Volume 2 Issue 1, March 1997

Contents:

• Traumatic Facial Nerve Palsy
• Traction Splints
• Points from Trauma Audit
• Letters to the Editor
• Backchat
• Case of the Month

Introduction

Welcome to the newly formatted Trauma Grapevine, which has increased in size and now issued quarterly. The readership will expand to 1500 throughout Australasia.

Trauma and Injury have recently returned to forefront of public attention with the dramatic increase in road deaths tolls. Unfortunately trauma remains a major public health issue. A new approach will be required in two key areas, injury prevention and secondly acute trauma care if the road toll is to be reduced. Based on the RTA statistical report for 1995, there were 52,120 road traffic accidents in NSW in 1995, resulting in 26,583 casualties of which 620 were killed and 6016 admitted to hospital.

Our 2 year registry report from SWSAHS will show that over 50% of our admitted trauma in not road related.

Trauma care requires a closer liaison between the injury prevention programmes, acute trauma care and rehabilitation. Benchmarks in trauma care need to be established and acceptable targets in patient outcome achieved. The establishment of organized institutional and regional trauma services, with outcome analysis along with the implementation of the NRTAC report will improve hospital care.

A potentially exciting new development in trauma is the launch of the Australasia Trauma Society. Enquires should be made to Dr Tony Joseph at Royal North Shore Hospital.

If you wish to attend our July 15th Trauma Education Evening please ring Thelma on 98283928.

Michael Sugrue

Director Trauma Services

Liverpool Hospital

Traumatic facial nerve palsy:

Case: A 51 year old man fell down his stairs secondary to alcohol intoxication with subsequent bleeding from the left ear. The patient presented to the Emergency Department 3 hours later. On examination, primary survey was normal. Secondary survey findings: GCS 14. Haemotympanum. A left lower facial nerve palsy and a base of skull fracture (temporal - occipital) was noted. (Fig.1)

Discussion:

The diagnosis of a base of skull fracture may be made clinically and is frequently not seen on plain x-rays.

Clinical findings include:

1. Haemoptympanum (early)

2. Mastoid ecchymoses (Battle's sign)

3. Bilateral/unilateral periorbital ecchymoses (Raccoon eyes)

4. Impaired hearing.

5. Facial nerve palsy - ipsilateral.

6. Blood for CSF rhinorrhoea or otorrhea (compound fracture).

Most base of skull fractures include temporal bone fractures which may involve: cochlea, vestibule, facial nerve canal, jugular vein and internal carotid artery. (80% longitudinal and 20% transverse).

Management: Observe or surgery?

Traumatic facial nerve palsy immediately following temporal bone fracture may need surgical decompression once the patient is stable(6). This is advisable because nerve regeneration occurs early and empty axonal tubules are seen as early as day 5. Hence poor re-innervation.(1) Delayed onset of facial nerve palsy is treated conservatively with steroids assuming the cause is an underlying oedematous process.

As an aside, other indications of surgical repair include, otorrhoea prolonged beyond 2 weeks, recurrent leaks secondary to fistula formation, recurrent meningitis, and herniation of neural structures through the fracture.

The monitoring of the progress of facial nerve injuries is done using the House-Brackmann facial nerve recovery scale which is a clinical assessment.(3) Evoked electromyography (E.G.) was shown in a trial to have less predictive value in evaluating traumatic facial nerve palsy.(7)Unfortunately large series of patients have not been studied making prognostic predictions difficult.

A retrospective review by McKennan 5 of 36 patients (19 delayed onset and 17 immediate onset) demonstrated that recovery of normal function was seen in up to 94% in the delayed onset-conservative management group. The immediate onset group had a poorer prognosis. For extratemporal facial nerve palsy secondary to trauma, nerve grafting provided significant improvement of function (2)

In summary, surgery may be indicated in patients with immediate onset of facial nerve palsy post trauma which places the importance of early recognition in the Emergency Department.

