Der Würzburger Schockraumalgorithmus

Indications for total-body computed tomography in blunt trauma patients: a systematic review

PURPOSE

Total-body CT scanning (TBCT) could improve the initial in-hospital evaluation of severe trauma patients. Indications for TBCT, however, differ between trauma centers, so more insight in how to select patients that could benefit from TBCT is required. The aim of this review was to give an overview of currently used indications for total-body CT in trauma patients and to describe mortality and Injury Severity Scores of patient groups selected for TBCT.

METHODS

A systematic review was performed by searching MEDLINE and Embase databases. Studies evaluating or describing criteria for selection of patients with potentially severe injuries for TBCT during initial trauma care were included. Also, studies comparing total-body CT during the initial assessment of injured patients with conventional imaging and selective CT in specific patient groups were included.

RESULTS

Thirty eligible studies were identified. Three studies evaluated indications for TBCT in trauma with divergent methods. Combinations of compromised vital parameters, severe trauma mechanisms and clinical suspicion on severe injuries are often used indications; however, clinical judgement is used as well. Studies describing TBCT indications selected patients in different ways and were difficult to compare regarding mortality and injury severity.

CONCLUSIONS

Indications for TBCT in trauma show a wide variety in structure and cut-off values for vital parameters and trauma mechanism dimensions. Consensus on indications for TBCT in trauma is lacking.

[From fishing trip to the critical care unit : Successful resuscitation after a near drowning accident]

BACKGROUND

In the context of the European Resuscitation Council (ERC) guidelines, modifications of the proposed treatment algorithm need to be performed in order to respond to different parameters. In this respect several factors interacting with cardiac arrest are essential and need to be included in the therapy. This case report demonstrates an example of resuscitation in the situation of hypothermia.

CASE REPORT

After a near drowning accident and approximately 30 min underwater, a patient suffering from severe hypothermia initially required resuscitation after the rescue. A return of spontaneous circulation (ROSC) was successfully achieved within a short length of time and after 15 days on the intensive care unit the patient was discharged to a rehabilitation facility without any signs of focal neurological deficits.

DISCUSSION

Section 8 of the ERC guidelines provides additional information for resuscitation under specific conditions. In this case report, hypothermia was one of the main criteria leading to an adjusted pharmacological therapy. Furthermore, selection of the appropriate hospital for an optimal advanced treatment including controlled warming of the patient and management of hypothermia-induced complications had to be evaluated.

[German trauma centers: level-dependent differences in polytrauma care regarding resources and diagnostic concepts]

BACKGROUND

The aim was to survey the radiological diagnostics and type of primary radiological examination of polytraumatized patients treated in German hospitals at various levels in the three-tiered system.

MATERIAL AND METHODS

A questionnaire was sent in October 2007 to every traumatology department registered in the DGU (German Society for Trauma Surgery) databank and forms returned by January 2008 were included in this study.

RESULTS

A total of 273 (54.71 %) of forms were returned and were applicable to statistical analysis. In the three-tiered hospital system 35.9 % of returned questionnaires came from third-tier hospitals, 41.02 % from second-tier and 23.08 % from highest tier (maximum care) hospitals. With a higher hospital level of inpatient care more computed tomography (CT) scans were examined by a radiologist during 24 h daily (p = 0.0014) and CT scanners were located closer to the resuscitation room (p < 0.0001). We found significant differences in the ratios of primary whole-body CTs (WBCT) performed depending on the hospital level: third-tier hospitals 44 %, second tier hospitals 67 % and maximum care hospitals 84 % (p < 0.05).

CONCLUSIONS

Standardized structures regarding radiological diagnostics of polytraumatized patients do not exist at either the same level of the three-tiered hospital system or between levels of care of German hospitals..

[The TraumaRegister DGU® as the basis of medical quality management. Ten years experience of a national trauma centre exemplified by emergency room treatment]

BACKGROUND

The trauma register of the German Society of Trauma Surgery (TraumaRegister DGU®/TR-DGU) has been proven to be a valuable tool for external assessment of quality in the treatment of patients with major trauma. This publication shows for the first time how the quality of trauma treatment in a level I trauma centre could be improved over a period of almost ten years with the help of continuous quality management, i.e. recognizing a problem, developing a solution and evaluating its effect.

MATERIALS AND METHODS

Tracer parameters and indicators of quality are presented in four periods over a total study period from 1st January 1989 to 31st March 2007. The division into four periods is due to major changes in the trauma treatment algorithms or structural changes in the trauma room. The results are displayed for all patients treated in the trauma room and for those patients with an injury severity score (ISS)≥16.

