ophthalmology, otolaryngology, and neurology. CONCLUSIONS: Combat-injured polytrauma patients have complex rehabilitation needs that require a high level of specialized training and skill. Physical medicine and rehabilitation specialists treating war injured service members need a high level of expertise in assessment and treatment of co-occurring pain, TBI, and stress disorders. Physiatrists are playing an important role in providing and coordinating the rehabilitation care for individuals with significant polytraumatic war injuries from the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts.Notes & Commentary:
PubMed ID: 19627946
PM R. 2009 Jun;1(6):560-75
Authors: Devine JM, Zafonte RD.
Abstract:
OBJECTIVE: Physical exercise has been shown to play an ever-broadening role in the maintenance of overall health and has been implicated in the preservation of cognitive function in both healthy elderly and demented populations. Animal and human studies of acquired brain injury (ABI) from trauma or vascular causes also suggest a possible role for physical exercise in enhancing cognitive recovery. DATA SOURCES: A review of the literature was conducted to explore the current understanding of how physical exercise impacts the molecular, functional, and neuroanatomic status of both intact and brain-injured animals and humans. STUDY SELECTION: Searches of the MEDLINE, CINHAL, and PsychInfo databases yielded an extensive collection of animal studies of physical exercise in ABI. Animal studies strongly tie physical exercise to the upregulation of multiple neural growth factor pathways in brain-injured animals, resulting in both hippocampal neurogenesis and functional improvements in memory. DATA EXTRACTION: A search of the same databases for publications involving physical exercise in human subjects with ABI yielded 24 prospective and retrospective studies. DATA SYNTHESIS: Four of these evaluated cognitive outcomes in persons with ABI who were involved in physical exercise. Three studies cited a positive association between exercise and improvements in cognitive function, whereas one observed no effect. Human exercise interventions varied greatly in duration, intensity, and level of subject supervision, and tools for assessing neurocognitive changes were inconsistent. CONCLUSIONS: There is strong evidence in animal ABI models that physical exercise facilitates neurocognitive recovery. Physical exercise interventions are safe in the subacute and rehabilitative phases of recovery for humans with ABI. In light of strong evidence of positive effects in animal studies, more controlled, prospective human interventions are warranted to better explore the neurocognitive effects of physical exercise on persons with ABI.Notes & Commentary:
PubMed ID: 19628092
Surgery. 2009 Aug;146(2):325-33.
Authors: Alam HB, Shuja F, Butt MU, Duggan M, Li Y, Zacharias N, Fukudome EY, Liu B, Demoya M, Velmahos GC.
Abstract:
BACKGROUND: We have demonstrated previously that valproic acid (VPA), a histone deacetylase inhibitor, can improve survival in lethal models of hemorrhagic shock. This study investigated whether VPA treatment would improve survival in a clinically relevant large animal model of poly-trauma/hemorrhagic shock, and whether the protective effects are executed through the Akt survival pathway. METHODS: Yorkshire swine were subjected to a poly-trauma protocol including: (1) Pre-hospital phase- Femur fracture, 60% hemorrhage, 30 min of shock (mean arterial pressure [MAP]: 25-30 mmHg), and infusion of 154mM NaCl (3 x shed blood); (2) Early hospital phase A Grade V liver injury (simulating rupture of a previously contained hematoma) followed by liver packing; (3) Treatment/monitoring phase randomization to 3 treatment groups (n = 6-8/group): no treatment (control), fresh whole blood (FWB), and intravenous VPA (400 mg/kg, given during the pre-hospital phase). Animals were monitored for 4 h, with survival being the primary endpoint. Liver tissue was subjected to Western blot analysis. RESULTS: FWB (n = 6) and VPA treatments (n = 7) significantly increased survival (100% and 86%, respectively) compared to control group (n = 8) (25%). The protocol produced significant anemia (Hb<6 g/dL) and lactic acidosis (lactate 3-5 mmol/L). Acidosis improved after blood transfusion and worsened in the other two groups. VPA treatment increased phospho-Akt (activated), phospho-GSK-3beta (Glycogen synthase kinase 3beta), beta-catenin and Bcl-2 (B-cell leukemia/lymphoma 2) protein levels compared to control group (P = .01, .01, .03, and .02, respectively). There was no significant difference in the level of these proteins between the control and FWB groups. CONCLUSION: Treatment with VPA without blood transfusion improves early survival in a highly lethal poly-trauma and hemorrhagic shock model. The survival advantage is due not to improvement in resuscitation but to better tolerance of shock by the cells, in part due to the preservation of the Akt survival pathway.Notes & Commentary:
Sodium valproate protects cells from ischaemic damage in this haemorrhagic shock model. There are a number of potential therapeutics options for both ischaemia protection and ischaemia rescue ready for translational trials now.
PubMed ID: 19630126
Am J Phys Med Rehabil. 2009 May;88(5):387-98.
Authors: Sirois MJ, Dionne CE, Lavoie A.
Abstract:
OBJECTIVES: The aims of this study were to compare regional differences in perceived needs for postacute rehabilitation services, perceived barriers to postacute rehabilitation services, and long-term functional and physical health outcomes among multiple trauma survivors. DESIGN: A population-based cohort study with retrospective measures of exposure and cross-sectional health outcomes measures was conducted in regions with different levels of rehabilitation services availability in the province of Quebec, Canada. The study included 435 participants, aged 18-65 yrs, admitted to level I or level II trauma centers in 2000-2001, who required rehabilitation services. The participants were interviewed by telephone 2-4 yrs postinjury. Needs for (yes/no) and perceived barriers (yes/no) to obtain 18 posttraumatic rehabilitation services were assessed. Physical health was measured with the medical outcome study SF-12 and functional status with the functional independence measure. RESULTS: There were no significant regional differences in the proportions of perceived barriers to functional rehabilitation (39.4%), to social/vocational rehabilitation (52.2%), and to community integration services (46.5%). Adjusted-SF-12 and functional independence measure scores were similar across regions. CONCLUSION: Contrary to expectations, there were no regional differences in perceived barriers to rehabilitation services for multiple trauma survivors. Rather, surprisingly high proportions of barriers were reported across the province.Notes & Commentary:
Interesting - given Quebec 's a relatively mature and comprehensive trauma system. Perhaps locals can comment on the perception of high barriers to rehab access across the province?
As some of you have surmised this is a typical (if rare) picture of cardiac herniation. This is not dextrocardia/situs as the anatomy of the aortic arch is normal. Also the high vasopressor requirement suggests that this is not normal for the patient! Similarly the picture is not typical of other postulated causes such as tension pneumothorax, tension pneumomediastinum, tension pneumopericardium etc. The patient was taken to the operating room. A left anterolateral thoractomy incision was performed and the pericardium opened. The pericardium was empty which confirmed the diagnosis. The incision was extended into a full clamshell incision.
The heart was twisted on the SVC/IVC axis and was oedematous and engorged. The right phrenic nerve was intact but torn free from the pericardium. The preidcardial tear was widened and the heart relocated, with a good return in blood pressure and a decrease in vasopressor requirements.
The right lateral tear in the pericardium was closed to avoid the heart re-twisting into the right chest. The surgical pericardial incision was left widely open as the heart was too engorged for it to be closed. The clamshell incision was closed and the patient taken to the intensive care unit for further management.
Cardiac herniation is rare but is a correctable cause of traumatic arrest or profound hypotension and must be considered. There are several cases in the literature and two case reviews [PMIDs 9253902 and 16096553]. The Chest X-ray and CT findings of a right-sided herniation are clear here, although many are left-sided and the chest X-ray may be normal.