References:

1. Barrs. DM: Traumatic Facial Nerve Paralysis. Current therapy in otolaryngology head and neck surgery. Edt. 5 St. Louis. Mosby, 1994

2. Ferreira MC, Besteiro JM. Tuma Junior P. Results of reconstruction of the facial nerve. Microsurgery 15 (1): 5 - 8, 1994.

3. House JW. Facial nerve grading systems. Laryngoscope. 93: 1056-67, 1983

4. Mary TH, Charles ES. Current emergency diagnosis and treatment. Third Edition. 1990 Appleton and Lange publishers.

5. McKennan KX, Chole RA. Facial paralysis in temporal bone trauma. American Journal of Otology. 13 (2): 167-72, 1992

6. Nageris B, Hansen MC, Lavelle WG, Van Pelt FA. Temporal bone fractures. American Journal of Emergency Medicine 13 (2): 211-4. 1995

7. Sillman JS Niparko JK, Lee SS Kileny PR. Prognostic value of evoked and standard electromyography in acute facial paralysis. Otolaryngology - Head and neck surgery. 107 (3): 377-81, 1992

Dr. Timothy Diep,

R.M.O. Liverpool Hospital, Liverpool NSW

COMMENTS: Dr. Martin McGee-Collett, Director, Neurosurgery, Liverpool Hospital

Traumatic Facial Nerve Palsy needs early recognition because complications, which include, exposure, hepatitis and corneal ulceration can lead to blindness. I think the timing of surgery could be clarified a little bit. Certainly there is little role for immediate surgery, but the problem should be recognised immediately. Surgery is under taken when the facial canal is completely disrupted as soon as the patient is stable. Detailed CT study of the petrous temporal is indicated. This may be within several weeks of the accident since such severe fractures are often associated with other, particularly intracranial, injuries. Where the facial nerve canal is intact it is hoped that the injury is a neuropraxia and a period of time is allowed for clinical and E.G. improvement, usually being up to several months.

TRACTION SPLINTING IN LIMB FRACTURES - A VITAL MANOEUVRE

The aim of this short paper is to highlight the need for early application of traction splints in the management of femoral shaft fractures.

Over the last four weeks I have been consulted as a Vascular Surgeon, to review three patients with femoral shaft fractures, in whom absent pulses had been noted below the groin. The first patient reviewed in the Emergency Department of a tertiary referral hospital, had sustained a combination of chest, abdominal and right leg injuries. The acute management of the patient had been appropriate but during the secondary survey, the obviously angulated and externally rotated pulseless right leg, caused a lot of consternation in the attending staff, who asked for a vascular surgical review.

Prompt application of a Hare traction splint resulted in brisk restoration of popliteal and pedal pulses. Failure of both Ambulance and Emergency Department staff to identify the need for this device in the management of a simple femoral shaft fracture was interesting.

Two further cases presented within a week to Liverpool Hospital Emergency Department. In the first instance, a male motorcyclist had sustained a simple transverse fracture of the femoral shaft at the junction of the middle and distal third. This had resulted in leg shortening and external rotation of the distal leg. Emergency Department staff, concerned at the absence of pulses, were arranging for radiography and Doppler studies. A consultation to the Vascular Surgical Service was also requested. Prompt application of a Hare traction splint was all that was necessary to realign the femoral shaft and restore the pulses, avoiding unnecessary radiography or vascular studies.

The final case again involved a male motorcyclist who had sustained a transverse fracture of the distal left femur with slight comminution. A transverse laceration of the popliteal fossa had resulted in degloving to the level of the gastrocnemius muscle of the distal portion of the wound. The leg was obviously deformed, the thigh shortened and grossly swollen. Two x-rays were performed to confirm the bony injury which was quite clinically apparent (Figure 2). Nothing had been done to restore the pulse deficit below the left groin.

In this case, again, the application of a Hare traction splint resulted in prompt restoration of pulses during the interval prior to placement of a Denham tibial pin in the Operating Theatre.