RESULTS

Over all four periods a total number of n=2,239 patients were admitted to the trauma room. Based on the results of the trauma register a number of changes were made, not only structural changes, such as the introduction of point-of-care diagnostics, initially conventional X-ray, then digital X-ray and finally multislice computed tomography (CT) scanning in the trauma room but also changes in the way personnel participating in the trauma treatment are trained. Advanced trauma life support (ATLS®) has become the standard training for doctors and prehospital trauma life support (PHTLS®) for nurses. Time efficient treatment algorithms were introduced. All measures led to changes in several parameters which are chosen as indicators for good treatment quality. It was for instance possible to reduce the average total trauma treatment time for patients with an ISS≥16 from initially 90.9±48.6 min to 37.4±18.  min in the final study period.

CONCLUSIONS

The external quality management performed by the TR-DGU has proved to be a constant source of inspiration. The effects of the changes made can be scientifically proven. It is to be discussed to what extent a sole external quality management can be useful.

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients

BACKGROUND

The aim of this review was to assess the value of immediate total-body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

METHODS

A systematic search of the literature was performed in MEDLINE, Embase, Web of Science and Cochrane Library databases. Reports were eligible if they contained original data comparing immediate total-body CT with conventional imaging supplemented with selective CT in injured patients. The main outcomes of interest were overall mortality and time in the emergency room (ER).

RESULTS

Four studies were included describing a total of 5470 patients; one study provided 4621 patients (84.5 per cent). All four studies were non-randomized cohort studies with retrospective data collection. Mortality was reported in three studies. Absolute mortality rates differed substantially between studies, but within studies mortality rates were comparable between immediate total-body CT and conventional imaging strategies (pooled odds ratio 0.91, 95 per cent confidence interval 0.79 to 1.05). Time in the ER was described in three studies, and in two was significantly shorter in patients who underwent immediate total-body CT: 70 versus 104 min (P = 0.025) and 47 versus 82 min (P < 0.001) respectively.

CONCLUSION

This review showed differences in time in the ER in favour of immediate total-body CT during the primary trauma survey compared with conventional radiographic imaging supplemented with selective CT. There were no differences in mortality. The substantial reduction in time in the ER is a promising feature of immediate total-body CT but well designed and larger randomized studies are needed to see how this will translate into clinical outcomes.

The role of early multislice computed tomography in major trauma

Whole-body multislice spiral computed tomography (MSCT) has become a very important dignostic tool in the management of patients with multiple injuries. Many reports exist which demonstrate the feasibility and the benefit when using whole-body MSCT in the early phase of in-hospital management of trauma patients. Even in hemodynamically instable patients (except cardiac arrest), whole-body MSCT can be used and is a safe diagnostic procedure. While the diagnostic superiority of multislice computed tomography is proven for different organ regions (e.g. head/brain, chest, abdomen, pelvis and spine), its use as a single whole-body scan is still part of an ongoing discussion. Especially concerns about radiation exposure are the reason for uncertainty about when using whole-body trauma scan. Predefined scan protocols and individual positioning of patients may help to keep radiation dose as minimal as possible. To justify higher radiation dose, the indication must be chosen appropriately. Therefore, the use of a sensitive and specific triage scheme seems to be reasonable. Overscanning patients with minor trauma needs to be avoided, while the benefit for patients with severe multiple injuries is obvious.

[Emergency room management of severely injured patients]

BACKGROUND

In cases involving major trauma life-threatening situations should be immediately diagnosed and treated. Clinical algorithms can potentially decrease the rate of complications and errors. The purpose of this study was to investigate the incidence of deviations from a multislice computed tomography based trauma room algorithm.

MATERIALS AND METHODS

During a primary trauma survey an independent study monitor observed the on site treatment sequence step by step. Time intervals between admission and start of each procedure were recorded. Deviations from the algorithm and delays were analyzed.

RESULTS

In 57 trauma patients a total of 49 deviations were documented. Median time between admission and transfer to the adjacent MSCT room was 9 min. Of the patients 11 were bypassed to the MSCT suite without a primary survey (19.3%). In 2 cases an absence of non-invasive blood pressure monitoring was recorded (3.5%) and 3 patients with potential cervical spine trauma were not immobilized at the scene or during primary survey (5.3%). In 8 cases focused assessment with sonography for trauma (FAST) was not performed (14%). Contrary to the algorithm 10 patients received an arterial or central venous line during initial treatment (18%) resulting in a median delay of 8 min. The deviations from the algorithm resulted in no adverse effects on complications or mortality.

