Trauma care in the tropics: addressing gaps in treating injury in rural and remote Australia.

In Australia, over half a million people are admitted to hospital every year as a result of injury, and where you live matters. Rural populations have disproportionately higher injury hospitalisation rates (1.5-2.5-fold), higher rates of preventable secondary complications, higher mortality rates (up to fivefold), and higher costs (threefold) than patients injured in major cities. These disparities scale up rapidly with increased remoteness, and shift the service needle from 'scoop and run' to 'continuum of care'. Poorer outcomes, however, are not solely due to longer retrieval distances or delays; they arise from inefficiencies in one or more potentially modifiable factors in the chain of survival. After discussing the burden of injury in Australia, we present a brief history of retrieval services in Queensland and discuss how remoteness requires a different kind of service delivery with many moving parts from point of injury to definitive care. We next address the ongoing challenges for the Australian Trauma Registry, and how centralisation of data from the metropolitan cities masks the inequities in rural and remote trauma. There is an urgent need for accurate data from all service providers around Australia to inform state and federal governments, and we highlight the paucity of trauma data analysis in North Queensland. Last, we identify some major gaps in treating rural and remote polytrauma and en-route patient stabilisation, and discuss the relevance of combat casualty care research and practices. We conclude that a greater emphasis should be placed on collecting more robust trauma patient records, as only accurate data will drive change.

Don't Blow It! Extensive Subcutaneous Emphysema of the Neck Caused by Isolated Facial Injuries: A Case Report and Review of the Literature.

BACKGROUND: Although subcutaneous emphysema resulting from maxillofacial surgery is well described in the literature, the association with maxillofacial trauma is less firm. Clinically evident subcutaneous emphysema from facial injury is uncommon and extension into the cervical and mediastinal tissues is exceedingly rare, with few reported cases. CASE REPORT: An unusual case of extensive subcutaneous emphysema after facial trauma is presented. The case posed a diagnostic dilemma in our emergency department. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Facial fractures are a rare but important cause of surgical emphysema. Emergency physicians need to be aware of the diagnostic possibility and the need to avoid factors that may precipitate secondary injury.

The utility of Advanced Trauma Life Support (ATLS) clinical shock grading in assessment of trauma.

BACKGROUND: Acute haemorrhage is a major contributor to trauma related morbidity and mortality. Quantifying blood loss acutely and accurately is a difficult task and no currently accepted standard exists. We introduce a simple shock grading tool incorporating vital signs, fluid response and estimated blood loss to describe shock grade during the primary survey based on the original Advanced Trauma Life Support (ATLS) classification. METHODS: We performed a prospective cohort study of all trauma patients admitted to our emergency room over a 1-year period to evaluate the utility of this tool for emergency physicians to detect significant haemorrhage in the trauma patient. Shock grades were prospectively assigned to patients by the trauma team as part of the primary survey, and followed up to assess for outcomes. The primary outcome was a composite endpoint of clinical, radiological and operative findings consistent with significant haemorrhage. Data were analysed using linear and logistic regression to assess predictive ability and receiver operator characteristic curve to assess overall diagnostic accuracy. RESULTS: The overall sensitivity of the shock grading tool was 83%. The diagnostic accuracy based on area under receiver operator characteristic curve was 0.86. There was also a significant association between increasing shock grade and both injury severity score (ß coefficient 7.0, p<0.001, 95% CI 6.2 to 7.8) and the presence of significant haemorrhage (OR 5.1, p<0.001, 95% CI 3.6 to 7.3). CONCLUSIONS: We conclude that a simple ATLS based clinical tool that objectively categorises haemorrhagic shock is a useful part of the primary survey of the trauma patient, although a larger study with higher statistical power is required to evaluate this conclusion further.

Emergency department management of ischaemic priapism.

This article reviews the pathophysiology of acute ischaemic priapism, as well as the role of medications as an adjunct to definitive treatment. A clear procedure for aspiration is described.

Informed consent in emergency care research: An oxymoron?

Emergency care needs to be underpinned by the highest quality evidence. However, research involving critically ill patients in the emergency setting has unique ethical, logistical and regulatory issues. Informed consent is a well-established principle in conventional research. In this article, we discuss informed consent as it pertains to the difficulties of research in the emergency setting. Alternatives to informed consent are discussed. Human research ethics committees require a greater understanding of consent issues in emergency care research for Australia to remain competitive internationally.

Trends in access block 2011 to 2013: the Redcliffe National Emergency Access Target experience.

OBJECTIVE: To evaluate the impact of the introduction of National Emergency Access Target (NEAT) on access block and long-stay patients in Redcliffe Hospital ED, and to evaluate the possibility of forward compliance with the 2014 and 2015 NEAT thresholds. SETTING AND DESIGN: Redcliffe hospital is a major urban district hospital in Brisbane with more than 55,000 adult and paediatric patients per annum. We evaluated aggregate Emergency Department Information System data for the years 2011, 2012 and 2013 to correlate presentations, NEAT compliance, access block and the number of long-stay patients in our department. RESULTS: There has been a significant reduction in both access block and our number of long-stay patients corresponding with improvements in NEAT compliance. Our forward analysis suggests that without substantial improvements in the NEAT for admitted patients, compliance with 2014 and 2015 thresholds is unlikely to be achievable. CONCLUSIONS: NEAT has been a driver of significant improvements in access block at our institution. We see significant issues with raising the NEAT threshold to the proposed 90% in 2015, and support recent calls for re-evaluation and modification of the target.