In all three scenarios, staff with at least moderate exposure to general principles of trauma management, failed to identify the need for application of a traction splint to restore pulses in the presence of a femoral shaft fracture. In part, their concerns related to the pain that movement of the leg would produce. Systemic analgesia with intravenous Morphine or inhaled nitrous oxide and reassurance and explanation, will usually allow the placement of traction splints. Patients usually experience significant relief from pain promptly after the leg is restored to normal alignment. The decision to x-ray prior to realignment, was made on one occasion in this trio of patients. In some ways this is analogous to x-raying a tension pneumothorax or dislocated ankle before treating these life or limb threatening conditions.

The need for application of the traction splint has higher priority than the need to image the bony deformity, which can be done with greater patient comfort and less threat to the limb, after application of the traction splint. The final observation was of the lack of familiarity of attending medical staff from two teaching hospitals with the traction devices which are available to them in their respective emergency departments. These three cases highlight the need for general awareness of first aid principles in the management of femoral shaft fractures and of the need for attending staff to be practised in the application of simple traction splints.

John Crozier, Vascular Surgeon, Lecturer in Surgery

Liverpool Hospital, LIVERPOOL

Letters to the Editor

Dear Sir,

I cannot allow the sweeping allegations about the cardiovascular consequences of intubation in the recent issue (No.4) of Trauma Grapevine to go unchallenged. It is blandly asserted that "intubation is likely to result in vasomotor collapse and cardiac arrest". In fact, the actual procedure of intubation is far more likely to produce hypertension and tachycardia, albeit transient. The cardiovascular consequences alluded to in the case review are far more likely to result from inappropriate choice and/or an injudicious dosage of sedative drugs and possibly muscle relaxants also. This is eminently preventable.

Not all sedatives, narcotics and muscle relaxants drop blood pressure. Some actually raise it, e.g. ketamine and pancuronium. With the range of sedatives, relaxants and adjuvant agents currently available, plus a good understanding of their pharmacokinetics in the hypovolaemic as well as the normovolaemic individual, it is just about possible to "dial in" any desired cardiovascular response. At the very least, skilled administration can avoid whichever sequelae of hypo or hypertension is considered the least desirable.

It should also be pointed out that, in the trauma patient prior to securement of surgical haemostasis, a modest (and carefully modulated) degree of hypotension may be of value in reducing ongoing blood loss and improving survival. This appears to be the principle underling the research suggesting delayed fluid resuscitation and the non use of pneumatic antishock garments (2,2,3). Intubation and ventilation in conjunction with judicious sedation and paralysis reduce tissue oxygen consumption as well as supply - a more physiologically desirable situation than hypovolaemia. There is certainly some evidence now that an earlier and more aggressive approach to intubation may improve the outcome (4,5).

In summary, I believe the article in Trauma Grapevine has overstressed the risks and under stressed the benefits of intubation and ventilation of the trauma patient. If the local incidence of severe cardiovascular sequelae to intubation is as frequent as suggested, then this is strongly suggestive that responsibility for this facet of management should be devolved to staff with more experience in anaesthesia than is currently the case.

Yours faithfully,

Blair Mumford

Visiting Anaesthetist, Liverpool Hospital &Senior Flight Physician CareFlight/NSW Medical Retrieval Service

1. Stern SA, Dronen SC et al (1993). Effect of blood pressure on haemorrhage volume and survival in a near fatal haemorrhage model incorporating a vascular injury. Ann Emerg. Med 22, 155

2. Martin RR, Bickell WH et al (1992) Prospective evaluation of pre-operative fluid resuscitation in hypotensive patients with penetrating truncal injury. A preliminary report., J. Trauma 33, 354

3. Mattox KL, Bicke WH et al (1989) Prospective MAST Study in 911 Patients, J. Trauma 29, 1104

4. Schmidt U. Brame SB et al (1992). On Scene Helicopter Transport of patients with Multiple Injuries - Comparison of a German and an American System J. Trauma 33, 548

5. Regel G. Stalp M. et al (1996). The Role of Emergency Measures in Air Rescue of the Polytraumatised Patient. Presented at AIRMED '96, 4th World Congress of Aeromedical Services, Munich, June, 1996.

