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  • 1
    Language: English
    In: Injury, 2012, Vol.43(1), pp.33-37
    Description: A high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) is currently recognised as the standard of care in some centres during massive transfusion post trauma. The aim of this study was to test whether the presumption of benefit held true for severely injured patients who received a massive transfusion, but did not present with acute traumatic coagulopathy. Data collected in The Alfred Trauma Registry over a 6 year period were reviewed. Included patients were sub-grouped by a high FFP:PRBC ratio (≥1:2) in the first 4 h and compared to patients receiving a lower ratio. Outcomes studied were associations with mortality, hours in the intensive care unit and hours of mechanical ventilation. Of 4164 eligible patients, 374 received a massive transfusion and 179 (49.7%) patients who did not have coagulopathy were included for analysis. There were 66 patients who received a high ratio of FFP:PRBC, and were similar in demographics and presentation to 113 patients who received a lower ratio. There was no significant difference in mortality between the two groups ( = 0.80), and the FFP:PRBC ratio was not significantly associated with mortality, ICU length of stay or mechanically ventilated hours. A small proportion of major trauma patients received a massive blood transfusion in the absence of acute traumatic coagulopathy. Aggressive FFP transfusion in this group of patients was not associated with significantly improved outcomes. FFP transfusion carries inherent risks with substantial costs and the population most likely to benefit from a high FFP:PRBC ratio needs to be clearly defined.
    Keywords: Wounds and Injuries ; Blood Coagulation Disorders ; Blood Transfusion ; Resuscitation
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 2
    Language: English
    In: Injury, February 2013, Vol.44(2), pp.249-252
    Description: Fractures of the tibial plateau present a treatment challenge and are susceptible to both prolonged operative times and high postoperative infection rates. For those fractures treated with open plating, we sought to identify the relationship between surgical site infection and prolonged operative time as well as to identify other surgical risk factors. We performed a retrospective controlled analysis of 309 consecutive unicondylar and bicondylar tibial plateau fractures treated with open plate osteosynthesis at our institution's level I trauma centre during a recent 5-year period. We recorded operative times, injury characteristics, surgical treatment, and need for operative debridement due to infection. Operative times of infected cases were compared to uncomplicated surgical cases. Multivariable logistic regression analysis was performed to identify independent risk factors for postoperative infection. Mean operative time in the infection group was 2.8 h vs. 2.2 h in the non-infected group (p = 0.005). 15 fractures (4.9%) underwent four compartment fasciotomies as part of their treatment, with a significantly higher infection rate than those not undergoing fasciotomy (26.7% vs. 6.8%, p = 0.01). Open fracture grade was also significantly related to infection rate (closed fractures: 5.3%, grade 1: 14.3%, grade 2: 40%, grade 3: 50%, 〈 0.0001). In the bicolumnar fracture group, use of dual-incision medial and lateral plating as compared to single incision lateral locked plating had statistically similar infection rates (13.9% vs. 8.7%, = 0.36). Multivariable logistic regression analysis of the entire study group identified longer operative times (OR 1.78, = 0.013) and open fractures (OR 7.02, 〈 0.001) as independent predictors of surgical site infection. Operative times approaching 3 h and open fractures are related to an increased overall risk for surgical site infection after open plating of the tibial plateau. Dual incision approaches with bicolumnar plating do not appear to expose the patient to increased risk compared to single incision approaches.
    Keywords: Tibia ; Plateau ; Infection ; Operative Time ; Fasciotomy
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 3
    Language: English
    In: Injury, June 2013, Vol.44(6), pp.713-721
    Description: The burden of injury is greatest in developing countries. Trauma systems have reduced mortality in developed countries and trauma registries are known to be integral to monitoring and improving trauma care. There are relatively few trauma registries in developing countries and no reviews describing the experience of each registry. The aim of this study was to examine the collective published experience of trauma registries in developing countries. A structured review of the literature was performed. Relevant abstracts were identified by searching databases for all articles regarding a trauma registry in a developing country. A tool was used to abstract trauma registry details, including processes of data collection and analysis. There were 84 articles, 76 of which were sourced from 47 registries. The remaining eight articles were perspectives. Most were from Iran, followed by China, Jamaica, South Africa and Uganda. Only two registries used the Injury Severity Score (ISS) to define inclusion criteria. Most registries collected data on variables from all five variable groups (demographics, injury event, process of care, injury severity and outcome). Several registries collected data for less than a total of 20 variables. Only three registries measured disability using a score. The most commonly used scores of injury severity were the ISS, followed by Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and the Kampala Trauma Score (KTS). Amongst the small number of trauma registries in developing countries, there is a large variation in processes. The implementation of trauma systems with trauma registries is feasible in under-resourced environments where they are desperately needed.
    Keywords: Trauma Registry ; Trauma Database ; Trauma Databank ; Developing Countries, Low Income Countries, Middle Income Countries
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 4
    Language: English
    In: Injury, December 2013, Vol.44(12), pp.1838-1842
    Description: There is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people. To identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures. We identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence. Sixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation. Geriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues.
