High quality acute care for the severely injured is not consistently available in England, Wales and Northern Ireland: report of a survey by the Trauma Committee, The Royal College of Surgeons of England.

INTRODUCTION: A survey was undertaken to determine the extent to which acute hospitals in England, Wales and Northern Ireland were meeting the acute trauma management standards published in 2000 by The Royal College of Surgeons of England and the British Orthopaedic Association. METHODS: A questionnaire comprising 72 questions in 16 categories of management was distributed in July 2003 to all eligible hospitals via the link network of the British Orthopaedic Association. Data were collected over a 3-month period. RESULTS: Of 213 eligible hospitals, 161 (76%) responded. In every category of acute care, failure to meet the standards was reported. Only 34 (21%) hospitals met all the 13 indicative standards that were considered pivotal to good trauma care, but all hospitals met at least 7 of these standards. Failures were usually in the organisation of services rather than a lack of resources, with the exception of the inadequate capacity for admission to specialist neurosurgery units. A minority of hospitals reported an inability to provide emergency airway control or insertion of chest tube. The data have not been verified and deficiencies in reporting cannot be excluded. CONCLUSIONS: The findings of this survey suggest that high quality care for the severely injured is not available consistently across England, Wales and Northern Ireland, and appear to justify concerns about the ability of the NHS to deal effectively with the current trauma workload and the consequences of a major incident.

Neurological outcome prediction in a cardiorespiratory arrest survivor.

Outcome prediction of neurological recovery in an unconscious survivor of cardiorespiratory arrest is difficult and uncertain. We describe the case of a 25-yr-old post-arrest survivor who made a remarkable neurological improvement despite a seemingly hopeless prognosis. Conventional clinical and neurophysiological assessments need to be interpreted with care in the presence of uncontrolled seizure activity and sedative medications. The measurement of biochemical markers in the serum and cerebrospinal fluid may be useful in helping the clinician to arrive at a more accurate neurological outcome prediction.

Triaging patients with serious head injury: results of a simulation evaluating strategies to bypass hospitals without neurosurgical facilities.

OBJECTIVES: to inform the debate on whether seriously head-injured adult patients should be transported directly to the regional neurosurgical unit or indirectly after evaluation and stabilisation at the nearest hospital. DESIGN: a simulation model was constructed to compare triage strategies and to identify those that predicted the maximum survivors. In each strategy, an estimate of the patient's condition in the field was used to determine the receiving hospital. The model used data from previous publications and local ambulance service and hospital databases. In the absence of valid data, expert clinical estimates were made and subjected to sensitivity analyses. SETTING: an area in the North West Midlands of UK, covered by six acute hospitals including one with a regional neurosurgical unit. OUTCOME MEASURE: the number of survivors predicted by each triage strategy. RESULTS: five strategies were identified which consistently predicted the highest number of survivors. Compared with current policy it was predicted that in the North West Midlands, ten lives per year could be saved (6 per million total population per year). The results from sensitivity analyses did not alter these successful policies. CONCLUSION: the successful strategies should be considered as potential improvements to be introduced into clinical practice.

Intensive care of the trauma patient.

Intensive care is a process and not a location and should commence as soon as major trauma is recognised. The management of severely injured patients requires all of the skills and resources of modern day intensive care medicine and can be challenging and expensive. Despite prolonged stays in the intensive care units and hospitals, the outcome for these patients is often excellent.

A comparison of patient characteristics and survival in two trauma centres located in different countries.

INTRODUCTION: The aim of the study was to compare patient characteristics and mortality in severely injured patients in two trauma centres located in different countries, allowing for differences in case-mix. It represents a direct bench-marking exercise between the trauma centres at the North Staffordshire Hospital (NSH), Stoke-on-Trent, UK and the Oregon Health Sciences University (OHSU) Hospital, Portland, Oregon, USA. METHODS: Patients of all ages admitted to the two hospitals during 1995 and 1996 with an Injury Severity Score >15 were included, except for those who died in the emergency departments. Twenty-three factors were studied, including the Injury Severity Score, Glasgow Coma Score, mechanism of injury and anatomical site of injury. Outcome analysis was based on mortality at discharge. RESULTS: The pattern of trauma differed significantly between Stoke and Portland. Patients from Stoke tended to be older, presented with a lower conscious level and a lower systolic blood pressure and were intubated less frequently before arriving at hospital. Mortality depended on similar factors in both centres, especially age, highest AIS score, systolic blood pressure and Glasgow Coma Score.The crude analysis of mortality showed a highly significant odds-ratio of 1.64 in Stoke compared with Portland. Single-factor adjustments were made for the above four factors, which had a similar influence on mortality in both centres. Adjusting for the first three factors individually did not alter the odds-ratio, which stayed in the range 1.53-1.59 and remained highly significant. Adjusting for the Glasgow Coma Score reduced the odds-ratio to 0.82 and rendered it non-significant. In a multi-factor logistic regression model incorporating all of the factors shown to influence mortality in either centre, the odds-ratio was 1.7 but was not significant. CONCLUSION: The analysis illustrates the limitations and pitfalls of making crude outcome comparisons between centres. Highly significant differences in crude mortality were rendered non-significant by case-mix adjustments, supporting the null hypothesis that the two centres were equally effective in terms of this short-term indicator of outcome. To achieve a meaningful comparison between centres, adjustments must be made for the factors which affect mortality.

