Improvements in trauma survival in Leeds

doi:10.1016/0020-1383(95)00059-I

Injury

Volume 26, Issue 7, September 1995, Pages 455-458

https://doi.org/10.1016/0020-1383(95)00059-I Get rights and content

Abstract

One hundred and eighty-six cases of major trauma (Injury Severity Score > 15) admitted to the two Leeds hospitals in 1988/89 were compared with 198 cases admitted in 1992/93 to ascertain if a system of trauma care which had evolved in the hospitals during this time had affected outcome of these patients. Injury severity score, age, and sex distribution were similar for the two groups. There were significantly fewer deaths in 1992/93, particularly in those patients with a score less than 41. It would appear that the emphasis, since 1988, on timely and definitive management of patients with major trauma has led to improved survival of the seriously injured in Leeds.

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Anxiety and depression following traumatic limb amputation: A systematic review
2014, Injury
Citation Excerpt :
This may be an underestimate given that 90% of injuries occur in low or middle-income countries. It is estimated 10,500 serious injuries with an Injury Severity Score (ISS) of 16 or more occur in the United Kingdom each year [3]. These resulted in 337 lower limb and 113 upper limb traumatic amputations in 2007 [4].
Traumatic amputation can result in multiple physical, psychological and socio-economic sequalae. While there has been a significant increase in investment and public profile of the rehabilitation of patients who have experienced traumatic limb amputation, little is known about the prevalence of anxiety and depression, especially in the long term.
To determine the association between traumatic limb amputation and anxiety and depression.
A literature search of available databases including Cochrane, Medline, Embase, and PsycINFO was performed for relevant studies since 2002. Secondary outcomes included the effect on employment, substance misuse, relationships and quality of life.
Randomised control trials, observational studies or reviews which met the inclusion, exclusion and quality criteria.
Levels of anxiety and depression are significantly higher than in the general population. Significant heterogeneity exists between studies making meta-analyses inappropriate. Improved rehabilitation is having a positive effect on employment rates. There appears to be no significant effect on substance abuse and relationships.
All studies demonstrated high prevalence of anxiety and depression in post-traumatic amputees. No good prospective data exists for levels of anxiety and depression beyond two years of follow up and this should be an area of future study.
Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?
2009, Injury
Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990 s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality.
In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or “Will Rogers” phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.
The multiply injured patient
2008, Foundation Years
Citation Excerpt :
In the Western world, the incidence of multiple trauma is decreasing due to a reduction in heavy industry, improved motor vehicle safety and more stringent drink-driving legislation. Nonetheless, it has been estimated that 1 in 1000 attendances in accident and emergency in the UK each year are for the multiply injured patient and that most acute hospitals will receive approximately one case per week.2 The financial cost of major trauma in terms of medical expenditure, loss of economic activity and social impact can also be substantial, with an estimated cost of £102,880 per case.3
Management of the multiply injured patient requires a co-ordinated multi-disciplinary approach in order to optimise patient outcomes. With most acute hospitals receiving at least one multiple trauma case per week it is highly likely that a foundation doctor will be involved in the care of these patients, either in the acute resuscitation phase or following surgery. A working knowledge of the sort of problems these patients encounter is therefore vital to ensure that life-threatening injuries are recognised and treated in a timely fashion and that more minor associated injuries are not forgotten. This article outlines the management of polytrauma patients using the Advanced Trauma Life Support (ATLS) principles and highlights the areas of specific involvement from the musculoskeletal team.
Major trauma & cervical clearance radiation doses & cancer induction
2008, Injury
Citation Excerpt :
Multiply injured patients have high Injury Severity Scores (ISS)8 and a high mortality, despite the increasing input of more senior doctors in A&E.33 In Leeds, the survival of a patient with an ISS of over 15 improved from 52% to 76% between 1988 and 1993.9 The overall incidence of cervical spine injury in multiply injured in level I trauma centres is low.11,14,16,3,1
To compare the radiation dose of cervical spine clearance and body CT in a cohort of unconscious, major trauma patients for three different protocols, comparing spiral to multislice CT. To quantify the radiation exposure effect of the protocols on the lifetime cancer risk.
The hospital trauma database was used to find the unconscious (GCS < 9), severely injured (Injury Severity Score >15) from 1 January 2001 to 31 December 2003, excluding isolated head injuries. The protocols used for imaging the brain and cervical spine were, including the radiographs performed as a mode:
- (1)
  Three cervical radiographs (lateral, antero-posterior and open-mouth peg views) and CT of the brain and cranio-cervical junction.
- (2)
  CT of the brain, cranio-cervical and the cervico-dorsal junctions with two radiographs (lateral and antero-posterior).
- (3)
  A lateral radiograph and CT of the brain and whole cervical spine. The dose of the initial body CT was recorded.