Reply:

The reference to intubation of trauma patients who are hypovolaemic in the June issue of Grapevine related to potential premature intubation of in-hospital patients outside the Operating Room e.g. in the Resuscitation Room. I am sorry that this may have caused some confusion or anxiety for Dr. Mumford and his comments are very welcome and important.

The articles referred to by Schmidt et al and Regel (kindly translated by Dr Bernie Hanrahan,Careflight), suggest that earlier pre-hospital intubation improves outcome. There is no doubt that in the pre-hospital setting hypoxia is a potential confounder of morbidity and a source of mortality in a small subset of seriously injured patients and therefore an early scene intubation can be life-saving in this subset.

The issue of intubation and anaesthesia is important and as vital as other aspects of care in the trauma patient and will be featured in our Trauma Education Evening on 15th July, 1997 in the Education Block. This will be open to all those interested in trauma.

Editor

Dear Dr. Sugrue,

I read your recent report on the launch of the "Trauma Injury Research and Education Fund" for Liverpool Hospital with great interest. Clearly the epidemic of trauma continues to grow in South Western Sydney as your report states, and the continued efforts of your trauma service is highly commendable.

I would, however, like to address a point in your introductory statement, where you mention that "South Western Sydney now sees the greatest number of trauma patients in New South Wales and probably in Australia". In the 18 months ending February, 1996 there were 8,530 trauma admissions in Hunter Area Health Service hospitals with 4,754 in John Hunter Hospital alone which is a larger volume than South Western Sydney and Liverpool Hospital received according to your recent report.

I point this out merely to acknowledge the volume and quality of trauma management in the Hunter area which I feel goes largely unheralded. Unfortunately our resources limit us to a single data manager who struggles to collage even this basic information, limiting our possibilities for research, publication and education.

Congratulations on the publication of Trauma Grapevine which is an interesting and exciting new forum for the discussion of trauma issues.

Yours sincerely,

Brian Daganic,

Surgical Registrar, Department of Surgery, John Hunter Hospital

Reply:

It is evident that trauma is a major health problem in both South Western Sydney Area Health Service and the Hunter Area. The number of patients being treated is the key issue and I hope no offence was taken. Certain registries use different criteria for counting cases and we do not include 4 or 6 hour admissions as a criteria for inclusion in our registry. Your feedback is very welcome and your registry report makes very interesting reading. Production of more information from different health regions will provide a clearer picture of trauma demographics and a useful analysis of trauma care. .

Editor

RECOMMENDATIONS FROM THE TRAUMA AUDIT:

Failure to intubate at the scene:

A case was discussed where a man had been thrown from a car 8km from an urban hospital. At the scene there was some airway obstruction with secretions and gastric content. content. The patient was suctioned and nursed in the lateral position. He remained mildly hypoxic until arrival at the urban hospital. On arrival the airway was partly compromised and breathing was shallow, respiratory rate 18/m and pulse 50/m. The patient was intubated and his hypoxia improved.

Issue: Pre-hospital intubation of hypoxic patients is optimal therapy. The constraints of our service require that a Level 5 Paramedic or a Retrieval Team be present for intubation to occur. Where the GCS is beyond 3 or 4, relaxing drugs are required for site intubations. I would refer you to the excellent article referenced by Dr. Mumford in this issue by Schmidt et al and the interesting discussion about the article in the Journal of Trauma, 1992. This highlights the potential benefit of scene intubation in improving survival.

Assessment of the Abdomen in the unconscious head injured patient:

A recent patient involved in a high speed motor vehicle accident sustaining the clinical scenario of brain death was transferred from an urban hospital to our hospital. Studies were performed revealing that the patient was brain dead and there was no intention to treat. It became evident, however, at post mortem that the lady had a ruptured spleen and a retroperitoneal haematoma. While this injury did not effect this particular patient it emphasises the need for assessment of unconscious or unco-operative patients either with a diagnostic peritoneal lavage or an abdominal CT scan. In a recent article by Martin Keller from Vermont Journal of Trauma,1996,Volume 41, Page 471, they have evaluated the success rate for non-operative management and the impact of this approach in patients with both abdominal and head injury. They looked at 107 patients from 1994 to 1995 and found that 42% had head and splenic injury, 48% had head and liver injury. Only 20% of their patients required surgery. They concluded that there is a possible role for non-operative management of blunt splenic and hepatic injuries in abdominal trauma.

