MSc(Med), Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand / Introduction Many patients that have suffered traumatic injuries require admission to Intensive Care Unit (ICU). Mechanical ventilation (MV) is deemed to be the defining event marking many ICU admissions. As many as 30% of admissions, and 90% of all critically ill patients will require at least a short period of MV. There are many risks and complications associated with prolonged MV, such as rate of pneumonia, morbidity and mortality, increased cost, hospital LOS, emotional distress and decreased bed availability. To minimize these risks and complications it is important that patients be weaned and extubated from MV at the earliest possible time. However, just as delayed weaning and extubation carries the risk of complications, premature extubation and subsequent re-intubation should be avoided where possible, as extubation failure leads to an eight-fold higher risk of infection and a twelve-fold increase in mortality. Weaning is the transition from ventilatory support to spontaneous breathing and can often be achieved easily, but may be difficult in up to 25% of patients. Numerous studies have shown the benefit of allied health care worker (nurses and physiotherapists) driven weaning protocols in decreasing MV days and costs. Purpose To determine if the use of a nurse and therapist-driven weaning protocol to wean and extubate long-term patients with trauma from MV in an open ICU results in decreased total MV days and ICU length of stay (LOS), and to determine time to spontaneous breathing trial (SBT) failure. Methods A weaning protocol was developed by the researcher using clinical guidelines compiled for the American Association for Respiratory Care, American College of Chest Physicians and American College of Critical Care Medicine. A total of 56 mechanically ventilated trauma patients were enrolled in two phases of the study. A prospective cohort of 28 patients (Phase I), weaned according to the protocol, was matched retrospectively with a historical cohort of 28 patients (Phase II), weaned according to physician preference. Pairs in the two groups were matched to be similar for gender, age, type and severity of injury. Data analyzed for both groups were number of MV days, number of ICU days, self-extubation and need for re-intubation. For Phase I patients, time to SBT failure and reason for failure was recorded. v Results and Discussion With respect to the mean MV days it was found that the two protocol groups did not differ significantly (p = 0.3 ; Phase I = 14.4 days vs Phase II = 16.3 days), although the two day reduction in MV was considered clinically significant in view of the complications associated with additional MV days. The difference of 0.25 days for length of ICU stay between the groups was not statistically significant (p = 0.9; Phase I = 20.8 days vs Phase II = 21 days), and demonstrates that a reduction in MV days may not necessarily result in a reduction of ICU LOS. Rate of re-intubation was similar in the two groups (Phase I = 3/28 vs Phase II = 4/28). Eleven patients (39%) in Phase I failed at least one SBT and four of these patients (36%) failed two SBTs prior to successful extubation. Failure of the first SBT occurred an average of 18 hours after onset of SBT. Injury severity scores for these patients were higher than the average for Phase I (16.1 vs 14.5). Mean MV time in this group was 20.5 days as opposed to 14.4 days in the total Phase I group. This indicates that these patients were more critically ill and that they may require longer SBTs than advocated in many studies. All patients failed SBT due to increased RR. Conclusion In this study of longer-term ventilated patients who had traumatic injury as reason for admission to ICU and mechanical ventilation, the use of a standardized protocol to assist with weaning and extubation from MV demonstrated a clinically significant reduction in total MV time, even though this did not reach statistical significance. The reduction in MV time did not lead to a reduction in ICU LOS, however it reduces the risks of ventilator-associated complications such as VAP. The use of a weaning and extubation protocol did not lead to a higher rate of re-intubation, demonstrating its safety for use in this patient population. This protocol was driven by nurses and physiotherapists, and the role of physiotherapists and nursing staff in weaning and extubation of patients from MV could be greatly expanded in the majority of ICUs in South Africa.

