Trauma

Undertreatment of acute, moderate-to-severe pain in children is common, due in part to barriers to the use of opioids. Low-dose methoxyflurane is an inhaled, non-opioid analgesic widely used in Australia and recently approved in Europe for the emergency relief of acute moderate-to-severe trauma pain in adults.

Using an integrative review framework, we conducted a literature analysis to examine the potential utility of methoxyflurane in children with acute pain. EMBASE®, MEDLINE® and PubMed were searched (criteria included ‘methoxyflurane’ ‘child*’ or ‘adolescent’ or ‘pediatr*’ or ‘paediatr*’) from January 2000 to October 2017, along with internet-based sources to identify relevant grey literature (no predefined search criteria). A series of investigative questions were developed regarding the safety and efficacy of methoxyflurane in this setting and addressed using evidence collated from the identified studies.

Of 366 results from the literature searches, 6 clinical trials and observational studies were identified which explored the safety and/or efficacy of inhaled methoxyflurane in individuals < 18 years in either a clinical trial or observational study. All six studies concluded that methoxyflurane provides effective and rapid analgesia for paediatric acute moderate-to-severe pain. Methoxyflurane was well tolerated and associated with good levels of patient/healthcare provider satisfaction in this setting.

While large-scale studies are needed to better inform treatment approaches for paediatric use, inhaled methoxyflurane has potential to provide easy to administer, needle-free analgesia with a rapid onset and good safety profile.

There have been many reports of electronic cigarette burns and lithium ion battery explosions leading to property and/or bodily damage, but there is a paucity of data about these injuries in the medical literature. We present a series of patients treated for electronic cigarette burns and lithium ion explosions and review the literature.

Patients treated for electronic cigarette burns between January 2012 and December 2016 were identified. Patients were included if they suffered injuries from either an electronic cigarette device or from batteries used in the devices. Data were collected on the mode of injury, depth, size, and location of the burn, whether or not they had any surgeries and length to recovery.

Fourteen patients were treated for electronic cigarette burns between 2012 and 2016. Burn size ranged from <1% to 6% total body surface area. Most patients suffered burns to their thighs because the battery or device exploded in their pocket. The majority suffered partial thickness burns while four patients had full thickness burns. Three patients required excision and autografting, all of which were full thickness burns. The average time to recovery was 24.5 days.

Electronic cigarettes pose a new and unique risk to consumers. Lithium ion battery explosions can cause severe injury and significant burns requiring surgery. The incidence of e-cigarette burns are expected to increase as the number of users grow.

Musculoskeletal pain caused by trauma is one of the common complaints of patients referred to the emergency department. Due to the lack of a proper pain control protocol, doctors and nurses do not pay attention to pain, and physicians may tend to request too many radiographs, many of which will be unnecessary. We aimed to study the effect of pain management by fentanyl in reducing the number of radiographs, reducing hospital costs and increasing satisfaction in the patients on patients with isolated trauma in limbs and spine causing musculoskeletal pain.

A cohort of patients who were referred to the fast-track emergency department with isolated trauma of the upper and lower limbs or spine and triage levels 3, 4 and 5, were visited twice by an emergency medicine resident – before and after application of a pain management protocol using intravenous fentanyl as the principle analgesic. The primary outcome measure was the reduction in the number of radiographs requested; secondary outcomes included alterations in pain levels and patient satisfaction.

A total of 158 patients were included in the study. The median age was 27.5 years, three quarters were male and 20.88% had a positive history of opium addiction. The number and costs of diagnostic radiography significantly decreased after the administration of fentanyl (P < 0.0001), as did pain levels measured on visual analogue scale with a consequent increase in patient satisfaction. There were only six complications resulting from fentanyl administration which were mild and transient. Follow-up after 24–72 h, revealed no missed fractures.

The administration of fentanyl as a strong analgesic as part of an emergency department pain management protocol for trauma patients can be performed with limited minor complications; it can reduce the number of unnecessary X-rays performed, exposure to ionizing radiation and hospital costs as well as improving patient satisfaction without missing fractures.

To assess the differences in the types of injuries sustained by surfboard and bodyboard riders and to identify common mechanisms of injury.

Subjects were prospectively recruited to the study on presentation to one of the six hospital emergency departments. Consented subjects completed a questionnaire while in the emergency departments. Data regarding radiological investigations undertaken and their findings were collected retrospectively.

A total of 224 males and 28 females in the surfing group and 14 males in the bodyboard group were recruited. In surfers, the most common injured body parts were the head/face (115; 45.6%) and lower limb (69; 27.4%). Surfers were most commonly injured by a surfboard, either their own (178; 70.6%) or someone else’s (18; 7.1%). Unfortunately, the small number of subjects recruited to the bodyboard group precluded meaningful comparison with the surfing group.