We would like to caution against this approach in adults, especially in patients who may be difficult to monitor such as those undergoing interhospital transfer. A significant missed intra-abdominal injury may be the source of intra-abdominal bleeding with resulting hypotension that can convert a minor primary brain injury into a fatal secondary brain insult. We would advocate early diagnostic peritoneal lavage in our unit in patients who have head injury with multi system trauma. These patients, would, in the current environment tend not to be managed non-operatively.

BACKCHAT:

Meetings:

SWAN V Trauma Symposium will be held on October 22nd/23rd, 1997 in the Auditorium of the Education Block at Liverpool Hospital. This exciting programme will be spread over one and a half days and will feature Professor Larry Marshall, Neurosurgeon from San Diego, Dr. Anne Kolbe, Paediatric Surgeon from Auckland, Mrs. Trish McDougall, Trauma Co-ordinator from Westmead and Dr. Danny Cass Associate Professor of Paediatric Surgery, New Children's Hospital.

The programme will be as dynamic, focusing on head injury care and paediatric management. Registration forms can be obtained from the Conference Secretariat, Trauma Department, Liverpool Hospital.

AusTrauma, 1997 held recently at Westmead Hospital with over 150 registrants was a very successful two day Trauma Seminar. Congratulations to the hard working Committee of Trish McDougall, Andrea Delprado and Dr. Jim McGrath.

REGISTRY UPDATE:

Erica Caldwell, our Trauma Data manager is just completing our two year Registry Report which should be available in late March. Copies of the Report will be available at a cost of $15.00 which will include postage. The Registry will provide an overview of the demographics of trauma in South West Sydney reviewing over 8,000 trauma admissions over the last 24 months. It will provide some analytical comments, describe the methodology used in outcome analysis and report on performance indicators. In addition a detailed Cook Book on all the definitions used in our Registry plus an actual data set used to collect information will be included with the Report.

TRAUMA EDUCATION:

Our Regional Trauma Education Programme will continue in South Western Sydney with Dr. Janjua organising meetings on a weekly basis, rotating six weekly through the different hospitals. Michelle McClymont will be meeting with local Emergency Departments organising trauma education focusing on nursing issues in trauma.

Trauma Education Packages for visiting nursing, ambulance, paramedic and general practitioners are available on request from the department. We will welcome visitors to our unit. We have recently had the pleasure of having Dr. Silent Tovosia visit us for a period of four weeks during which time he has obtained his EMST Certificate. We wish him all the best on his return to the Solomon Islands.

WEB PAGE:

Dr. Jon Ryan is continually modifying our Web Page and International interest is expanding, with increasing correspondence from the United States and Great Britain. Your potential input to our Web Page on the Internet would be very welcome.

CASE OF THE MONTH:

A 37 year old male was involved in a high speed motor vehicle accident on Newbridge Road at 1703 when he hit a tree at high speed. When the Ambulance Officers arrived 6 minutes later they noticed that he was in distress. His airway was intact.

Airway - intact

Breathing - RR 40 per minute, decreased air entry left side,

Circulation- Pulse 110 per minute

BP 90 systolic

Disability - Alert, GCS 15

En route to hospital he received I.V. Morphine, 1.5 litres of Haemaccel. On arrival at the hospital Resuscitation Room, 22 minutes after the accident, his primary survey revealed the following:

Primary Survey:

Airway - intact

Breathing - RR 24/m, decreased air entry left base

Circulation- Pulse 110/m

BP130 mmHg

Disability - GCS 15 - patient alert

Secondary survey:

In view of the respiratory distress and reduced air entry it was decided to proceed with stabilisation of breathing prior to secondary survey. A chest x-ray was obtained and simultaneous with the chest x-ray a chest tube was inserted into the left chest using an open technique under local anaesthetic. At the time of insertion of the chest tube the patient's trachea was deviated to the right and his saturation was 90%. A detailed secondary survey revealed some facial laceration, bruising left chest, tenderness with guarding throughout the abdomen and a clinically fractured left ankle. His chest x-ray is shown in figure 2.