There is an ongoing debate concerning the nature of warfare and violence in the Iron Age of Britain. Interpretations regarding material remains from this period fluctuate between classifying instruments of violence (i.e. swords, spears, hillforts) as functional tools of war and as ritual symbolic devices. Human skeletal remains provide the most unequivocal evidence for violent encounters, but were often missing from these debates in the past. This thesis addresses this lack of treatment by analyzing the patterns of traumatic injuries at sites from two distinct regions in Iron Age Britain (East Yorkshire and Hampshire). The human remains from these sites show clear markers of interpersonal violence. When the remains are placed in context with the mortuary treatment, it is evident that violence and ritual were inextricably linked. In East Yorkshire, combat may have been ritualized through duelling and competition performance. In Hampshire, individuals with perimortem injures are often found in special deposits such as pits, ditches and domestic areas, suggesting their use in ritual processes that distinguish them from the general population. This provides a basis for understanding warfare and violence during the Iron Age of Britain and how communities negotiated the social tensions caused by violent interactions.

There is an ongoing debate concerning the nature of warfare and violence in the Iron Age of Britain. Interpretations regarding material remains from this period fluctuate between classifying instruments of violence (i.e. swords, spears, hillforts) as functional tools of war and as ritual symbolic devices. Human skeletal remains provide the most unequivocal evidence for violent encounters, but were often missing from these debates in the past. This thesis addresses this lack of treatment by analyzing the patterns of traumatic injuries at sites from two distinct regions in Iron Age Britain (East Yorkshire and Hampshire). The human remains from these sites show clear markers of interpersonal violence. When the remains are placed in context with the mortuary treatment, it is evident that violence and ritual were inextricably linked. In East Yorkshire, combat may have been ritualized through duelling and competition performance. In Hampshire, individuals with perimortem injures are often found in special deposits such as pits, ditches and domestic areas, suggesting their use in ritual processes that distinguish them from the general population. This provides a basis for understanding warfare and violence during the Iron Age of Britain and how communities negotiated the social tensions caused by violent interactions. / Note: Content of Appendix 2 is not available.

Trauma and Injury Severity Score (TRISS) é um índice que permite calcular probabilidade de sobrevida de pacientes traumatizados. Para seu cálculo são necessárias as informações: idade; tipo de trauma - penetrante ou contuso; valor do Revised Trauma Score (RTS); e pontuação do Injury Severity Score (ISS). Em 1997 foi realizada uma revisão do ISS com o intuito de melhorar sua acurácia na determinação da gravidade do trauma. Essa revisão resultou em mudança no cálculo desse índice e, consequentemente, em uma nova versão, o New Injury Severity Score (NISS). Resultados de estudos têm indicado que o NISS se iguala ou supera o ISS na previsão de mortalidade. Procurou-se neste estudo verificar se a substituição do ISS pelo NISS, na fórmula original do TRISS, melhora sua estimação de sobrevida. Trata-se de pesquisa retrospectiva realizada no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A população foi constituída por 533 pacientes traumatizados atendidos e internados no Pronto-Socorro deste hospital pelo período de um ano. Foi realizada análise descritiva das características das vítimas e calculadas as medidas de posição para as variáveis contínuas. Para verificar qual o melhor indicador (TRISS ou NTRISS) para probabilidade de sobrevida e o melhor ponto de corte, foi utilizada a curva ROC. Os resultados foram confrontados com as mortes e sobrevidas observadas com o intuito de se identificar a fórmula mais acurada para cálculo da probabilidade de sobrevida. Fizeram parte do estudo pacientes traumatizados entre 18 e 95 anos, sendo a maioria jovens (61,9%), do sexo masculino (80,5%). Os acidentes de transporte foram as causas externas mais frequentes (61,9%), e, consequentemente, houve predomínio de trauma contuso (87,1%). Do total de pacientes, 82,9% foram atendidos por unidades sistematizadas de atendimento pré-hospitalar. A região mais freqüentemente traumatizada foi a