Initial assessment and outcome of head injured patients transferred to a regional neurosurgical service: what do we miss?

Clinical and Autopsy Analysis of Delayed Diagnosis and Missed Injuries in Trauma Patients

Delayed diagnosis of injury (DDI) during hospitalization and missed injuries (MI) on autopsy in trauma deaths result in untoward outcomes. Autopsy is an effective educational tool for health care providers to evaluate trauma care. A retrospective study of trauma registry patients and coroner's records was categorized into groups 1 (alive patients) and 2 (trauma deaths) and analyzed. DDI incidence was similar in group 1 (1.8%) and group 2 (1.9%). Autopsy analysis (163 patients) yielded 139 MI in 94 patients (57.6%), <3 per cent of MI had negative impact on survival. Bony injuries comprised 68 per cent of DDI and 19 per cent of MI. Group 1 DDI patients were sicker with higher injury severity score (ISS: 16.07) than their cohorts (ISS 7.13, P value <0.05). These patients had higher Glasgow Coma Scale (14.41) and lower ISS (16.07) as compared with group 2 MI patients (ISS: 33.49, GCS: 6.45, P value <0.05). Autopsy rate was 99.5 per cent in trauma deaths, 57 per cent for nontrauma deaths, and 79 per cent for all deaths. Less than 3 per cent of MI had negative impact on survival. Routine ongoing patient assessment with pertinent diagnostic workup is essential in reducing DDI. Trauma autopsies reveal MI, which aid performance improvement (PI).

Secondary transport of the critically ill and injured adult

There is significant interest in the secondary transport of the critically ill and injured. High profile cases entailing the long distance transfer of patients have highlighted the lack of availability of critical care beds and appropriate systems for transferring this patient group. These and other issues have culminated in the release of Comprehensive Critical Care by the Department of Health in 2000. It has been shown that a large number of critical care transfers originate in the emergency department. The transportation of patients has not traditionally been part of the core curriculum of emergency medicine specialists in the UK. It is imperative that clinicians have an understanding of the issues surrounding transportation of the critically ill and injured. This should include appreciation of the local and regional organisational frameworks implemented for this patient group. This review describes the core issues relevant to emergency medicine relating to the transportation of the critically ill and injured.

Have ATLS and national transfer guidelines improved the quality of resuscitation and transfer of head-injured patients? A prospective survey from a Regional Neurosurgical Unit

High-quality resuscitation and care during transfer of head-injured patients is essential to prevent secondary brain injury. We have prospectively assessed the standard of resuscitation in 50 consecutive head-injured patients transferred to our unit, and compared our findings with previous studies performed before the advanced trauma life support course (ATLS) had become widespread and national guidelines on the transfer of head injuries had been produced by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). Delays in transfer, management of the airway, adequate cervical spine assessment, hypoxia (P(a)O(2) <13 kPa), hypotension (systolic BP <90 mmHg), missed injuries and the experience of the medical escort were compared against the standards laid out in ATLS and AAGBI Guidelines. The mean, unavoidable delay from arrival at the local accident and emergency unit to arrival was 7.4+/-1.9h (mean+/-95%CI) with most of the delay being prior to initial referral. Two patients arrived with an unsecured airway with a GCS=8/15; 26 had inadequate cervical spine imaging; 7 patients arrived hypoxic and 2 patients arrived hypotensive; most of these insults occurred during the transfer. Forty-six percent of medical escorts did not fulfil the minimum standard of experience. ATLS and AAGBI guidelines have provided only modest improvements in patient care at the expense of long delays in transfer. The incidence of hypoxia and hypotension remains unacceptably high.