emergency medicine journal 2015 trauma audit research...

TITLE OF PRESENTATION

The Changing Face of Major Trauma in the UK

• Emergency Medicine Journal 2015 • Trauma Audit Research Network (TARN)

database • Review 1990 to end 2013 n=116,467

• Data interrogation:

– Age – Gender – Mechanism of injury – Use of CT

Kehoe A et al

Emerg Med J 2015;32:911-15


Results – ISS>15

• Mean age

• 1990 = 36.1 years

• 2013 = 53.8 years

• Group Size (age)

• 1990 = under 25 years (39.3%)

• 1990 = over 75 years (8.1%)

• 2013 = under 25 years (17%)

• 2013 = over 75 years (26.9%)

• Males

• 1990 = 72.7%

• 2013 = 65.3%

• CT Scans

– 1990 = 33.6%

– 2013 = 86.8%

Kehoe A et al

Emerg Med J 2015;32:911-15


Mechanism of Injury

• 1990

• RTC (59.1%)

• Falls greater than 2 metres (18.6%)

• Falls less than 2 metres (4.7%)

• Shootings and stabbings (0.2%)

• Others (17.4%)

• 2013

Kehoe A et al

Emerg Med J 2015;32:911-15

?


Fall <2m as Mechanism of Injury 2013

• 1 – 8%

• 2 – 15%

• 3 – 25%

• 4 – 40%

• 5 – 50%

Kehoe A et al

Emerg Med J 2015;32:911-15


Who to worry about?


Stealth trauma

• Designed (by technology) to make detection (by radar) difficult

• Significant (major) trauma sustained after falling from standing i.e. low impact mechanism


Progress – who’s involved

• Clinical Reference Group for Major Trauma and Burns

Recognizing: • Frailty • Futility • Different care

pathways • Balancing needs of

patient and carers • Complexity of triage

Perception: • Not de-stabilising newly

established pathways • Do not want 2 tier

system • Do not want to over

treat

Matthew Wyse QE Hospital Elderly Trauma Lecture


CRG-Principles

• The majority can be managed in their local Trauma Unit.

• Major Trauma Centres and Operational Delivery Networks should support the care Trauma Units

• Elderly trauma patients requiring higher level of care should be rapidly transferred to Major Trauma Centres

• Care of the Elderly clinicians should have shared responsibility for the management of elderly major trauma patients

• Elderly trauma patients should have the same standard of care as non- elderly major trauma patients

• The major trauma network should be actively engaged in the falls prevention strategy



CRG-Commissioning standards

• MTCs: All elderly major trauma patients should be admitted under joint care of a trauma service and elderly care team. They should be assessed by care of the elderly teams within 72 hours of admission

• TUs: All elderly trauma patients should be admitted under care of the elderly teams, with active input from relevant surgical specialties

• Elderly trauma patients should have a frailty assessment / comprehensive geriatric assessment commenced within 72 hours

• The management and outcomes of elderly major trauma patients should be regularly audited by the Major Trauma Network





• PanLondon Elderly Trauma Group

• Northumbria’s Elderly Trauma Campaign






• Heartlands Elderly Care Trauma and Ongoing Recovery


HECTOR The Heartlands’ Elderly Care Trauma & Ongoing

Recovery Programme

The ethos of the course is to attempt to ensure that patients of advancing age receive safe and high quality trauma care. This care should focus on them as individuals and be directed towards treating the patient with

injuries, not injuries on a patient.






• Heartlands Elderly Care Trauma and Ongoing Recovery

• Regional Elderly Trauma Group for NTN


Regional Elderly Trauma Group

• Set up by NTN August 2016

Networkwide forum for development of strategy & pathway of care for the management of major trauma in the elderly. Including pre-hospital & in-hospital identification, & the ongoing treatment & rehabilitation of this cohort of patients.


Scenario 1

• 85 year old lady, been ‘a bit wobbly’ lately and has macular degeneration. Fell in sitting room and hit left side of chest on chair

• Mildly impaired mobility recently under GP review, registered blind due to macular degeneration

• Sitting in wheel chair in waiting room complaining of left sided chest pain, ‘not too bad’, 4 or 5/10

• Observations all within normal limits, sats 98% on air, good air entry throughout chest

• ECG SR nil acute


Scenario 1

1 – Analgesia & CI advice

2 - Physio/OT assessment

3 – CXR

4 – CT thorax

5 – PAN scan


CT report - Fractures of left 4th, 5th, 6th and 7th ribs. Small left sided haemothorax, minor basal contusion and very small left apical pneumothorax.


Scenario 1- Issues

• Where to admit?

• Correct level of analgesia

• Risk of delirium, need for baseline screen

• Other risks – constipation, AKI, PNEUMONIA

• Why fell?

• Further down the line DNAR and TEP?

• Deconditioning, risk that won’t get back to baseline


Scenario 2

• 83 year old lady with dementia in a nursing home,

brought in by carers after a witnessed fall

• Report her normal level of cognitive function but

complained of neck pain at triage

• On examination no c spine tenderness, moving all 4

limbs normally.


Scenario 2

• 1 - Home with HIWA

• 2 – Physio/OT assessment

• 3 – CT head

• 4 – c-spine x-ray

• 5 – CT c-spine

• 6 – CT head & c-spine


Scenario 2

• Returned 2 further times over the next 3 days

• Developed delirium on top of dementia

• Treated for presumed UTI

• Third attendance had CT head & c-spine

Fractured C2 involving both sides of the vertebra as well as possibly right foramen transversarium, therefore an unstable fracture

ELDERLY TRAUMA IN THE FRAIL

• Whole system change

• MDT approach – avoid the chaos!

• Join in, help make the change


• [email protected]

• @v_lottie

mailto:[email protected]

emergency medicine journal 2015 trauma audit research...

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