    Keywords: Cervical Spine Fracture ; Older Adults
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 5
    Language: English
    In: Injury, October 2014, Vol.45(10), pp.1653-1658
    Description: Knowledge about the functional consequences of lower limb long bone fractures is helpful to inform patients, clinicians and employers about their recovery process and prognosis. This study aims to describe the epidemiology and health outcomes of femoral and tibial shaft fractures treated at two level I trauma centres, by comparing the differences between patients with delayed union or nonunion and patients with union. An analysis of registry data over two years, supplemented with medical record review, was conducted. Fracture healing was retrospectively assessed by clinical and radiological evidence of union, and the need for surgical intervention. SF-12 scores, and work and pain status were prospectively recorded at six and twelve months post injury. 285 fractures progressed to union and 138 fractures developed delayed union or nonunion. There was a significant difference between the two cohorts with regards to the mechanism of injury, association with multi-trauma, open fractures, grade of Gustilo classification, patient fund source, smoking status and presence of comorbidities. The SF-12 physical component score was less than 50 at both six and twelve months with improvement in the union group, but not in the delayed union or nonunion group. 72% of patients with union had returned to work at one year, but 54% continued to have pain. The difference compared to patients with delayed union or nonunion was significant. Even patients whose fractures unite in the expectant time-frame will have residual physical disability. Patients with delayed union or nonunion have still poorer outcomes, including ongoing problems with returning to work and pain. It is important to educate patients about their injury so that they have realistic expectations. This is particularly relevant given that the patients most likely to sustain femoral or tibial shaft fractures are working-age healthy adults, and up to a third of fractures may develop delayed union or nonunion. Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year. Patients with delayed union or nonunion can expect poorer outcomes.
    Keywords: Trauma ; Outcomes ; Femur ; Tibia ; Fracture ; Nonunion ; Delayed Union
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 6
    Language: English
    In: Injury, October 2014, Vol.45(10), pp.1545-1548
    Description: To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. Retrospective review. Two level one trauma centres. Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, 〈 0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, = 0.333). A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. Level III.
    Keywords: Distal Humerus Fracture ; Extra-Articular ; Approach ; Triceps Split ; Triceps Sparing ; Outcomes
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 7
    Language: English
    In: Injury, 2010, Vol.41(9), pp.894-898
    Description: The purpose of this study was to assess the role of decompressive craniectomy (DC) in patients with post-traumatic intractable intracranial hypertension (ICH) in the absence of an evacuable intracerebral haemorrhage. Retrospective study at LAC+USC Medical Centre including patients who underwent DC for post-traumatic malignant brain swelling or ICH without space occupying haemorrhage, during the period 01/2004 to 12/2008. The analysis included the effect of DC on intracranial pressure (ICP) and timing of DC on functional outcomes and survival. Of 106 patients who underwent DC, 43 patients met inclusion criteria. Of those, 34 were operated within the first 24 h from admission. DC decreased the ICP significantly from 37.8 ± 12.1 mmHg to 12.7 ± 8.2 mmHg in survivors and from 52.8 ± 13.0 to 32.0 ± 17.3 mmHg in non-survivors. Overall 25.6% died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). No tendency towards either increased or decreased incidence in favourable outcome was found relative to the time from admission to DC. Six of the 18 patients (33.3%) with favourable outcome were operated on within the first 6 h. DC lowers ICP and raises CPP to high normal levels in survivors compared to non-survivors. The timing of DC showed no clear trend, for either good neurological outcome or death. Overall, the survival rate of 74.4% is promising and 41.9% had favourable neurological outcome.
    Keywords: Decompressive Craniectomy ; Severe Traumatic Brain Injury ; Intractable Intracranial Hypertension ; Glasgow Outcome Score
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 8
    Language: English
    In: Injury, January 2018, Vol.49(1), pp.62-66
    Description: Higher transfusion ratios of plasma to packed red blood cells (PRBC) and platelets (PLT) to PRBC have been shown to be associated with decreased mortality in major trauma patients. However, little is known about the effect of transfusion ratios on mortality in patients with isolated severe traumatic brain injury (TBI). The aim of this study was to investigate the effect of transfusion ratios on mortality in patients with isolated severe blunt TBI. We hypothesized that higher transfusion ratios of plasma to PRBC and PLT to PRBC are associated with a lower mortality rate in these patients. Retrospective observational study. Patients with isolated severe blunt TBI (AIS head ≥ 3, AIS extracranial 〈 3) admitted to an urban level I trauma centre were included. Clinical data were extracted from the institution’s trauma registry, blood transfusion data from the blood bank database. The effect of higher transfusion ratios on in-hospital mortality was analysed using univariate and multivariable regression analysis. A total of 385 patients were included. Median age was 32 years (IQR 2–50), 71.4% were male, and 76.6% had an ISS ≥ 16. Plasma:PRBC transfusion ratios ≥ 1 were identified as an independent predictor for decreased in-hospital mortality (adjusted OR 0.43 [CI 0.22–0.81]). PLT:PRBC transfusion ratios ≥ 1 were not significantly associated with mortality (adjusted OR 0.39 [CI 0.08–1.92]). This study revealed plasma to PRBC transfusion ratios ≥ 1 as an independent predictor for decreased in-hospital mortality in patients with isolated severe blunt TBI.
