Scottish Trauma Audit Group Database Research Articles

Time to CT and Surgery for HPB Trauma in Scotland Prior to the Introduction of Major Trauma Centres

To assess the time taken to CT and emergency surgery for trauma patients with an injury to liver, spleen or pancreas prior to the introduction of major trauma centres (MTCs) in Scotland. A search was performed of the Scottish Trauma Audit Group database for any patient with relevant injuries over a 2-year period. Primary outcome measures were time to CT and emergency surgery. Patient demographics were also recorded. A total of 211 patients were identified of whom 23 had more than one organ affected. There were a total of 234 injuries (123 liver, 99 splenic and 12 pancreatic) in these patients. A total of 160 injuries (75.8%) suffered blunt trauma. Of 211 patients, 157 underwent emergency CT with a median time to scan of 73min (range 4-474). Hospitals provisionally designated as MTCs were 9min faster than non-MTCs in time to CT. There was no difference in time of day. Ninety-nine patients had surgery within 24h at a median time of 200min. Twenty-five patients with hypotension on presentation took a median time of 130min. Only 44 patients (27%) had a CT or emergency surgery within the expected MTC target of 1h. Thirty-nine patients required transfer to another centre. Current management of patients with abdominal trauma and haemodynamic instability remains sub-optimal in Scotland when compared to recognized performance indicators of CT and emergency surgery within 1h. Implementation of a major trauma network in Scotland should improve access to emergency radiology and surgery and efforts to shorten current timelines should improve patient outcomes.

Long-term outcomes of major trauma without head injury in the West of Scotland: pilot case???control study

The aim of this study was to identify the outcomes of survivors of blunt major trauma (without head injury) 2 years or more following injury. The study uses a case-control design, is set in the West of Scotland and includes trauma patients treated in Greater Glasgow NHS Board hospitals. Participants consisted of patients who had sustained major trauma (injury severity score >15) with little or no head injury at least 2 years before assessment, identified from the Scottish Trauma Audit Group database, and age and sex-matched controls nominated by the index case's general practitioner. Nineteen cases and seven controls completed the study from 223 potential cases and 39 potential controls. Participants and non-participants had comparable injury severity score, probability of survival (Ps) and length of stay. American Medical Association impairment scores show survivors were more impaired than controls (25.9 vs 7.4%, P=0.043). No differences were observed in Functional Independence Measure (FIM) or Community Integration Questionnaire (CIQ) scores, although a type II error is possible. Short-form 36 (SF36) Physical Component Summary (PCS) scores of survivors showed no difference compared with controls although survivors' PCS scores were below UK and US means (P=0.008). SF36 Mental Component Summary (MCS) scores of survivors were below those of controls (45.07 vs 56.65, P=0.004) and normal values of the UK population (P=0.036). No differences in work status were noted, but small sample sizes were used. Non-head-injured survivors of major trauma in the West of Scotland have poorer health status (SF36), physically and mentally, than the UK population. They have greater impairment, but have an employment status comparable to that of the controls. The lack of differences in FIM and CIQ scores between survivors and controls may be due to small sample sizes.

A Population‐Based Study of Pancreatic Trauma in Scotland

The aim of this population-based study was to assess the incidence, mechanisms, management and outcome of patients who sustained pancreatic trauma in Scotland over the period 1992-2002. The Scottish Trauma Audit Group database was searched for details of any patient with pancreatic trauma. About 111 of 52,676 patients (0.21%) were identified as having sustained pancreatic trauma. The male-to-female ratio was 3:1, with a median age of 32 years. Blunt trauma accounted for 66% of injuries. Road traffic accidents were the most common mechanism of injury (44%), followed by assaults (35%). Thirty-four patients (31%) were haemodynamically unstable on arrival at hospital. Pancreatic trauma was associated with injuries to the chest (56%), head (30%) and extremities (30%); 73% of patients had other intra-abdominal injuries. Of those who left the emergency department alive, at least 77% required a laparotomy. The mortality rate (46%) was directly proportional to the number of injuries sustained (P < 0.05) and was higher in patients with increasing age (P < 0.05), haemodynamic instability (P < 0.05) and blunt trauma (P < 0.05). Pancreatic trauma is rare in Scotland but is associated with significant mortality. Outcome was worse in patients with advanced age, haemodynamic instability, blunt trauma and multiple injuries.

