Evaluation of the prehospital management of road traffic fatalities in Victoria, Australia.

INTRODUCTION: This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes. METHODS: The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion. RESULTS: One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable. CONCLUSION: The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.

Local recurrence following surgical treatment for carcinoma of the lower rectum.

BACKGROUND: The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). METHODS: During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. RESULTS: The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. CONCLUSION: The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).

Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial.

CONTEXT: Prehospital hypertonic saline (HTS) resuscitation of patients with traumatic brain injury (TBI) may increase survival but whether HTS improves neurological outcomes is unknown. OBJECTIVE: To determine whether prehospital resuscitation with intravenous HTS improves long-term neurological outcome in patients with severe TBI compared with resuscitation with conventional fluids. DESIGN, SETTING, AND PATIENTS: Double-blind, randomized controlled trial of 229 patients with TBI who were comatose (Glasgow Coma Scale score, <9) and hypotensive (systolic blood pressure, <100 mm Hg). The patients were enrolled between December 14, 1998, and April 9, 2002, in Melbourne, Australia. INTERVENTIONS: Patients were randomly assigned to receive a rapid intravenous infusion of either 250 mL of 7.5% saline (n = 114) or 250 mL of Ringer's lactate solution (n = 115; controls) in addition to conventional intravenous fluid and resuscitation protocols administered by paramedics. Treatment allocation was concealed. MAIN OUTCOME MEASURE: Neurological function at 6 months, measured by the extended Glasgow Outcome Score (GOSE). RESULTS: Primary outcomes were obtained in 226 (99%) of 229 patients enrolled. Baseline characteristics of the groups were equivalent. At hospital admission, the mean serum sodium level was 149 mEq/L for HTS patients vs 141 mEq/L for controls (P<.001). The proportion of patients surviving to hospital discharge was similar in both groups (n = 63 [55%] for HTS group and n = 57 [50%] for controls; P =.32); at 6 months, survival rates were n = 62 (55%) in the HTS group and n = 53 (47%) in the control group (P =.23). At 6 months, the median (interquartile range) GOSE was 5 (3-6) in the HTS group vs 5 (5-6) in the control group (P =.45). There was no significant difference between the groups in favorable outcomes (moderate disability and good outcome survivors [GOSE of 5-8]) (risk ratio, 0.99; 95% confidence interval, 0.76-1.30; P =.96) or in any other measure of postinjury neurological function. CONCLUSION: In this study, patients with hypotension and severe TBI who received prehospital resuscitation with HTS had almost identical neurological function 6 months after injury as patients who received conventional fluid.

Gender differences in outcome in patients with hypotension and severe traumatic brain injury.

BACKGROUND: Animal studies have identified hormonal influences on responses to injury and recovery, creating a potential gender effect on outcome. Progesterone and oestrogen are thought to afford protection in the immediate post-injury period, suggesting females have an advantage, although there has been limited evidence of this in human outcome studies. METHODS: This study examined the influence of gender on outcome in 229 adults (151 males), aged >17 years, with severe blunt head trauma, initial GCS <9 and hypotension, recruited into a randomised controlled trial of pre-hospital hypertonic saline resuscitation versus conventional fluid management. Outcome was measured by survival and Glasgow Outcome Scale-Extended version (GOS-E) scores at 6 months post-injury. RESULTS: Females recruited into the study had a higher mean age. Females were more likely to be injured as passengers and pedestrians and males as drivers or motorcyclists. There were no gender differences in GCS or injury severity scores, ICP, cerebral perfusion pressure, gas exchange (PaO2/FiO2 ratio), or duration of mechanical ventilation. After controlling for GCS, age and cause of injury, females had a lower rate of survival. They also showed a lower rate of good outcome (GOS-E score >4) at 6 months, but this appeared to reflect the lower rate of initial survival. Those females surviving had similar outcomes to males. CONCLUSIONS: The study provides no evidence that females fare better than males following severe TBI, suggesting rather that females may fare worse.

Early modifiable factors associated with fatal outcome in patients with severe traumatic brain injury: a case control study.

OBJECTIVE: Survival of patients with severe traumatic brain injury may be improved by minimizing secondary brain injury. We aimed to identify potentially modifiable contributors to secondary brain injury that may persist and adversely affect patient outcome. DESIGN: Retrospective case control study. Nonsurviving patients with traumatic brain injury were selected and matched 1:1 for age, Glasgow Coma Scale score, Abbreviated Injury Scale: Head (AISHEAD), Revised Trauma Score, and Injury Severity Score with survivors. Potentially modifiable contributors to secondary brain injury were examined and compared in both groups. SETTING: A level I trauma center in Melbourne, Australia. PATIENTS: Patients with traumatic brain injury caused by blunt trauma with an AISHEAD >or=4 were identified from a prospective intensive care database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Between January 1, 1999, and July 30, 2000, 74 patients, including 37 nonsurvivors, were identified. By design, the groups were well matched for injury severity and baseline conditions. In nonsurvivors, mean arterial pressure was similar to that of survivors at hospital arrival but was lower at 4 hrs after arrival (71 +/- 16 vs. 80 +/- 15 mm Hg, p = .016). A mean arterial pressure