Trauma

Early burn excision has reduced the mortality from major burns. This practice presents the problem of wound coverage after excision, since the availability of autologous donor sites is limited in very large burns. This article reviews the methods available for covering burn wounds. Methods of expanding autologous skin are discussed as well as techniques using allogeneic tissue and xenograft. Newer synthetic skin substitutes have become an important advance and are also described. Cultured skin replacements are also discussed along with their shortfalls. The treatment of a patient with major burns may require the use of many different skin substitutes, as none is entirely satisfactory on its own.

The role of radiological imaging modalities in the investigation of head trauma is reviewed with reference to the mechanisms of head injury, as well as the recent guidelines for investigation produced by the National Institute for Clinical Excellence (NICE), and the Royal College of Radiologists. Lesions resulting from head trauma and the associated radiological ndings are described.

Acute post-traumatic renal failure is one of the most serious complications that can affect polytrauma patients, with a high morbidity and mortality. The kidney is vulnerable to developing acute renal failure by virtue of the arrangement of its blood supply and the high metabolic demands involved in the production of urine. While several intrinsic mechanisms exist to protect the kidney, these may be swamped following polytrauma. In particular haemorrhage and hypotension can lead to early renal failure; and the massive release of cytokines occurring in the systemic inflammatory response syndrome can lead to renal failure as part of the multiorgan failure syndrome. Early initiation of a renal protection protocol, followed by early conversion to renal replacement therapy if failure develops, reduces both morbidity and mortality. Continuous veno-venous haemofiltration mimics normal production of a glomerular filtrate and forms the basis of renal replacement strategies. It has several potential complications, but modern computerized systems have minimized these.

The commonest cause of death in children is trauma, yet few studies have been undertaken to study their needs in the prehospital setting. This article examines the problems associated with seriously traumatized children in the prehospital setting and reviews their management with reference to the specific differences between adults and children. A systematic review of the primary survey is made. Other important aspects of their care including equipment, analgesia, child abuse and accident prevention are also discussed. The need for further research in this field to allow children to enjoy the standard of care afforded adults is emphasized.

Increasing elderly population means an increasing proportion of elderly trauma patients. This group commonly have associated chronic medical disorders which can influence the presentation and outcome of trauma. The common medical causes of trauma include falls, syncope, obstructive sleep apnoea and diabetes mellitus. Comorbid medical conditions mean poor physiological reserve and therefore the importance of timely medical intervention by early identification of a deteriorating patient. Modified Early Warning Score (MEWS) is one such tool which can help early idenfication of a deteriorating patient. Elderly trauma patients frequently develop medical complications while in the hospital and the trauma surgeon should be alert to this and initiate appropriate early management. The Acute Life-threatening Events Recognition and Treatment (ALERT^TM) course assessment algorithm (Figure 1) helps in this by providing a system for the comprehensive review of a critically ill patient. Trauma in elderly calls for a multidisciplinary approach and close cooperation between the elderly care physician and the trauma surgeon.

External fixation is a method of immobilization that uses percutaneous pins placed in bone and linked with external connectors to maintain the fracture segments in a desired spatial relationship. It is a valuable clinical treatment option, providing surgeons with the ability to affect the spatial relationship of tissues, both statically and dynamically, via minimally invasive techniques. The ease and speed of application, adjustability of the frame, and minimization of blood loss with preservation of blood supply at the cutaneous and osseous levels are advantages of the external fixation technique. Care of the trauma patient remains one of the major applications for external fixation. Open fractures with severe soft tissue injuries and/or massive contamination are ideally suited to this technique. External fixation is also a versatile salvage technique for the complications arising from extremity trauma. The management of residual fracture deformity, bone loss, infections, and complex post-traumatic arthritis are often facilitated by external fixation.

On average, 140 cyclists are killed each year on Britain’s roads and a further 22 785 injured. About a third of those injured are children. This review examines the nature and circumstances of cycling injuries and contrasts them with the risks associated with other modes of transport. It looks at the effectiveness of cycle helmet use and suggests other measures to best reduce cycling injuries.

Myocardial contusion can be a difficult diagnosis to make. There is currently no gold standard of investigation that allows its accurate diagnosis in the clinical setting. Trauma surgeons need to have a high degree of clinical suspicion when dealing with patients who have received blunt thoracic injuries in order that the diagnosis of myocardial contusion may be made. In this article we discuss the diagnosis, potential complications and investigation of patients with suspected myocardial contusion and also present a fl ow diagram for the possible management of patients with trauma who may have suspected myocardial contusion.