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Random snippets and thoughts - hopefully mostly trauma related!

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Karim's Weblog

Random snippets and thoughts - hopefully mostly trauma related!

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NAO CoverThe 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.

 

 

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!  

Trauma Massive Transfusion - Epidemiology & Outcomes

 

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.

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.

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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.

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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.

So this patient came with a CT scan.  

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Those of you thinking dextrocardia - does this help you at all?  What exactly is going on here??

Very interesting case a couple of weeks ago.  This patient suffered significant blunt force trauma to the chest and was secondarily transferred to us for management of a thoracic spinal fracture-dislocation with associated spinal cord injury.  He arrived 12 hours or so following the injury on very large doses on inotropes to support his blood pressure.  Here's his chest X-ray.

 

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Something's not quite right here.  Is there a clear diagnosis?  What's your next move?  Let's have some ideas in the comments...

Today we've had a major overhaul of TRAUMA.ORG's services.  Most of these are back-end improvements to community features.  Users should now find it a lot easier to contribute images and cases, and institution to post fellowships and student elective opportunities. 

As part of our commitment to supporting and developing the global trauma community, this update of TRAUMA.ORG sees the addition of community blogs (including this one!).  The first one to role out is a trauma research blog.  New or interesting research will be highlighted here with a short editorial comment.  You're all welcome to discuss the article in the comments, and of course recommend articles yourselves.  Maybe it should be completely open for all to submit articles to?  We'll see how it develops! 

I thought we should have a momentous first post in the research blog.  So what is the most important trauma paper ever written?  There were a few candidates, but I finally settled on one that I think changed the way the world views trauma.  Which one did I choose?

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