Best Practice Tariff (BPT) recommends operation for hip fracture within 36 hours. Anticoagulation reversal often delays this. Audit of our service, to establish the impact on BPT of anticoagulation reversal, showed a loss of revenue and delays. Subsequently an ‘early trigger’ Intravenous Vitamin K (IVK) pathway was introduced and re-audit completed. Hip fracture patients admitted over a 32-month period were reviewed. Primary outcome was time to theatre for warfarinised and non-warfarinised patients. This was analysed using independent t-tests. A change in practice, involving nurse led administration of 2mg IVK in the Emergency Department prior to knowledge of the coagulation screen, was instigated. Three months later a re-audit occurred. In the first audit cycle, 83 patients were admitted on warfarin with a median time to theatre of 49.7 hours. 21% of these patients gained BPT. Following protocol change, over three months, 14 warfarinised hip fracture patients were admitted. Twelve patients achieved satisfactory reversal; eight with one IVK administration. Median time to theatre was 33.9h. Compliance with BPT in terms of delay due to anticoagulation was 86%. Our audit demonstrates that ‘early-trigger’ IVK reduces delays to theatre and helps reduce BPT related financial loss. It enables high quality patient-centred care within financial constraints.
Commissioning for quality and innovation (CQUIN) guidelines specify that diaphyseal fractures of the tibia should be treated within 24 hours of admission. We aimed to identify our compliance at a Major Trauma Centre. Restrospective analysis of all tibia fractures over 12 months. Fractures that were not diaphyseal nor open were excluded. Time of presentation, x-ray, arrival to ward and arrival in theatre were analysed against CQUIN guidelines. 43 fractures, 18 (42%) arrived in theatre for operative management within 24 hours. 15 (35%) were managed operatively in the subsequent 24 hours and 10 (23%) were managed after 48 hours. Average time to theatre was 38 hrs 37 mins (SD 29hrs 42mins). It took on average 51mins (SD 43 mins) for a patient to have an xray and 3 hrs 53 mins (SD 1hr 47mins) to arrive on the ward, and average 3 hrs 2 mins (SD 1hr 43mins) between xray and the ward. 42% of patients are making CQUIN standards for closed tibial shaft fractures. There are logistical and resource factors contributing towards this as well as clinical issues. To address this there needs to be an agreed multidisciplinary pathway developed to ensure compliance with CQUIN standards.
In a recent publication, 4.6% of 6450 Coalition deaths over ten years were reported to be due to junctional bleeding. The authors suggested that some of these deaths could have been avoided with a junctional hemorrhage control device. Prospectively collected data on all injuries sustained in Afghanistan by UK military personnel over a 2 year period were reviewed. All fatalities with significant pelvic injuries were identified and analysed, and the cause of death established. Significant upper thigh, groin or pelvic injuries were recorded in 124 casualties, of which 92 died. Pelvic injury was the cause of death in 42; only 1 casualty was identified where death was at least in part due to a vascular injury below the inguinal ligament, not controlled by a tourniquet, representing <1% of all deaths. Twenty one deaths were due to vascular injury between the aortic bifurcation and the inguinal ligament, of which 4 survived to a medical facility. Some potentially survivable deaths due to exsanguination may be amenable to more proximal vascular control. We cannot substantiate previous conclusions that this can be achieved through use of a groin junctional tourniquet. There may be a role for more proximal vascular control of pelvic bleeding.
Aim To develop a militarily relevant complex extremity wounding model. Study Design Controlled laboratory study with New Zealand White Rabbits. Method Phase One: Injury Development. Under general anaesthesia, the flexor carpi ulnaris of the right forelimb was exposed and high energy, short duration impact delivered via drop test rig. Anaesthesia was maintained for three hours, the animal was recovered and saline soaked gauze and supportive bandaging applied. 48 hrs later, the animal was culled and muscle harvested for histological analysis. Analgesia was administered daily, animals checked by experienced staff at least twice daily and temperatures recorded by subcutaneous transponder. Phase Two: Contamination. Sequential groups of animals had inoculums of 1×102, 1×106 and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered as phase one. At 48 hours, animals were culled, muscle harvested and axillary lymph nodes sampled. Quantitative microbiological analysis was performed on the muscle. Results: Six animals given a loading of 0.5kg yielded consistent injury with 20% of the muscle becoming necrotic. Representative of injury from ballistic trauma, this was adopted as standard. Twenty-two subsequent animals were exposed to the injury and inoculated with the challenge doses. 1×106/100μl S.aureus provided the greatest consistency in recovered yield. There were no adverse effects on animal welfare and body temperatures were always within normal limits. Discussion. This model enables a consistent, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management including wound coverage and fracture fixation.
Introduction. This is the first study to illustrate spinal fracture distribution and the impact of different injury mechanisms on the spinal column during contemporary warfare. Methods Retrospective analysis of Computed Tomography (CT) spinal images entered onto the Centre for Defence Imaging (CDI) database, 2005-2009. Isolated spinous and transverse process fractures were excluded to allow focus on cases with implications for immediate management and prospective disability burden. Fractures were classified by anatomical level and stability with validated systems. Clinical data regarding mechanism of injury and associated non-spinal injuries for each patient was recorded. Statistical analysis was performed by Fisher's Exact test. Results 57 cases (128 fractures) were analysed. Ballistic (79%) and non-ballistic (21%) mechanisms contribute to vertebral fracture and spinal instability at all regions of the spinal column. There is a low incidence of cervical spine fracture, with these injuries predominantly occurring due to gunshot wounding. There is a high incidence of lumbar spine fractures which are significantly more likely to be caused by explosive devices than gunshot wounds (p<0.05). 66% of thoracolumbar spine fractures caused by explosive devices were unstable, the majority being of a burst configuration. Associated non-spinal injuries occurred in 60% of patients. There is a strong relationship between spinal injuries caused by explosive devices and lower limb fractures Conclusion Explosive devices account for significant injury to both combatants and civilians in current conflict. Injuries to the spine by explosions account for greater numbers, associated morbidity and increasing complexity than other means of injury.