CONCLUSION

Self-critical analysis of trauma resuscitation can increase the quality of treatment by revealing constantly recurring faults.

Abdominal trauma: from operative to nonoperative management

The nonoperative care of intraabdominal trauma in the polytraumatised patient greatly depends on imaging techniques. The haemodynamically unstable patient should undergo expedient sonography to rule out abdominal haemorrhage. The use of computer tomography (CT) in this difficult patient group is also currently evaluated, however it takes specific amendments to the protocol and institution. In the hemodynamically stable patient however, computer tomography is the modality of choice to evaluate the injured abdomen. Nonoperative treatment can be successful in up to 80% of selected cases. Adjuncts to nonoperative care include embolisation of the spleen and liver in cases of arterial bleeding, and endoscopic retrograde cholangio pancreaticography (ERCP) and stenting for injuries to the biliary tree.

[Polytrauma management in a period of change: time analysis of new strategies for emergency room treatment]

BACKGROUND

Quality management and the early implementation of whole-body multi-slice spiral computed tomography (whole-body MSCT) are becoming increasingly important in the management of patients with multiple trauma. The aim of this study was to evaluate both components with respect to the time factor for treatment.

METHODS

The investigation involved a retrospective data analysis of the time needed in the emergency room for the initial stabilization (phase A), completing the diagnosis (phase B) and the emergency room treatment (phase C). The investigation included three groups: trauma patients imaged in the emergency room with conventional imaging procedures (group I), with whole-body MSCT alone (group II) and those who were imaged with whole-body MSCT after the introduction of a quality management system with standard operating procedures (group III).

RESULTS

The times for resuscitation (phase A), for diagnostic evaluation (phase B) and for total treatment (phase C) were analyzed. The times for phase A were for group I (n=79) 10 min (interquartile range, IQR 8-12 min), group II (n=82) 13 min (IQR 10-17 min) and group III (n=79) 10 min (IQR 8-15 min; p<0.001). The times for phase B were 70 min (IQR 56-85 min) for group I, 23 min (IQR 17-33 min) for group II and 17 min (IQR 13-21 min; p<0.001) for group III. For phase C the times were 82 min (IQR 66-110 min) for group I, 47 min (IQR 37-59 min) for group II and 42 min (IQR 34-52 min; p<0.05) for group III.

CONCLUSION

Quality management and the early implementation of whole-body MSCT can accelerate the treatment work flow. A rapid initial diagnosis represents an important component in the high quality of treatment of polytrauma patients.

Whole-body multislice computed tomography as the first line diagnostic tool in patients with multiple injuries: the focus on time

OBJECTIVE

Whole-body multislice helical computed tomography (MSCT) becomes increasingly important as a diagnostic tool in patients with multiple injuries. We describe time requirement of two different diagnostic approaches to multiple injuries one with whole-body-MSCT (MSCT Trauma-Protocol) as the sole radiologic procedure and one with conventional use of radiography, combined with abdominal ultrasound and organ focused CT (Conventional-Trauma-Protocol).

METHODS

Observational study with retrospective analysis of time requirements for resuscitation, diagnostic workup and transfer to definitive treatment after changing from conventional to MSCT Trauma-Protocol. Group I: data from trauma patients imaged with whole-body MSCT. Group II: data of trauma patients investigated with conventional trauma protocol before the introduction of MSCT-Trauma-Protocol.

RESULTS

The complete diagnostic workup in group I (n = 82) was finished after 23 minutes (17-33 minutes) [median; interquartile range (IQR)] and after 70 minutes (IQR, 56-85) in group II (n = 79). The definitive management plan based on a completed diagnostic workup was devised after 47 minutes (IQR, 37-59) in group I and after 82 minutes (IQR, 66-110) in group II.

CONCLUSION

A whole-body MSCT-based diagnostic approach to multiple injuries might shorten the time interval from arrival in the trauma emergency room until obtaining a final diagnosis and management plan in patients with multiple injuries and might, therefore, contribute to improvements in patient care.

Initial clinical experience with a 64-MDCT whole-body scanner in an emergency department: better time management and diagnostic quality?

