Radiography for head trauma in children: what guidelines should we use?

OBJECTIVE: To audit the appropriateness of skill radiography in children attending an accident and emergency (A&E) department with head injuries. METHODS: 569 children presenting to a large teaching hospital A&E unit were retrospectively audited. The indications for radiography according to British published guidelines and American published guidelines were compared with the actual requests for radiography. The criteria for admission from the two guidelines were also compared with the actual admissions. RESULTS: 50% of children presenting with head injury actually had skull radiography. If British guidelines for the use of skull radiography had been complied with, 63% of children should have had radiography, but if American guidelines had been used, 18% would have required radiography. All the actual fractures identified were in this 18%. CONCLUSIONS: The British guidelines overinvestigate children with head injury. This seems to have been recognised clinically, and the doctors did not adhere to the guidelines. Neither did they adhere to the American guidelines, which would have resulted in a further reduction in radiography. All the fractures identified were covered by the American guidelines. The American guidelines for skull radiography can be safely used in a British A&E unit.

Changing patterns in accident and emergency attenders.

OBJECTIVE: To investigate demographic changes in attenders at an accident and emergency (A&E) department. METHODS: Patients attending Leeds General Infirmary A&E department in 1990 were compared with those attending in 1993 and 1994. Internal quality control suggested that 99% of patients were correctly registered for details of method of arrival, age, and departure (admission/discharge). RESULTS: By 1994 there had been a 6.9% increase in total numbers, including a disproportionate rise in elderly patient attendances. The overall number of patients admitted increased, as did the proportion of those attending the A&E department. There was a 28% increase in number of patients arriving by ambulance between 1990 and 1993, and this rose to 32% in 1994. CONCLUSIONS: The increasing number of new patients, especially elderly people, has implications for future planning of A&E departments. The expected demographic rise in the elderly population means that A&E departments must expect to receive more elderly patients. Our figures, if generally applicable, suggest that this is already occurring. Staffing requirements and the physical space necessary to care for these extra patients needs to take these figures into account. These factors are of relevance to both purchasers and providers.

Rules for collection of clinical data: the eight Rs.

Many reports in medical journals give advice on statistical analysis of data collected in clinical studies. The terms used are statistical, and clinicians often ponder how their data stand up to these analyses. Eight simple, easy to remember words are suggested that will help clinicians both to interpret their own data and to assess the accuracy of presented or published data.

Lyell's syndrome on a burns unit.

Two cases of Lyell's syndrome (toxic epidermal necrolysis) managed on a burn unit are presented. The various methods of management are discussed, and the arguments for treating this life-threatening condition on an intensive care burn unit are analysed.

The hit and miss of ISS and TRISS. Yorkshire Trauma Audit Group.

OBJECTIVE: To measure interobserver variation in recording injury from case notes and its effect on calculating injury severity scores (ISS) from identical data and predicting probabilities of survival by using the combined trauma and injury severity score (TRISS). DESIGN: Observer variation study using injury severity scoring and subsequent calculation of probability of survival based on combined trauma and injury severity scores. SUBJECTS: 16 patients with a range of injury severity scores, and 15 observers. RESULTS: There was a wide variation in recorded injury severity scores, the probability of two observers agreeing on the score being 0.28 (28%). The probability of any two observers agreeing over which severity band the patient should be in was 0.5 (50%). Observer variation was independent of the training and type of observer. Survival probability (calculated by combined trauma and injury severity scoring methodology from individual observers' scores) varied by over 0.2 in six of the 16 patients and by over 0.5 in three. CONCLUSIONS: There is wide observer variation in injury severity scoring, which highlights a potential fallibility in its use for trauma audit. The use of combined trauma and injury severity scoring for individual prediction of survival is potentially inaccurate except at the extremes of probabilities. The use of the 0.5 survival line on a combined trauma and injury severity score "pre-chart" is statistically and clinically inappropriate.

Radiography for back pain presenting to accident and emergency departments.

In order to determine the relevance of radiographs of the lumbar spine in an A&E department 225 consecutive patients presenting in a 6-month period with acute back pain were studied. An analysis of the number of radiographs performed and their association with particular factors in the history and examination of the patient was performed. A total of 108 patients had radiographs (48%), with a total of seven fractures (6% of radiographs). All the patients with fractures had a history of direct trauma. Radiographs had no bearing on the decision to admit the patient. The indications for radiography of the lumbar spine in the A&E department are discussed.

Is iliac node clearance necessary for stage II melanoma?

In a retrospective review (1970-1983), survival following block dissection of the groin was compared in two groups with clinical stage II melanoma. Twenty patients under one surgeon had ilioinguinal (high) block dissection, and 22 patients under another surgeon had inguinal (low) block dissection. The high block 5-year survival was 40 percent, and the low block 5-year survival was 35 percent. There was no statistical difference between groups on life-table or log-rank test analysis. It is concluded that the extent of groin dissection has no effect on survival of stage II melanoma.

Fractures of the body of the hamate.

Eight cases of fracture of the body of the hamate are presented, with descriptions of the injury and management. This fracture may be considerably more common than indicated by standard texts and previous published reports.

The use of the lateral arm flap in upper limb surgery.

Twenty patients who had had upper limb reconstruction using the lateral arm free microvascular flap are reviewed. The size of the flap, modifications to the flap, and complications were documented. There was one flap failure, and nine flaps required surgical thinning at a second procedure. This sole disadvantage was outweighed in clinical usage by the advantages and versatility of the lateral arm flap.

Further experience with the lateral arm free flap.

Our experience with the lateral arm free flap over the last 7 years was reviewed in detail, placing emphasis on the clinical aspects and modifications of the flap. A total of 150 patients have undergone reconstructive procedures with the flap for small to medium-sized defects. This included 18 split flaps, 11 osteocutaneous flaps, 6 with vascularized triceps tendon, 5 neurosensory flaps, and 5 fascia-fat flaps. The donor-site scar was generally acceptable; only 3 patients required scar revision and 15 patients required debulking of the flaps. With use of the split flap for wide defects, tension-free primary closure of the donor site can be achieved. In most cases, a two-team approach may be adopted, thereby increasing the efficiency of this microvascular transfer.

Adequacy of general practitioners' premises for minor surgery.

OBJECTIVE: Assessment of facilities for minor surgery in general practitioners' premises. DESIGN: Independent inspection of premises and equipment. SETTING: Large urban district. SUBJECTS: Premises of all general practitioners who applied to be reimbursed for minor surgery. MAIN OUTCOME MEASURE: Fullfilment of 14 pre-selected criteria. RESULTS: 69 of 111 premises met all criteria and were approved; 23 failed on only one criterion. The commonest reasons for failure were inadequate record keeping and lack of resuscitation equipment. Twelve practices had out of date adrenaline. CONCLUSIONS: Most premises are suitable for minor surgery, some with attention needed to record keeping. Practices must pay careful attention to the expiry date of adrenaline.

Upper gastro-intestinal complications in major head and neck surgery.

The recovery of patients from major head and neck surgery can be compromised by severe upper gastro-intestinal complications. We present two cases with such problems and discuss the rationale for our current management of prophylaxis.

Tissue expansion: a unit review of non-scalp, non-breast expansion.

The results in 76 tissue expansions of sites other than the breast and scalp in 56 patients are presented. The overall failure rate was 12%, being particularly high in the arm (31%) and low in the leg (0%). Details of the technique used and their relevance to success are discussed.

Tissue expansion technique and the transposition flap.

A simple clinical guide is provided for calculation of the size of tissue expander necessary for any given defect. The use of an expanded transposition flap is demonstrated and its advantages expounded.