Proceedings of the British Trauma Society S-B 17

craniotomy or craniectomy. All the patients received post-

operative supportive care in the intensive care unit. There was a clear trend of increasing mortality associated with

advancing age although this was not statistically significant. The average age for the entire series was 31 (2-89); 57 per cent of those under 30 died; of those between 30 and 59, 80 per cent died whilst the mortality in those over 60 was 79 per cent. There was no significant difference in outcome between males and

females. The primary causes of ASDH were falls (53 per cent), road

traffic accidents (46 per cent) and assaults (12 per cent). The worst outcomes were seen in motorcyclists.

The average GCS for the entire series was 4.9. In survivors, the GSC was 5.4 and in those that died was 4.5. Patients with decerebrate posturing and bilateral absence of pupillary reflexes had a very high mortality rate of 90 per cent. When the post-operative intracranial pressure (ICP) was controlled below

20 mmHg the mortality was 40 per cent; but when it rose above 40 mmHg the mortality rate was 100 per cent -with a statistical difference (PC 0.07) between these two groups. The mean time from injury to definitive operative intervention was 4 h. There

was no statistical difference between survivor and non-survivor groups. The majority of the cases were operated upon in less than 1.5 h, but one was delayed 24 h.

When hypoxia and hypovolaemia were present, the outcome was affected adversely. However, hypovolaemia was almost always due to chest or intra-abdominal bleeding. Other injuries increased the severity of the injury and due affected brain swelling by hypovolaemia.

The overall mortality was 28 per cent. Acute subdural haemotoma (ASDH) continues to be one of the most lethal of all intracranial injuries. In the first half of the century mortality rates remained TO- 90 per cent

Our prospective study confirmed the importance of early intervention in the management of ASDH; in addition careful analysis of mechanism of injury, age, sex, GCS on presentation, hypovolaemia, hypoxia and intensive monitoring of the intra- cranial pressure have indicated that the outcome of ASDH is dependent on the severity of the cellular damage of the brain tissue. Vascular complications with minimal brain tissue damage are usually compatible with a good recovery, Extensive neuronal damage produces most of the major motor and cognitive residual defects.

At the present time, available pharmacological methods to control the intracranial pressure are not satisfactory and until more effective pharmacological approaches become available for the management of intracranial pressure, the mortality and morbidity from ASDH will remain high. Although patients with ASDH need urgent resuscitation and operative intervention, the outcome in terms of mortality and morbidity is totally depen- dent on the severity of the cellular damage of the brain tissue.

F. W. Cross, C. J. Kirk, T. J. Coats, A. W. Wilson (London, UK) O~I-scme medical CLUP: the limitations of TRISS Two hundred consecutive cases of blunt trauma brought to a level I trauma centre by helicopter were assessed for outcome

using TRISS methodology. 68 per cent of these patients were anaesthetized and intubated at scene by the emergency physi- cian, thus rendering the Revised Trauma Score (RTS) immeasur- able in the emergency room (ER). For this reason, the RTS was measured at scene in all patients instead of in the ER. Under TRISS, the W score ( - 6.15) appears very poor (2 = - 3.24):

however, the A4 score of 0.65 is far below the acceptable value for comparing the data group with MTOS data because injury severity was much greater in this group, attended by a physician and transported by helicopter, than in the MTOS group.

Groups Sl-S6 for the characterization of the M value are:

Ps range Helicopter MTOS

0.96-l 0.48 0.828 0.91-0.95 0.115 0.045 0.76-0.90 0.100 0.044 0.51-0.75 0.095 0.029

0.2&0.50 0.060 0.017 0.00-0.25 0.150 0.036

TRISS is, therefore, unsuitable for the evaluation of a group of patients attended by a helicopter trauma service manned by a doctor who can carry out advanced on-scene procedures.

M. W. Flowers, J. P. Sloan, N. Zoltie (Oxford, UK) The kit and

miss of ISS and TRISS Sixteen patients were scored independently for ISS and Revised Trauma Score (RTS) by 15 observers with subsequent calculation of the TRISS probability of survival. There was a wide variation

in recorded ISS scores with the probability of any 2 observers agreeing over the exact score being 0.28 (28 per cent). The probability of any 2 observers agreeing over which severity band the patients should be in was 0.5 (SO per cent). In all but 3 of the 16 patients we found a wide observer variation, which was independent of the training and type of observer. This variation resulted in TRISS probabilities of survival varying with maximal variation when the TRlSS was between 0.01 and 0.9.