“Eleven Years of Liver Trauma: the Scottish Experience”

The aim of this population based study was to assess the incidence, mechanisms, management, and outcome of patients who sustained hepatic trauma in Scotland (population 5 million) over the period 1992–2002. The Scottish Trauma Audit Group database was searched for details of any patient with liver trauma. Data on identified patients were analyzed for demographic information, mechanisms of injury, associated injuries, hemodynamic stability on presentation, management, and outcome. A total of 783 patients were identified as having sustained liver trauma. The male-to-female ratio was 3:1 with a median age of 31 years. Blunt trauma (especially road traffic accidents) accounted for 69% of injuries. Liver trauma was associated with injuries to the chest, head, and abdominal injuries other than liver injury; most commonly spleen and kidneys. In all, 166 patients died in the emergency department, and a further 164 died in hospital. The mortality rate was higher in patients with increasing age (p < 0.001), hemodynamic instability (p < 0.001), blunt trauma (p < 0.001), and increasing severity of liver injury (p < 0.001). The incidence of liver trauma in Scotland is low, but it accounts for significant mortality. Associated injuries were common. Outcome was worse in patients with advanced age, blunt trauma, multiple injuries and those requiring an immediate laparotomy.

Aortic Trauma in Scotland – A Population Based Study

This population-based study aims to determine the incidence, mechanisms and outcomes of aortic trauma in patients from Scotland between 1992-2002. Patients with aortic trauma were identified from the Scottish Trauma Audit Group database. Demographics, mechanism of injury, initial management and outcome were analysed. 165 (0.3%) patients suffered trauma to the thoracic or abdominal aorta. Of these, 130 (79%) patients had an injury of the thoracic aorta, 33 (20%) an injury of the abdominal aorta and two (1%) had injuries of both. There were 123 (75%) men and 42 (25%) women with a median (range) age of 36 (14-90) years. Blunt trauma was responsible for 121 (73%) injuries, of which road traffic accidents were the most common mechanism. A further 44 (27%) aortic injuries were due to penetrating trauma, of which assault was the most common cause. The median (range) Injury Severity Score was 43 (16-75). Ninety (55%) patients died in the emergency department while 59 (32%) underwent attempted operative repair. The operative mortality was 35 (59%) of 59 patients and overall mortality 141 (86%) of 165 patients. The incidence of aortic trauma presenting to Scottish hospitals is low. The majority of patients do not survive to surgical repair and operative and overall mortality remain prohibitive.

Mortality after trauma intubation without drugs in Scottish emergency departments

Trauma patients who are intubated without anaesthetic drugs in the pre-hospital phase of care have universally poor outcomes. This study aimed to determine the mortality of trauma patients intubated without drugs in emergency departments in Scotland. This retrospective cohort study used the prospective Scottish Trauma Audit Group (STAG) database to identify how many patients were intubated and how many required drugs for intubation between 1 January 1999 and 31 December 2002. The mortality of those intubated with drugs and without drugs was determined from the database. 24,756 patients were included in the STAG database. There were 1469 intubations: 1287 with drugs and 182 without drugs. 92.5% of all intubations were for blunt trauma. There was no difference in the proportion of males or median age between groups. Median GCS was 8 (E1M5V2) in the drugs group and 3 (E1M1V1) in the no drugs group (p<0.001). Median ISS was higher in those intubated without drugs (33 versus 25, p<0.001). Median RTS and probability of survival were lower in those intubated without drugs (both p<0.001). Mortality was higher in those intubated without drugs (91.2% versus 29.4%, p<0.001). Sixteen patients, intubated without drugs, survived. These patients had a higher median respiratory rate (9 versus 0, p=0.013) and higher median systolic blood pressure (80 mmHg versus 0 mmHg, p=0.041) than non-survivors. Trauma patients in Scottish emergency departments who are intubated without drugs have high mortality rates. Outcomes are not universally fatal and aggressive resuscitation efforts may be of benefit to a small number of such patients.