The exposure factors and field of view used were put into the Monte Carlo software, to estimate the CT and radiographic X-ray doses to the body as a whole and the dose to the thyroid associated with each region imaged. The associated nominal additional lifetime cancer risk was assessed.
Excluding inter hospital transfers, where data was incomplete, 87 patients survived to be admitted and fulfilled the criteria. In 30 cases, the CT films were missing, the exposure factors were not recorded or no imaging was performed. In a further 21 cases, the X-ray packets were missing. Three patients had brain and cervico-dorsal CT imaging only, leaving 33 cases for evaluation.
The effective radiation dose for a spiral CT of the brain using the Toshiba Xpress GX CT scanner was 3.8 mSv. The total effective doses for imaging the brain and cervical spine using the three protocols with the same CT scanner were (S.D. as % of mean): (1) 4.4 mSv (5%), (2) 7.1 mSv (10%) and (3) 8.2 mSv (15%). The corresponding mean thyroid doses were: (1) 8.5 mGy (25%), (2) 48.9 mGy (20%) and (3) 66.5 mSv (20%). The resultant nominal lifetime cancer risks were: (1) 1:4500, (2) 1:2800 and (3) 1:2400.
For the Siemens Sensation 16 multislice CT scanner, the total effective doses (S.D. as % of mean) were: (1) 2.3 mSv (10%), (2) 4.3 mSv (25%) and (3) 5.4 mSv (35%). The mean doses to the thyroid were: (1) 5.9 mGy (30%), (2) 36.1 mGy (50%) and (3) 52.4 mGy (40%). The lifetime cancer risks were: (1) 1:8700, (2) 1:4600 and (3) 1:3700.
Using the Toshiba spiral CT scanner, the total dose and additional lifetime nominal cancer risk associated with CT of the chest, abdomen and pelvis (CAP) as 16 mSv and 1:1250, respectively. Using the Siemens multislice CT scanner, these were 11.8 mSv and 1:1700. The cancer risk for protocol 1 when combined with a CT scan of the chest, abdomen and pelvis was 1:1000 for the spiral CT scanner and 1:1500 for the multislice CT (MCT) scanner. The cancer risk for protocol 2 with CAP CT using the MCT was 1:1200. The cancer risk for protocol 3 when combined with a CT scan of the chest, abdomen and pelvis was 1:1100 for the multislice CT scanner. Prior to the introduction of the BTS guidelines for cervical clearance, 12% of cases had CT of the body, which increased to 16% post-guidelines.
CT of the trunk (chest, abdomen and pelvis) is associated with the greatest risk of inducing a fatal cancer in the severely injured patient with a GCS less than 9. In our institution the multislice CT protocols expose the patient to less radiation than single slice CT, which is contrary to much of the published work to date. CT scanning the thyroid (or whole cervical spine) still has a marked effect on the cancer risk in cervical clearance.
Many centres will relax cervical spinal precautions in unconscious trauma patients if the cervical spine CT with reconstructions is normal. CT of the whole cervical spine may be justified in the unconscious, severely injured patient. In conscious trauma patients, the additional lifetime risk may not justify CT of the whole cervical spine as a routine practice.
Improvement in initial survival of spinal injuries: A 10-year audit
2005, Injury
A 10-year retrospective study of all spinal injuries presenting to the Leeds Teaching Hospitals between 1991 and 2001.The hospitals provide secondary care to a population of 750,000 and tertiary care to a population of 2–3 million.
In total 1119 spinal injuries were studied. The overall survival rate was 89%. The commonest age group for presentation was 25–29 years with a secondary peak in the seventh decade, a mean overall of 43 years. 66% of injuries occurred in males. The commonest cause was a fall from a height (44%), with road traffic accidents (RTA) causing 43%. Pedestrians were most at risk within the road traffic group, making up 63% of cases. Isolated cervical spine injuries made up 37% of all cases. Cervical fractures were most associated with neurological injury (50%).
Immediate survival has increased over the decade from 83% in 1991 to 93% in 2001. The probability of survival was significant at P = 0.006 and actual survival at P = 0.012 (Pearson correlation). The causal analysis has not been carried out but it is thought likely that improved quality of care is responsible.
Imaging of acute cervical spine injuries: Review and outlook
2004, Clinical Radiology
Advances in imaging technology have been successfully applied in the emergency trauma setting with great benefit providing early, accurate and efficient diagnoses. Gaps in the knowledge of imaging acute spinal injury remain, despite a vast wealth of useful research and publications on the role of CT and MRI.
This article reviews in a balanced manner the main questions that still face the attending radiologist by embracing the current and evolving concepts to help define and provide answers to the following; Imaging techniques – strengths and weaknesses; what are the implications of a missed cervical spine injury?; who should be imaged?; how should they be imaged?; spinal immobilisation – help or hazard?; residual open questions; what does all this mean?; and what are the implications for the radiologist?
Although there are many helpful guidelines, the residual gaps in the knowledge base result in incomplete answers to the questions posed. The identification of these gaps in knowledge however should act as the initiating stimulus for further research. All too often there is a danger that the performance and productivity of the imaging modalities is the main research focus and not enough attention is given to the two fundamental prerequisites to the assessment of any imaging technology – the clinical selection criteria for imaging and the level of expertise of the appropriate clinician interpreting the images.

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PaperImprovements in trauma survival in Leeds

Abstract

Injury

Injury

Injury

Injury

Injury

Injury

Retrospective study of 1000 trauma deaths from injury in England and Wales

Br Med J

Preliminary analysis of the care of the injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study

Br Med J

Paper
Improvements in trauma survival in Leeds