What would you do next?

Should the patient be intubated?

Should the patient have an abdominal CT scan DPL ?

What are the other potential injuries that this patient may have?

What basic set of x-rays would be most appropriate?

- For more information, see next issue.

What should you have done? A review of last issue's Case of the Month.

A 58 year old male was stabbed in the epigastrium. At the scene he was pale, his observations were normal but he had a long bladed knife protruding from his mid epigastrium directed towards the xiphoid notch. In resuscitation room, 9 minutes later, his primary survey revealed hypotension (BP 96 mmHg systolic). The Trauma Team were in attendance.

If you were the Trauma Team Leader what would be your plan?

Firstly accurate patient information transfer from the ambulance officer has allowed you to focus on the primary survey,

A Intact

B RR 24/m equal air entry

C The patient looked terrible, P increased from 130/m to 140/m and BP was now 85 systolic, despite 1L of Haemaccel.

As team leader my priority would be arrest of haemorrhage, which presumably is either into the abdomen or chest. This requires a surgeon and an operating theatre. This patient may be dead in 10-20 minutes and I would set a target on having him in the operating theatre in 8 minutes. The priorities are outlined in order below

Airway Leave intubation for the operating theatre.

Breathing Ideally I should have had the radiographer place a chest X-ray plate on the trauma trolley before the patient arrived, allowing an immediate CXR (with lead gowning of trauma team)

Circulation Surgery - Stop the bleeding- Surgery! Resuscitation in terms of IV fluids should be kept at a minimum if immediate surgery is possible. Theatre and Anaesthetic Team must be notified immediately

On this particular day I have access to a surgeon immediately (he actually walked in behind the patient) and therefore I would not consider pericardiocentesis. When pericardial tamponade is suspected surgical decompression and arrest of haemorrhage is the first choice. Pericardiocentesis is difficult and should really be reserved for situations when there is a potential delay in obtained surgical services. A MAST suit is contra-indicated ( even if he did not have a knife sticking out it).

Disability The patients level of consciousness will be an important indicator of cerebral perfusion and resuscitation should aim to maintain an alert status and BP>80 mmHg systolic (palpable pulse).

A number of key additional procedures may help

*Orderly ready with oxygen (this could take 5 minututes if you are not thinking ahead).

*Patient initially connected to portable cardiovascular monitor to save time.

*Setting a target time for length of time to be spent in the resuscitation room. For example a decision should be made for the patient to be in the operating theatre in 8 minutes and every member of the team knows this, by the Team Leader clearly expressing his target.

*Blood request flexible to included either O negative or O positive Blood as stocks of O negative blood are often low.

*Watching patients core temperature and warming fluid. (We keep our Saline and Haemaccel in a fluid warming cabinet at 38oC).

*Not allowing and unnecessary tests (ECG, ECHO ) or God forbid a CT scan request! Procedures such as urinary catheterisation should not be undertaken at this stage as they may divert priorities in the exsanguinating patient.

As there was 6 minutes prior notification of the patient arriving, what are the critical preparations you would undertake in the resuscitation room.?

Notification of the Specialist Surgeon

Alert the team to be ready with Blood and Haemaccel

primed in a rapid infusion system

Alert the operating and Anaesthetic Staff

The patient was transported to the operating theatre 7 minutes post arrival in resuscitation room. The team consisted of 3 specialists and 3 registrars. The surgeon arrived in room at 1 minute after the patient.

Outcome

The patient underwent a midline laparotomy and there was about 1000ml of blood in the peritoneal cavity. The surgeon had requested a sternal saw and thoracotomy instruments. The surgical findings revealed a 2cm mid diaphragmatic penetration with resultant pericardial tamponade. The pericardium was opened from below and there were two stab wounds in the right ventricle. These were oversewn ( from the abdomen) with 3/0 prolene. There were other cardiac stab wounds. The patient made an excellent recovery and was discharged on day 8.

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