The ethical and medico-legal issues of trauma care

Ethical issues confront trauma clinicians on a daily basis. This article highlights the similarities of trauma ethical dilemmas to those faced by other emergency care providers and takes the reader through the inpatient aspects of trauma care

An analysis of patients transported by a private helicopter emergency medical service in South Africa

Background. A helicopter emergency medical service (HEMS) is a specialist flying emergency service where on-board medical personnel have both the knowledge and equipment to perform complicated medical procedures. The paucity of literature describing the types of patients flown by HEMS in South Africa (SA) and their clinical outcome poses a challenge for current aeromedical services, as there is no baseline information on which to base flight criteria, staffing and policy documents. This has the potential to hamper the advancement of HEMS in SA.Objectives. To undertake a descriptive analysis of patients flown by the Netcare 911 HEMS over a 12-month period in Gauteng and KwaZulu-Natal (KZN) provinces, SA, and to assess patient outcomes. The clinical demographics of patients transported by the HEMS were analysed, time frames from dispatch of the helicopter to delivery of the patient to the receiving hospital determined, and patient outcomes at 24 hours and 72 hours analysed.Methods. The study utilised a retrospective quantitative, descriptive design to analyse patients transported by a private HEMS in SA. All complete records of patients transported by the Netcare 911 HEMS between 1 January and 31 December 2011 were included.Results. The final study population comprised 537 cases, as 10 cases had to be excluded owing to incomplete documentation. Of the 537 cases, 82 (15.3%) were managed by the KZN HEMS and 455 (84.7%) by the Gauteng HEMS. Adult males were the patients most commonly flown in both Gauteng and KZN (350/455 patients (76.9%) in Gauteng and 48/82 (58.5%) in KZN were males, and 364/455 patients (80.0%) in Gauteng and 73/82 (89.0%) in KZN were adults). Motor vehicle collisions were the most common incidents necessitating transport by HEMS in both operations (n=193, 35.9%). At the 24-hour follow-up, 339 patients (63.1%) were alive and stable, and at the 72-hour followup, 404 (75.3%) were alive and stable.Conclusions. The study findings provided valuable information that may have an impact on the current staffing and authorisation criteria of SA HEMS operations

Early enteral nutrition compared to outcome in critically ill trauma patients at a level one trauma centre

Objectives: The benefit of an early enteral nutrition start in critical ill patients is widely accepted. However, limited published data focus on trauma patients. This study aimed to investigate the effect of early enteral nutrition initiation on length of stay and mortality in an intensive care unit (ICU), as well as explore if enteral nutrition initiation could serve as a prognostic marker in trauma patients.Design: This was a retrospective audit of a prospective ethics-approved database (University of KwaZulu-Natal Biomedical Research Ethics Committee No BE207-09) which compared enteral nutrition to outcome.Setting: The setting was a level 1 trauma ICU in Durban, South Africa.Subjects: The subjects were critically ill trauma patients.Outcome measures: Demographic data, enteral nutrition timing, feed tolerance, and the outcome of early versus late initiation of enteral feeding were the outcome measures.Results: Nine hundred and fifty-two patients were included. Eight hundred and ninety-eight received enteral nutrition and were divided into three subgroups (tertiles T1-T3) according to their Injury Severity Score (ISS). The statistical analysis demonstrated that an early enteral nutrition start had a significant positive effect on both length of stay (13.7 vs. 16.4 days, p-value 0.00315) and mortality (9.5 % vs. 20.7 % p-value 0.0062). A multiple logistic regression model was developed, using multiple variables, to test the factors that affected the outcome. There was a significant effect on length of stay with an early enteral nutrition start in patients with a low to medium ISS (T1), and a highly significant effect on mortality in patients with a low to medium, and high, ISS (T1 and T2). Early initiation of enteral nutrition is strongly favoured in regression analyses.Conclusion: Patients in the trauma ICU benefit from an early enteral nutrition. The model used featuring the three independent variables, i.e. the day on which enteral nutrition is commenced, age and ISS, may serve as a prognostic marker with regard to length of stay and mortality in the ICU.Keywords: enteral nutrition, early initiation, outcome predictio

Complications relating to enteral and parenteral nutrition in trauma patients: a retrospective study at a level one trauma centre in South Africa

Objectives: The aim of the study was to compare the incidence of complications in patients receiving enteral and parenteral nutrition (PN), and review how the early initiation of enteral feeding and early achievement of caloric goal would affect the incidence of complications.Design: The design was a retrospective audit of an ethics-approved prospective trauma registry and electronic medical record.Setting: The setting was a level one trauma centre intensive care unit.Subjects: One thousand and two consecutively treated patients were selected from 1 096 in the database.Outcome measures: Demographic data, nutrition, route of administration, time of initiation and complications in the form of sepsis, pneumonia and feed intolerance, were determined.Results: Patients receiving total PN (TPN) during their length of stay had a hazard ratio of 9.11 for the development of sepsis, compared to patients who were solely fed via the enteral route (p-value <0.001). The patients who reached their nutritional goal late showed a hazard ratio of 2.67 for the development of sepsis, compared to patients who reached the goal early (p-value < 0.001). Patients with late initiation of feeding also had a greater risk of developing sepsis, with a hazard ratio of 2.41, compared to patients with early initiation (p-value < 0.001). Patients achieving the nutritional goal late had a 17.9% increased risk of developing pneumonia (p-value < 0.001).Conclusion: This study confirms previous findings that the use of TPN is a strong predictor of the development of sepsis, compared to enteral nutrition. Causality linkage should be made with caution owing to the study design.Keywords: complications, critical illness, nutrition, trauma, outcom