Eleven Years of Liver Trauma: The Scottish Experience

The aim of this population based study was to assess the incidence, mechanisms, management, and outcome of patients who sustained hepatic trauma in Scotland (population 5 million) over the period 1992-2002. The Scottish Trauma Audit Group database was searched for details of any patient with liver trauma. Data on identified patients were analyzed for demographic information, mechanisms of injury, associated injuries, hemodynamic stability on presentation, management, and outcome. A total of 783 patients were identified as having sustained liver trauma. The male-to-female ratio was 3:1 with a median age of 31 years. Blunt trauma (especially road traffic accidents) accounted for 69% of injuries. Liver trauma was associated with injuries to the chest, head, and abdominal injuries other than liver injury; most commonly spleen and kidneys. In all, 166 patients died in the emergency department, and a further 164 died in hospital. The mortality rate was higher in patients with increasing age (p < 0.001), hemodynamic instability (p < 0.001), blunt trauma (p < 0.001), and increasing severity of liver injury (p < 0.001). The incidence of liver trauma in Scotland is low, but it accounts for significant mortality. Associated injuries were common. Outcome was worse in patients with advanced age, blunt trauma, multiple injuries and those requiring an immediate laparotomy.

Diaphragmatic rupture and the association with occupant position in right-hand drive vehicles

Ruptured diaphragm following blunt trauma occurs with an incidence of 3 to 8% with right-sided rupture recognised with increasing frequency. This study aimed to investigate the influence of occupant position in right-hand drive (RHD) vehicles on the side of diaphragmatic injury. A retrospective analysis of the Scottish Trauma Audit Group database was performed to gather data on blunt diaphragmatic lacerations. Police records were also searched to ascertain the point of impact in the accidents studied. In total, 35 patients were studied, 25 drivers and 10 front-seat passengers. The incidence of right-sided rupture was 40% in drivers and 20% in FSPs. The incidence of associated pulmonary contusion, rib fracture and liver injury was also higher in drivers. Given the small sample size, these differences were not statistically significant, but they show an interesting trend. The right side of a driver's body is more exposed to injury in RHD vehicles, a fact that explains the significant association between driver's side impact and right-sided rupture. As right-sided injury is more difficult to detect, it is important that a high index of suspicion is maintained, especially when managing drivers from RHD vehicles.

Pedestrian deaths following collisions with heavy goods vehicles.

Pedestrian fatalities following collisions with heavy goods vehicles ('lorries') in south-east Scotland were studied between 1992 and 1998. Data sources included police and ambulance reports, forensic medicine records, hospital casenotes and the Scottish Trauma Audit Group database. All injuries were scored according to the Abbreviated Injury Scale, yielding Injury Severity Scores (ISS). Sixteen pedestrians (mean age 60.2 years) died after being hit by a lorry. Actions of pedestrians were implicated in causing all the collisions--four of which appeared to be suicides. Four of the apparently accidental deaths involved pedestrians with significant blood alcohol levels. Thirteen pedestrians were dead when found. Ten pedestrians had an ISS of 75, having a total of 13 injuries acknowledged to be unsurvivable (Abbreviated Injury Scale = 6), largely to the head and chest. The unsurvivable injuries reflect huge forces, explaining why only a small proportion of the pedestrians survived to hospital. There is little potential to reduce the number of deaths by improving hospital treatment, rather the focus needs to be directed towards injury prevention. Although pedestrians appeared to be responsible for the collisions, the results suggest it may be more feasible and effective to direct injury prevention measures towards lorry drivers.