superfície externa (63,0%), seguida por cabeça e pescoço (55,5%). Os pacientes estiveram internados por uma média de 11,0 dias (+ 18,0). Dos 533 pacientes, 42,2% necessitaram de internação em Unidade de Terapia Intensiva. A taxa de sobrevida foi de 76,9%. A maioria dos indivíduos (54,5%) apresentou valor de RTS de 7 a 7,84. O escore do ISS e do NISS variou de 0 a 75, com predomínio do escore de 9 a 15 (40,0%) para o ISS e de 16 a 24 (25,5%) para o NISS. O valor do TRISS e do NTRISS variou de 0 a 100,0%; probabilidade de sobrevida maior ou igual a 75,0% foi apresentada por 83,4% dos pacientes segundo o TRISS e por 78,4% dos pacientes de acordo com o NTRISS. O TRISS superestimou a probabilidade de sobrevida dos pacientes traumatizados. Houve diferença estatisticamente significativa entre a previsão de sobrevida dada pelo TRISS e NTRISS, e o NTRISS foi mais assertivo que o TRISS para prever sobrevida dos pacientes atendidos neste centro de trauma / The Trauma and Injury Severity Score (TRISS) is an index that permits the calculation of survival probability in trauma victims. The following information is necessary to perform this calculation: age, trauma type -penetrating or contusion; value from the Revised Trauma Score (RTS); and the scores from the Injury Severity Score (ISS). In 1997, a revision was done to the ISS to improve its accuracy for determining the severity of traumas, thus resulting in a new version called the New Injury Severity Score (NISS). Studies have shown that this NISS is equal to or greater than the ISS in the prediction of mortality. The objective of this study was to verify if substituting the ISS with the NISS, in the original TRISS form, improved the survival rate estimate. This retrospective study included 533 trauma victims who were attended and interned in the emergency room during a period of 1 year, in \"Hospital das Clínicas\" of the Medical School of the University of Sao Paulo. A descriptive analysis of the characteristics of the victims was performed and the position measurements for the continuous variables were calculated. An ROC curve was used to verify which would be the best indicator (TRISS or NTRISS) for calculating the survival probability. The results were compared with the deaths and survivors in order to indentify the most accurate formula for calculating survival probability. Included in this study were trauma victims, between the ages of 18 to 95, with the majority being youths (61.9%) and of the male gender (80.5%). Contributing causes were predominantly from motor vehicle accidents (61.9%), and predominantly with contusions (87.1%). Of the total victims, 82.9% were treated in first aid clinics. The most frequent trauma regions were superficial (63%) followed by the head and neck (55.5%) The victims were interned on an average of 11 days. ( +18.0). Of the 533 victims 42.2% were interned in the Intensive Care Unit (ICU) and the survival rate was 76.9%. The majority of individuals (54.5%) had RTS scores between 7 and 7.84. The ISS and NISS score varied from 0 to 75, with the average ISS score ranging from 9-15 (40.0%) and the NISS score from 16-24 (25.5%). The TRISS and NTRISS scores varied between 0 and 100 %; probability of survival equal to or greater than 75.0% was presented for 83.4% of the victims according to TRISS and 78.4% according to NTRISS thus, the TRISS overestimated the probability of survival in trauma victims. There was a statistically significant difference in the estimate of survivability data between the TRISS and NTRISS with the latter being the more accurate scale for predicting survivability among the victims treated in this trauma center

Trauma and Injury Severity Score (TRISS) é um índice que permite calcular probabilidade de sobrevida de pacientes traumatizados. Para seu cálculo são necessárias as informações: idade; tipo de trauma - penetrante ou contuso; valor do Revised Trauma Score (RTS); e pontuação do Injury Severity Score (ISS). Em 1997 foi realizada uma revisão do ISS com o intuito de melhorar sua acurácia na determinação da gravidade do trauma. Essa revisão resultou em mudança no cálculo desse índice e, consequentemente, em uma nova versão, o New Injury Severity Score (NISS). Resultados de estudos têm indicado que o NISS se iguala ou supera o ISS na previsão de mortalidade. Procurou-se neste estudo verificar se a substituição do ISS pelo NISS, na fórmula original do TRISS, melhora sua estimação de sobrevida. Trata-se de pesquisa retrospectiva realizada no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A população foi constituída por 533 pacientes traumatizados