Empirical antimicrobial therapy for probable v. directed therapy for possible ventilator-associated pneumonia in critically injured patients

Background. Ventilator-associated pneumonia (VAP) has recently been classified as possible or probable. Although direct attributable mortality has been difficult to prove, delay in instituting appropriate therapy has been reported to increase morbidity and mortality. Recent literature suggests that in possible VAP, instituting directed therapy while awaiting microbiological culture does not prejudice outcome compared with best-guess empirical therapy.Objectives. To ascertain outcomes of directed v. empirical therapy in possible and probable VAP, respectively. Methods. Endotracheal aspirates were obtained from patients with suspected VAP. Those considered to have possible VAP were given directed therapy following culture results, whereas patients with more convincing evidence of VAP were classed as having probable VAP and commenced on empirical antimicrobials based on microbiological surveillance.Results. Pneumonia was suspected in 106 (36.8%) of 288 patients admitted during January - December 2014. Of these, 13 did not fulfil the criteria for VAP. Of the remaining 93 (32.2%), 31 (33.3%) were considered to have probable and 62 (66.7%) possible VAP. The former were commenced on empirical antimicrobials, with 28 (90.3%) receiving appropriate therapy. Of those with possible VAP, 34 (54.8%) were given directed therapy and in 28 (45.2%) no antimicrobials were prescribed. Of the latter, 24 recovered without antimicrobials and 4 died, 3 from severe traumatic brain injury and 1 due to overwhelming intra-abdominal sepsis. No death was directly attributable to failure to treat VAP. No significant difference in mortality was found between the 34 patients with possible VAP who were commenced on directed therapy and the 31 with probable VAP who were commenced on empirical antimicrobials (p=0.75).Conclusions. Delaying antimicrobial therapy for VAP where clinical doubt exists does not adversely affect outcome. Furthermore, this policy limits the use of antimicrobials in patients with possible VAP following improvement in their clinical condition despite no therapy

Direct admission versus inter-hospital transfer to a level I trauma unit improves survival An audit of the new Inkosi Albert Luthuli Central Hospital trauma unit

Objective. To audit the performance of a new level I trauma unit and trauma intensive care unit. Methods. Data on patients admitted to the level I trauma unit and trauma intensive care unit at Inkosi Albert Luthuli Central Hospital, Durban, from March 2007 to December 2008 were retrieved from the hospital informatics system and an independent database in the trauma unit. Results. Four hundred and seven patients were admitted; 71% of admissions were inter-hospital transfers (IHT) and 29% direct from scene (DIR). The median age was 27 years (range 1 - 83), and 71% were male. Blunt injury accounted for 66.3% of admissions and penetrating trauma for 33.7%. Of the former, motor vehicle-related injury accounted for 87.4%, with 81% of paediatric admissions due to pedestrian-related injuries. The median injury severity score (ISS) for the entire cohort was 22 (survivors 18, deaths 29; p<0.001). Patients in the DIR group had a significantly higher mean ISS compared with the IHT group (DIR 25, IHT 20; p<0.02). The overall mortality rate was 26.3%. There were 37 deaths (31.1%) in the DIR group and 70 (24.3%) in the IHT group (p=0.19). In patients surviving more than 12 hours the overall mortality rate was 21.1% (DIR 13.7%, IHT 23.5%; p=0.042). Conclusions. Trauma is a major cause of premature death in the young. Despite a significantly higher median ISS in direct admissions, there was no difference in mortality. Of those surviving more than 12 hours, patients admitted directly had a significant decrease in mortality. Dedicated trauma units improve outcome in the critically injured

Anticancer Gene Transfer for Cancer Gene Therapy

Gene therapy vectors are among the treatments currently used to treat malignant tumors. Gene therapy vectors use a specific therapeutic transgene that causes death in cancer cells. In early attempts at gene therapy, therapeutic transgenes were driven by non-specific vectors which induced toxicity to normal cells in addition to the cancer cells. Recently, novel cancer specific viral vectors have been developed that target cancer cells leaving normal cells unharmed. Here we review such cancer specific gene therapy systems currently used in the treatment of cancer and discuss the major challenges and future directions in this field

Fluid in prehospital care; Misdiagnoses in trauma; When to stop resuscitation in trauma.

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Operating on the Traumatized Patient: The team approach

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