Tertiary Survey Performance in a Regional Trauma Hospital Without a Dedicated Trauma Service

Background: Initial management of trauma patients is focused on identifying life- and limb-threatening injuries and may lead to missed injuries. A tertiary survey can minimise the number and effect of missed injuries and involves a physical re-examination and review of all investigations within 24 h of admission. There is little information on current practice of tertiary survey performance in hospitals without a dedicated trauma service. We aimed to determine the rate of tertiary survey performance and the detail of documentation as well as the baseline rate of missed injuries. Methods: We performed a retrospective, descriptive study of all multitrauma patients who presented to an Australian level II regional trauma centre without a dedicated trauma service between May 2008 and February 2009. A medical records review was conducted to determine tertiary survey performance and missed injury rate. Results: Of 252 included trauma patients, 20% (n = 51) had a tertiary survey performed. A total of nine missed injuries were detected in eight patients (3.2%). Of the multiple components of the tertiary survey, most were poorly documented. Documentation was more comprehensive in the subgroup of patients who did have a formal tertiary survey. Conclusions: Tertiary survey performance was poor, as indicated by low documentation rates. The baseline missed injury rate was comparable to previous that of retrospective studies, although in this study an underestimation of true missed injury rates is likely. Implementing a formal, institutional tertiary survey may lead to improved tertiary survey performance and documentation and therefore improved trauma care in hospitals without a dedicated trauma service

Emergency intubation for paralysis of the uncooperative trauma patient

The impact of paralysis followed by intubation was studied in patients who had been traumatized and subsequently admitted to Lehigh Valley Hospital Center. Trauma admission records between January 1987 and June 1988 were reviewed. Fifty-seven patients, intubated for control of agitation and combativeness, were divided into high injury severity (HIS) and low injury severity (LIS) subgroups using admission trauma (TS) and injury severity scores (ISS). Thirty-eight (70%) were classified as HIS and 19 (30%) as LIS. All HIS patients had significant injuries diagnosed following paralysis with intubation (PWI). Mortality in the HIS group was 9%. The LIS subgroup was compared to a randomly selected group of similarly injured blunt trauma patients who did not require PWI. There were significant differences (P 100 mg%. Emergency paralysis with intubation is an effective method for controlling the uncooperative, combative, seriously injured patient. However, patients with low injury severity who require restraint have higher costs and require more care if they are paralyzed and intubated than if they are not. © 1991

Final diagnosis by fine-needle aspiration biopsy for definitive operation in breast cancer.

This work has been based on 15 years experience with more than 10,000 needle aspiration biopsies of the breast. Fine-needle aspiration biopsy was used in place of open breast biopsy for definitive operation in breast cancer. Our experience with 2,623 aspiration biopsies over a 3 year period has been reviewed. There was a total of 323 cancers, of which 257 (80 percent) were unequivocally diagnosed by fine-needle aspiration biopsy. Definitive operation was performed in 244 of these patients (95 percent) without open biopsy. Thirteen had an excisional biopsy before definitive operation at the request of the referring physician. The sensitivity was 80 percent and the specificity was 98 percent. There were no false-positive diagnoses. The positive predictive value was 100 percent. False-negative diagnoses were made in 9 percent of the patients, half of whom had nonpalpable carcinomas. Our experience shows that fine-needle aspiration biopsy is accurate in the diagnosis of breast cancer, and when the finding is positive, it can be used for definitive breast operation, eliminating the need for open biopsy. A management algorithm has also been presented herein

The pediatric trauma center and the inclusive trauma system: Impact on splenectomy rates.

BACKGROUND: Before 2006, the Delaware Trauma System (DTS) did not include a designated pediatric trauma center (PTC). In 2006, the Delaware Trauma System designated and the American College of Surgeons Committee on Trauma verification/consultation program verified Nemours AI DuPont Hospital for Children, a freestanding children\u27s hospital, as a PTC. We evaluated the impact of the addition of the PTC to the state trauma system on pediatric traumatic splenectomy rates. METHODS: The study cohort comprised DTS trauma registry recorded children younger than 16 years with spleen injury (ICD-9 codes 865.0-865.9) from January 1998 through December 2012. This cohort was categorized into pre-PTC (1998-2005) and post-PTC (2006-2012) groups. Penetrating injuries were excluded. Comparisons between groups included age, gender, length of stay, organ-specific injury grade, Injury Severity Score, incidence of polytrauma, splenectomy rate, and admitting hospital. Management, operative versus nonoperative, of low grade (Organ Injury Scale [OIS] score, 1-3) and high grade (OIS score, 4-5) were also compared. Pearson\u27s χ analysis was performed for categorical variables. Continuous variables were reported as mean (standard deviation) and compared by Student\u27s t test for independent normally distributed samples. Mann-Whitney U-test was used for non-normally distributed variables. A value of p \u3c 0.05 was considered significant. RESULTS: Of the 231 pediatric spleen injuries, 118 occurred pre-PTC and 113 occurred post-PTC. There were no significant differences in age, gender, length of stay, Injury Severity Score, OIS grade, or incidence of polytrauma. Splenectomy rates decreased from 11% (13 of 118) pre-PTC to 2.7% (3 of 113) post-PTC (p = 0.012). CONCLUSION: The addition of an American College of Surgeons-verified PTC within an inclusive trauma system that was previously without one was associated with a significant reduction in the rate of blunt trauma-related splenectomy. Integration of a verified PTC is an influential factor in achieving spleen preservation rates equivalent to published American Pediatric Surgery Association benchmarks within a trauma system. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III