Paediatric trauma imaging in a regional Queensland hospital: Do we need clearer guidance?

OBJECTIVE: Paediatric trauma is a major cause of morbidity and mortality in those aged 0-14. Anatomical and physiological differences require a specialised approach to paediatric trauma care. Medical imaging, particularly computed tomography (CT) scans, requires specific consideration because of the consequences of radiation exposure in the paediatric population. The present study compares current practice of CT scan ordering in paediatric trauma patients at a regional Australian hospital against consensus guidelines published in the UK. METHODS: A retrospective audit of paediatric trauma CT scans referred from the ED from May 2017 to May 2018 was completed. Details relating to CT scan ordering were reviewed and compliance with the Royal College of Radiologists Paediatric trauma protocols, was determined. Descriptive statistics and χ2 tests comparing those that met and did not meet guidelines were performed. RESULTS: A total of 71 CT scans were included with an overall compliance rate of 56.3%. Specific regional compliance was lowest with CT neck at 14%. Patients where a trauma call was initiated were more likely to receive a full body (pan) scan rather than region specific imaging. Compliance improved when paediatric team involvement was documented. CONCLUSIONS: Evidence-based guidelines for CT imaging in paediatric trauma are essential to reduce unnecessary radiation exposure for children. The present study has demonstrated that current practice has the potential to be improved and that decisions should involve a multidisciplinary team.

Tranexamic Acid Use During Surgery Associated with Extension of Acute Perioperative Type 1 Myocardial Infarction: A Case Report.

CASE PRESENTATION: A 70-year-old women presented to a regional hospital after a fall, resulting in a periprosthetic femoral fracture. Preoperative echocardiogram was ordered to investigate a cardiac murmur, and unexpectedly, a significant regional wall abnormality was found. Further repeat electrocardiograph and troponin blood biomarker analysis demonstrated the patient had suffered an acute type 1 myocardial infarction after admission to the ward, without exhibiting classical ischemic cardiac symptoms. A multidisciplinary decision was made for the patient to proceed to surgery, and at that time, she received tranexamic acid (TXA). Postoperatively, there was notable echocardiographic extension of the infarction, which required transfer to a tertiary center for management with complex coronary artery stenting. The patient once discharged was followed up by cardiology at the 3-month interval. CONCLUSION: The use of TXA in arterial thromboembolic disease requires thorough consideration because it may contribute to further myocardial damage. A patient-specific approach should be adopted with the risk of thrombosis extension being considered.

Trauma Teams in Aotearoa New Zealand-a national survey.

AIMS: Improved survival of trauma patients has been shown when a multidisciplinary trauma team is available. The aim of this study is to investigate the composition of trauma teams, trauma call criteria and the role of anaesthetists in trauma care across New Zealand. METHODS: A survey was distributed using the modified Dillman's technique. Data was collected and aggregated using an online platform. The survey consisted of two streams of questions depending on trauma team availability. Trauma nurse specialists were the first contact point and if not available, direct contact with the hospital was made for completion of the survey. RESULTS: Seventy-five percent of hospitals had a trauma team and trauma call system and correlated to size of the hospital. The number of trauma team members ranged from six to 17, with a median of 10. Trauma call activation criteria encompassed physiological criteria, injury pattern and injury mechanism criteria. Physiological criterial of GCS, heart rate, blood pressure and respiratory rate were universally used. Sixty-two percent of trauma teams had involvement of anaesthetists. CONCLUSIONS: Trauma teams in New Zealand are common in regional and tertiary trauma hospitals. There is a wide variation in member numbers and criteria to trigger a trauma call. Anaesthetist involvement was in over half of trauma teams with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

Ventilation management in Victorian intensive care unit patients without acute respiratory distress syndrome.

BACKGROUND: The setting of tidal volume (VT) during controlled mechanical ventilation (CMV) in critically ill patients without acute respiratory distress syndrome (ARDS) is likely important but currently unknown. We aimed to describe current CMV settings in intensive care units (ICUs) across Victoria. METHODS: We performed a multicentre, prospective, observational study. We collected clinical, ventilatory and arterial blood gas data twice daily for 7 days. We performed subgroup analysis by sex and assessment of arterial partial pressure of carbon dioxide (PaCO2) management where hypercapnia was potentially physiologically contraindicated. RESULTS: We recorded 453 observational sets in 123 patients across seven ICUs. The most commonly selected initial VT was 500 mL (33%), and this proportion did not differ according to sex (32% male, 34% female). Moreover, 38% of patients were exposed to initial VT per predicted body weight (VT-PBW) > 8.0 mL/kg. VT-PBW in this range were more likely to occur in females, those with a lower height, lower ideal body weight or in those for whom hypercapnia was potentially physiologically contraindicated. As a consequence, females were more frequently exposed to a lower PaCO2 and higher pH. CONCLUSIONS: In adults without ARDS undergoing CMV in Australian ICUs, the initial VT was a stereotypical 500 mL in one-third of participants, irrespective of sex. Moreover, around 40% of patients were exposed to an initial VT-PBW > 8.0 mL/kg. Finally, women were more likely to be exposed to a high VT and hyperventilation.