There is wide observer variation in ISS, which highlights a potential fallibility in the use of ISS for trauma audit. The use of TRISS for individual prediction of survival is potentially inaccur- ate except at the extremes of probabilities.

T. J. Coats, 0. J. McAnena, F. W. Cross (London, UK) Physiological changes due to pre-hospital ATLS

The TRISS method conventionally measures RTS on arrivai in the Emergency Room following pre-hospital (PH) BTLS only. The effect of pre-hospital ATLS on this audit tool is not known.

A way to ‘partition’ the effects of pre-hospital from in-hospital

treatment was proposed by Sacco et al. in 1988 but the required database is not available. Data were examined from victims of blunt trauma aged over 55 who had been treated by a helicopter medical team, 68 per cent of whom received muscle relaxants during the PH phase, thus making it impossible to measure the RTS.

It was assumed that the Glasgow Coma Scale (GCS) was unchanged and the respiratory rate became ‘normal’ after ventilation.

In cases which survive the RTS, improvements are associated beneficial changes in physiology.

In many cases the RTS score on arrival at hospital is greatly influenced by pre-hospital care. The number of improvements is larger in number and magnitude than the number of deterior- atlons. The kind of pre-hospital care delivered thus affects the evaluation of trauma-outcome data. There is a need for a method to separate pre-hospital and in-hospital factors.

T. J. Coats, F. W. Cross (London, UK) Physiological changes as un audit tool in pre-kospihl cure

Advanced roadside trauma care by a physician invalidates current systems for the audit of trauma care. 68 per cent of patients transported by helicopter required a prehospital (PH) anaesthetic which renders the measurement of respiratory rate or Glasgow Coma Scale (GCS) and hence RTS impossible on arrival at the Emergency Room (ER).

An alternative audit tool may be derived from the use of

S-B 18 Injury: International Journal of the Care of the Injured (1994) Vol. 25/Suppl. 2

clinically defined physiological end-points (PEs).

Pre-hospital data for 3 11 patients attended by a physician and transported by helicopter to a trauma centre were examined. ‘Acceptable’ PEs were BP > 90 mmHg, oxygen saturation > 86

per cent, pulse 50-140, respiratory rate (RR) 10-29 or ventilated, GCS 12-15 or ventilated. Changes between the first PEs

recorded at scene and subsequent PEs in the ER were assessed.

BP Sat RR Pulse GCS

Initially unacceptable 45 27 93 45 162 Subsequently acceptable in ER 33 26 91 36 146

Of the PEs initially outside the acceptable range 89.2 per cent were corrected by pre-hospital intervention. This represents the

proportion of improvements due to PH treatment. A similar percentage can be calculated to represent the number of deteriorations. Of the initially accepted values, 3.3 per cent deteriorated during the PH phase. Two percentage figures can thus be used to represent the overall physiological change due to

(PH) treatment and they may be used as an audit tool either within or as a comparison between systems.

K. J. Heath, G. S. !%unra, G. E. Davis, A. B. Wilmink, A. W. Wilson (London, UK) (Joint winner - Biomet prize for best paper presented by a trainee). Blood pressure changes in head injury patients during pre-hospital anaesthesia Doctors working for the Helicopter Emergency Medical Services intubate serious head injured patients before transer to the most appropriate hospital. Propofol anaesthesia is often required to facilitate tracheal intubation.

Propofol may cause hypotension that can be greatly exagger-

ated in hypovolaemic patients. We studied 20 patients; 9 with isolated head injuries and II

with head injuries associated with multiple trauma. Propofof was titrated to ensure unconsciousness before

tracheal intubation. Blood pressure was measured before and at 2 min intervals after intubation using a Propac monitor with a printer.

The isolated head injury group sustained an average fall in mean blood pressure of 7 per cent (SD 12). The group with multiple injuries had an average fall in mean blood pressure of I1 per cent (SD 15).