atendidos e internados no Pronto-Socorro deste hospital pelo período de um ano. Foi realizada análise descritiva das características das vítimas e calculadas as medidas de posição para as variáveis contínuas. Para verificar qual o melhor indicador (TRISS ou NTRISS) para probabilidade de sobrevida e o melhor ponto de corte, foi utilizada a curva ROC. Os resultados foram confrontados com as mortes e sobrevidas observadas com o intuito de se identificar a fórmula mais acurada para cálculo da probabilidade de sobrevida. Fizeram parte do estudo pacientes traumatizados entre 18 e 95 anos, sendo a maioria jovens (61,9%), do sexo masculino (80,5%). Os acidentes de transporte foram as causas externas mais frequentes (61,9%), e, consequentemente, houve predomínio de trauma contuso (87,1%). Do total de pacientes, 82,9% foram atendidos por unidades sistematizadas de atendimento pré-hospitalar. A região mais freqüentemente traumatizada foi a superfície externa (63,0%), seguida por cabeça e pescoço (55,5%). Os pacientes estiveram internados por uma média de 11,0 dias (+ 18,0). Dos 533 pacientes, 42,2% necessitaram de internação em Unidade de Terapia Intensiva. A taxa de sobrevida foi de 76,9%. A maioria dos indivíduos (54,5%) apresentou valor de RTS de 7 a 7,84. O escore do ISS e do NISS variou de 0 a 75, com predomínio do escore de 9 a 15 (40,0%) para o ISS e de 16 a 24 (25,5%) para o NISS. O valor do TRISS e do NTRISS variou de 0 a 100,0%; probabilidade de sobrevida maior ou igual a 75,0% foi apresentada por 83,4% dos pacientes segundo o TRISS e por 78,4% dos pacientes de acordo com o NTRISS. O TRISS superestimou a probabilidade de sobrevida dos pacientes traumatizados. Houve diferença estatisticamente significativa entre a previsão de sobrevida dada pelo TRISS e NTRISS, e o NTRISS foi mais assertivo que o TRISS para prever sobrevida dos pacientes atendidos neste centro de trauma / The Trauma and Injury Severity Score (TRISS) is an index that permits the calculation of survival probability in trauma victims. The following information is necessary to perform this calculation: age, trauma type -penetrating or contusion; value from the Revised Trauma Score (RTS); and the scores from the Injury Severity Score (ISS). In 1997, a revision was done to the ISS to improve its accuracy for determining the severity of traumas, thus resulting in a new version called the New Injury Severity Score (NISS). Studies have shown that this NISS is equal to or greater than the ISS in the prediction of mortality. The objective of this study was to verify if substituting the ISS with the NISS, in the original TRISS form, improved the survival rate estimate. This retrospective study included 533 trauma victims who were attended and interned in the emergency room during a period of 1 year, in \"Hospital das Clínicas\" of the Medical School of the University of Sao Paulo. A descriptive analysis of the characteristics of the victims was performed and the position measurements for the continuous variables were calculated. An ROC curve was used to verify which would be the best indicator (TRISS or NTRISS) for calculating the survival probability. The results were compared with the deaths and survivors in order to indentify the most accurate formula for calculating survival probability. Included in this study were trauma victims, between the ages of 18 to 95, with the majority being youths (61.9%) and of the male gender (80.5%). Contributing causes were predominantly from motor vehicle accidents (61.9%), and predominantly with contusions (87.1%). Of the total victims, 82.9% were treated in first aid clinics. The most frequent trauma regions were superficial (63%) followed by the head and neck (55.5%) The victims were interned on an average of 11 days. ( +18.0). Of the 533 victims 42.2% were interned in the Intensive Care Unit (ICU) and the survival rate was 76.9%. The majority of individuals (54.5%) had RTS scores between 7 and 7.84. The ISS and NISS score varied from 0 to 75, with the average ISS score ranging from 9-15 (40.0%) and the NISS score from 16-24 (25.5%). The TRISS and NTRISS scores varied between 0 and 100 %; probability of survival equal to or greater than 75.0% was presented for 83.4% of the victims according to TRISS and 78.4% according to NTRISS thus, the TRISS overestimated the probability of survival in trauma victims. There was a statistically significant difference in the estimate of survivability data between the TRISS and NTRISS with the latter being the more accurate scale for predicting survivability among the victims treated in this trauma center