Injury
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Rupture of the diaphragm occurs in approximately 5 per cent of cases of severe blunt trauma to the trunk, and the mortality may be as high as 50 per cent. The diagnosis is important because of the high incidence of associated organ damage and complications of a missed injury. Successful diagnosis requires a high index of suspicion but can be made from the chest radiograph in 90 per cent of cases if visceral herniation has occurred. We present three cases of rupture of the diaphragm which highlight the frequent occurrence of a delayed or missed diagnosis.
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There were 83 survivors of the M1 aircrash admitted to hospital; of these, 28 patients sustained a total of 40 open fractures. These open fractures were classified as 19 grade 3, 16 grade 2 and five grade 1. There were six upper limb fractures and 34 lower limb fractures. ⋯ The early results in terms of the incidence of wound infection (15 per cent), delayed wound healing (7.5 per cent) and skin flap necrosis (7.5 per cent) were similar to other series. The controversy over whether to leave grade 3 wounds open or closed was not clarified by this study, but the closure of grade 3 wounds after internal fixation is to be avoided. This study emphasizes the need for provision of adequate specialist manpower, equipment and resources to manage the unexpected major disaster successfully.
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In response to recent reports questioning the adequacy of management of major trauma in the United Kingdom, the routine for handling such emergencies in one district general hospital was examined. Deficiencies in the current system of management were identified and are described. In order to improve the standard of care a protocol for the assessment and resuscitation of the seriously injured was devised. ⋯ In addition, a new form of documentation was designed to facilitate the recording of injuries, resuscitation measures required and physiological parameters. This documentation is described in detail. These measures have been favourably received by medical and nursing staff and have stimulated interest in the management of major injuries.