Survey of abdominal ultrasound and diagnostic peritoneal lavage for suspected intra-abdominal injury following blunt trauma.

Over a 3 year period all severely injured blunt trauma patients who were investigated with abdominal ultrasound examinations (AUS) or diagnostic peritoneal lavage (DPL) to exclude intra-abdominal injury were evaluated. The ultrasound examinations were performed by radiologists in 220 severely injured patients (20 of whom also had DPL). The overall sensitivity and specificity of abdominal ultrasound were 82.7% and 99.5%, respectively. The sensitivity increased to 89.1% by repeat scanning. In comparison, 72 DPLs were performed in severely injured patients; the overall sensitivity and specificity of DPL were 82.8% and 97.2%, respectively. DPL resulted in more non-therapeutic laparotomies, 9/25 (36%) compared with 3/23 (13%) with AUS. Abdominal ultrasound is now the first line investigation at this centre for evaluation of possible intra-abdominal injury in injured patients.

Role of the general surgeon in a British trauma centre.

A prospective audit of trauma patients seen or treated by the Department of General Surgery at the North Staffordshire Hospital Trauma Centre has been carried out, examining both the effect of a newly established trauma centre on overall workload and the outcome of patients admitted with severe injury. Trauma comprised approximately 2 per cent of the overall general surgical emergency workload. General surgeons were involved in the assessment of 25 per cent of severely injured patients but overall operated on fewer than 10 per cent of patients in this group. No patient died during the study period as a consequence of missed or inadequately treated intra-abdominal injury. These data suggest that there is insufficient work to justify specialist general surgical trauma surgeons in the UK. When general surgical intervention is required, however, it is usually vital and potentially life-saving.

Mask lung ventilation by ambulance personnel: a performance assessment.

We evaluated the ability of basic life support ambulance officers and anaesthetists to perform lung ventilation with a face mask. After induction of anaesthesia and institution of standardized airway conditions the ambulance officer or anaesthetist placed a mask on the patient's face and lung ventilation was commenced. The order of hand grip (one vs two hands) was randomized. The mask was connected to a ventilator which had flow and pressure transducers in the inspiratory and expiratory breathing circuits. The output of these devices was sent to an electronic integrator to determine volumes. Calibration of the flow transducers was made against a spirometer while ventilating a test lung. Oesophageal insufflation was determined by listening over the epigastrium with a stethoscope. Data collected included presence of gastro-oesophageal insufflation, inspiratory and expiratory volumes. Expiratory volumes for ambulance officers and anaesthetists at 30 cm H2O were greater than that of ambulance officers at 20 cm H2O (P < 0.001) but profession of the mask holder or hand grip had no effect on expiratory volume. There was no difference in the mask leak when the professions were compared but ambulance officers had a lower mask leak with a two-handed grip at 20 cm H2O (P < 0.001). Anaesthetists had a greater incidence of gastro-oesophageal insufflation when a two-handed mask grip was utilized (P < 0.05). In healthy relaxed patients there appeared to be little difference between the ambulance officers and qualified anaesthetists in airway maintenance or mask-holding ability.

Measurement of dead-space in a model lung using an oscillating inspired argon signal.

In a model lung, airways dead-space can be accurately measured using a forced inspired oscillating argon signal, which varies sinusoidally about a mean concentration of 6% v/v with an amplitude of +/- 4% v/v. With sinusoid forcing periods longer than 120 seconds, and at a breathing rate of 13.4 breaths minute-1, the mean airways dead-space can be measured with a standard error of less than 5%. Sinusoid forcing periods shorter than 120 s provided inaccurate estimates of dead-space and so should not be used with this technique.

Development of a concentric water-displacement model lung.

Simulation of lung ventilation using a model lung can provide a means of evaluating lung function tests, mathematical models and computer algorithms. We describe a new water-displacement lung model, which can simulate lung volumes up to 3.8 l and tidal volumes up to 1 l. Gas mixing is ensured by using a ring of venturi devices. Model compliance and airways resistance are described.

Inaccuracy and delay in decision making in paediatric resuscitation, and a proposed reference chart to reduce error.

Several surveys have noted the poor performance of junior hospital doctors in simulated cardiorespiratory arrest in adults. A further survey was undertaken to investigate inaccuracy and delay in the resuscitation of children. The results suggested that inaccuracy was a greater problem than delay. Because of the variation in size of children and the comparative infrequency of cardiorespiratory arrest in this age group a simple, versatile, and readily available reference chart is needed to aid rapid and accurate decisions.