In neither group was the fall in mean blood pressure statistically significant (P values 0.12 and 0.07 respectively). Propofol, used as described, does not cause important hypoten- sion in these potentially unstable patients. It may be used safely for pre-hospital anaesthesia in experienced hands.

D. Cox, P. Staniforth (Brighton, UK) The inter-hospital fransfer of patients with musculoskeletal injuries When patients sustain injuries away from home, they frequently receive primary management in the ‘foreign’ area, and not at their ‘own’ local hospital. If the inter-hospital transfer of these ‘orthopaedic’ emergencies is less than ideal, it may adversely affect the outcome of their injury. Many injuries can be treated as an outpatient and often occur out of normal working hours, further adding to the likliehood of a detrimental effect on the management of the fracture or soft tissue injury. There is a widespread reluctance to release the original radiographs leading to unnecessary further patient irradiation.

Fifty consecutive patients referred to the Royal Sussex County Hospital from other centres in the UK after January 1993 were analysed prospectively. The referral letters (if any) were graded according to the relevance of the content, and any delay

between the date of injury and the date of subsequent reassess- ment at the receiving fracture clinic was noted. Thirty-two per cent of patients were seen without the original radiographs and 16 per cent of patients had no accompanying referral letter. Thirty-two per cent of patients were referred via their general practitioner resulting in significant delays when compared with the patients referred directly to the patient’s local fracture clinic.

Firm national guidelines are needed to streamline the transfer of patient care and to maintain adequate care whilst continuing treatment is needed. The patient should be discharged with the original or copy radiographs; told when to attend the local fracture clinic; given a letter containing relevant past and suggested future treatment plans; with a date on the envelope suggesting the approximate follow-up date. Copies of this may be sent by post or fax but should not be relied upon alone.

A. Paterson, R. Loukota, H. Cannel1 (London, UK) Emergency treatment of crania-maxillofacial problems in the multiply injured patient within the ‘golden how’ Since August 1990, when the helicopter air ambulance (HEMS) commenced service, there have been 475 additional admissions of multiply injured patients to the Royal London Hospital; 69 (14.5 per cent) of these had craniofacial and/or maxillofacial injuries. Management of these complex cases was by inhospital protocol, consistent with the principles of ATLS. There were 46 survivors and 22 deaths. Management schemes using a multi- disciplinary approach were as follows:

1.

2.

3.

4.

5.

On-scene assessment. Only 4/69 patients were assessed by HEMS doctors solely as crania-maxillofacial injuries; 38/69 multiply injured patients with crania-maxillofacial injuries underwent oral intubation and 3 had crico-thyroidotomy. At triage, within the ‘golden hour’, 39/59 patients were assessed by the maxillofacial team, usually at or just following the secondary survey. Twenty of these were treated for haemorrhage from the maxillofacial area or for airway stabilization according to techniques refined at the Royal London hospital by Cannel1 and others. 23/69 patients had primary operative interventions within hours of admission as part of a multi-disciplinary treatment plan. Operations included II tracheostomies, 12 primary suturings of lacerations and 6 cases of open reduction with internal fixation of facial buttress bones. 20/69 underwent further definitive operations for repair of hard and of soft tissues, usually within 1 week following admission. Thirteen patients required craniofacial procedures such as bicoronal flaps, repair or exenteration of frontal sinuses and repair or orbital margins. Nine patients had to have further surgery as delayed or as revision procedures up to many months following initial discharge from hospital.

P. 0. Sherry, A. D. Pate], J. S. Albert (Norwich, UK) The Russell-Taylor humeral nail - early results of 34 cases Between July 1990 and January 1993, 33 patients had 34 Russell-Taylor humeral nails inserted. Of these there were 19

males and 14 females. The average age was 48 years with a range from 18 years to 86 years. Road traffic accident was the cause of the fracture in 17 of these cases, with falls accounting for 13 patients.

Eight patients including 2 with open fractures had multiple injuries. Eleven patients had isolated humeral fractures. There were 5 pathological fractures and 4 non-unions. Failed non- operative treatment and delayed union was the indication for intra-medullary fixation in 6 patients. The majority were trans- verse shaft fractures.

In 32 cases, the humeral nails were inserted through a precise