The most common body part injured in surfers is the head/face compared with the lower limbs in bodyboard riders. Contact with a surfer’s board (most commonly their own) is the most common cause of injury. Significant spinal fractures/injuries are sustained when the surfer (usually their head) strikes the seafloor. Head and facial fractures occur when the surfer is struck by their own board. Future research into surfboard design which incorporates softer compounds into the deck, rail, and fins is recommended. The need for local authorities and surf lifesavers to disseminate information relating to specific beaches to the general public regarding surf conditions, water depth, and the nature of the seafloor is also essential for injury prevention.

Whilst hearing injuries are not life threatening they may have a profound impact on the victim’s ability to understand and interact with the world around them. Noise-induced hearing loss is a common occupational injury and hearing impairment as a consequence of noise and blast exposure remains the most common injury in both war and peace for military personnel. Health and Safety legislation has made an impact and in the future innovative approaches to mitigate against acoustic injury sustained in the work place will be fundamental. For the Armed Forces, noise exposure during conflict is unpredictable. Furthermore, recent events in the UK and elsewhere have highlighted the potential civilian impact of blast injuries on hearing in the acute setting. No well-established protocol for the management of acute, blast-induced hearing injury currently exists.

Narrative review is supported by electronic literature searches of PubMed, Embase and the Cochrane Library. Synthesis of published literature and production of flow charts for the acute setting are part of the Emergency Preparedness, Resilience and Response programme.

Whilst there is a lack of high-quality randomised controlled trials, there are a number of studies that may inform our choice of acute management. Animal studies of acute acoustic trauma have shown the potential protective effects of corticosteroids. Human data may be extrapolated from sudden onset sensorineural hearing loss where again there is evidence for the use of corticosteroids. Less certainty exists around the use of other treatments including antioxidants. Intratympanic administration of corticosteroids may be superior to oral administration, particularly in the salvage setting. No evidence exists specifically pertaining to the paediatric population.

Prompt identification of any hearing deficit followed by administration of glucocorticoids either orally or via intratympanic preparations is the mainstay of management. Further research is needed to identify the optimum acute management.

The ‘found down’ patient presents a unique circumstance for the clinician in that the patients are often unable to provide history of the events preceding their presentation to the emergency department. Studies on this population are limited.

The trauma and emergency department registries from January 2013 through December 2014 at an urban level one trauma center were queried for patients described as ‘found down’ and related descriptions. Basic demographic data included patient disposition, Glasgow coma score and injury severity score (ISS), patient requiring intubation, imaging performed, and injuries sustained. Patients were stratified into those managed by the trauma service versus the emergency department.

A total of 298 patients met criteria to be included in this study, nine of whom died; the average age was 50 years old and 9% of this population was found to have an intracranial hematoma. The subset of patients who had a rapid return to Glasgow coma score 15 had a 6% incidence of having an intracranial hematoma. Four cervical fractures were identified. There was only one intra-abdominal injury.

Computerized tomography scans of the brain and cervical spine should be performed for all patients who are found down. Intra-abdominal injuries are exceedingly rare and selective use of computerized tomography should be made. Superficial injury does not indicate more significant injury in this population; however, lack of superficial injury does not preclude more significant injuries.

The elderly population in Iran is growing, and more medical comorbidities can be identified, so hospital admissions of burn patients with associated medical comorbidities are expected to rise as well. As these medical comorbidities may affect the prognosis of burn patients, additional health care services are likely to be required. Therefore, the aim of this study was to determine the prevalence of comorbidities among patients with burn injury.

A retrospective study of all burn patients admitted to the Motahari Burn Hospital, Iran over a 14-month period was conducted. Variables gathered from patients’ medical record files were demographic characteristics, clinical burn features, hospital course, and preexisting comorbidities. The comorbidity score of patients was calculated by using the updated Charlson comorbidity index.

A total of 732 patients were hospitalized, 136 (18.5%) patients had comorbidities, and more than 57% of elderly people (≥61 years) had one or more comorbid conditions. The most common cause of burn injury among the comorbid patients was scald (38.2%) injury. The two most frequent comorbid conditions among all cases were congestive heart failure (25.8%) and diabetes (23.5%), respectively. As patients got older, the Charlson score also increased. There were no significant differences between comorbid and noncomorbid patients in terms of hospitalization period and mortality rate. Those comorbid patients who died had significantly higher Charlson score and larger mean burn sizes compared to surviving comorbid patients; they were also significantly older.

The prevalence of comorbidities in burn patients was 18.5% and among older burn patients rose to 57%. Diabetes and congestive heart failure were the two most common comorbid conditions.