    Keywords: Brain Injury ; Blood Component Transfusion ; Transfusion Ratio ; Mortality ; Coagulopathy
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 9
    Language: English
    In: Injury, June 2013, Vol.44(6), pp.834-841
    Description: Trauma registries are central to the implementation of effective trauma systems. However, differences between trauma registry datasets make comparisons between trauma systems difficult. In 2005, the collaborative Australian and New Zealand National Trauma Registry Consortium began a process to develop a bi-national minimum dataset (BMDS) for use in Australasian trauma registries. This study aims to describe the steps taken in the development and preliminary evaluation of the BMDS. A working party comprising sixteen representatives from across Australasia identified and discussed the collectability and utility of potential BMDS fields. This included evaluating existing national and international trauma registry datasets, as well as reviewing all quality indicators and audit filters in use in Australasian trauma centres. After the working party activities concluded, this process was continued by a number of interested individuals, with broader feedback sought from the Australasian trauma community on a number of occasions. Once the BMDS had reached a suitable stage of development, an email survey was conducted across Australasian trauma centres to assess whether BMDS fields met an ideal minimum standard of field collectability. The BMDS was also compared with three prominent international datasets to assess the extent of dataset overlap. Following this, the BMDS was encapsulated in a data dictionary, which was introduced in late 2010. The finalised BMDS contained 67 data fields. Forty-seven of these fields met a previously published criterion of 80% collectability across respondent trauma institutions; the majority of the remaining fields either could be collected without any change in resources, or could be calculated from other data fields in the BMDS. However, comparability with international registry datasets was poor. Only nine BMDS fields had corresponding, directly comparable fields in all the national and international-level registry datasets evaluated. A draft BMDS has been developed for use in trauma registries across Australia and New Zealand. The email survey provided strong indications of the utility of the fields contained in the BMDS. The BMDS has been adopted as the dataset to be used by an ongoing Australian Trauma Quality Improvement Program.
    Keywords: Trauma Registry ; Trauma Systems ; Registry Dataset ; Outcome Monitoring
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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  • 10
    Language: English
    In: Injury, 1999, Vol.30(6), pp.431-437
    Description: There is a paucity of large cohort studies that address outcomes after acute orthopaedic trauma. The regional trauma registry is a powerful tool to study trends of large populations over long periods of time. We used such a regional trauma registry to review retrospectively a large subset of orthopaedic trauma patients over a long period of time and to evaluate the relationship between initial presentation, hospital course, hospital charges, and outcomes as a function of age. A retrospective review of 130,506 level I and II trauma admissions with acute orthopaedic injuries over 10 years (1985-1995) was conducted. Aggregate data were analyzed among five age groups. Descriptive analyses were conducted for mechanism of injury, mortality, time to death, injury type, injury severity score (ISS), Glasgow Coma Scale (GCS) on presentation, length of stay (LOS), discharge destination, and hospital charges. Forty-six percent of the patients were in the 18-35-year-old age group; however, 21% of all patients were older than 65 years of age at the time of injury. There were no differences in GCS or ISS on admission. Injury types were similar across all age groups, mostly extremity fractures. Younger patients were much more likely to be injured in a motor vehicle accident (MVA), whereas older patients were injured in a fall. Penetrating trauma was seen almost exclusively in the young. LOS in the hospital was longer in the elderly; however, LOS in the intensive care units were similar across all age groups. Time to death from initial presentation differed across age groups. Elderly patients who eventually died were much more likely to survive more than 24 h in the hospital as compared with young patients. Hospital charges per hospitalization increased with age, although the total charges to the youngest age group were higher due to the group's high volume. Younger American trauma patients with acute orthopaedic injuries are much more likely than their older counterparts to sustain penetrating trauma and pass the socioeconomic burden to society by way of large opportunity costs, lack of insurance, and high rates of recidivism. Elderly patients fared as well as younger patients after acute orthopaedic trauma, although their hospital stays were longer and resulted in increased hospital charges. The excessive costs of trauma, $100 billion and more than 150,000 deaths annually, necessitate study of general population trends. Indirect costs, including rehabilitation costs and opportunity costs, as well as direct costs, are incurred during the post-trauma hospitalization. Attention must focus on prevention of penetrating injuries in the young and falls in the elderly to reduce morbidity, mortality, and the costs of trauma.
    Keywords: Fractures, Bone -- Epidemiology;
    ISSN: 0020-1383
    E-ISSN: 1879-0267
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