BACKGROUND

The objective of this study was to assess time management and diagnostic quality when using a 64-multidetector-row computed tomography (MDCT) whole-body scanner to evaluate polytraumatized patients in an emergency department.

METHODS

Eighty-eight consecutive polytraumatized patients with injury severity score (ISS) > or = 18 (mean ISS = 29) were included in this study. Documented and evaluated data were crash history, trauma mechanism, number and pattern of injuries, injury severity, diagnostics, time flow, and missed diagnoses. Data were stored in our hospital information system. Seven time intervals were evaluated. In particular, attention was paid to the "acquisition interval," the "reformatting and evaluation time" as well as the "CT time" (time from CT start to preliminary diagnosis). A standardized whole-body CT was performed. The acquired CT data together with automatically generated multiplanar reformatted images ("direct MPR") were transferred to a 3D rendering workstation. Diagnostic quality was determined on the basis of missed diagnoses. Head-to-toe scout images were possible because volume coverage was up to 2 m. Experienced radiologists at an affiliated workstation performed radiologic evaluation of the acquired datasets immediately after acquisition.

RESULTS

The "acquisition interval" was 12 minutes +/- 4.9 minutes, the "reformatting and evaluation interval" 7.0 minutes +/- 2.1 minutes, and the "CT time" 19 minutes +/- 6.1 minutes. Altogether, 7 of 486 lesions were recognized but not communicated in the "reformatting and evaluation interval", and 10 injuries were initially missed and detected during follow-up.

CONCLUSION

This study indicates that 64-MDCT saves time, especially in the "reformatting and evaluation interval." Diagnostic quality is high, as reflected by the small number of missed diagnoses.

Polytrauma--pathophysiology and management principles

BACKGROUND

Multiple injury results in a complex pathophysiological and immunological response. Depending on the individual injury pattern, the time elapsed after injury, and the systemic "danger response", the surgical treatment has to be modified.

OBJECTIVES

This overview provides new insights in the pathophysiology of the early danger response after polytrauma and outlines the main resulting consequences for surgical management.

RESULTS

First, synchronically to the clinical assessment, life-saving procedures need to be performed rapidly, such as control of massive intra-thoracic or abdominal bleeding and decompression of the chest and brain, as standardized by advanced trauma life support guidelines. During the second phase of "day-one-surgery" damage-control interventions such as debridement, decompression and temporary fracture stabilization are needed to avoid an excessive molecular and cellular danger response. Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk. In the "vulnerable phase" when the patient's defense is rather uncontrolled, only "second look" debridement to minimize a "second hit" is recommended. After stabilization of the patient as indicated by improvement of tissue oxygenation, coagulation, and decreased inflammatory mediators, "reconstructive surgery" can be applied.

CONCLUSION

Individually adjusted surgical "damage control" and "immune control" are important interactive concepts in polytrauma management.

[Advanced Trauma Life Support. A training concept also for Europe]

Advanced Trauma Life Support (ATLS) is a concept for rapid initial assessment and primary management of an injured patient, starting at the time of injury and continuing through initial assessment, lifesaving interventions, re-evaluation, stabilization and, when needed, transfer to a trauma centre. Despite some shortcomings, it is the only standardized concept for emergency room management, which is internationally accepted. Because of its simple and clear structure, it is flexible and can be universally integrated into existing emergency room algorithms under consideration of local, regional as well as national and international peculiarities in the sense of a "common language of trauma". Under these aspects ATLS also seems to be a valid concept for Europe.

[Emergency treatment of thoracic trauma]

Thoracic trauma, most often associated with other serious injuries, is the main cause of death in the first 45 years of life. The percentage of chest injuries in multiple trauma, mainly from blunt impact, has remained relatively constant at 80% during the last 30 years. Isolated thoracic injuries comprise only 25% of all trauma cases, 90% of chest injuries are due to blunt impact, while penetrating injuries make up 5-10%. Since 25% of deaths from trauma are attributable to chest injuries, they determine the survival rate in multiple trauma to a significant extent. The pattern of chest injuries is variable, frequently in different combinations comprising rib cage and diaphragm, lung parenchyma, airway and mediastinal organs. This article details the immediate simultaneous diagnostic and therapeutic procedures in the prehospital phase, management in the emergency room, the relative importance of computed tomography, ultrasound examination and endoscopy in the primary diagnostic evaluation and the principles of anaesthetic management of thoracic trauma.

Multislice computed tomography in blunt abdominal trauma

Blunt abdominal trauma is a frequent finding in patients with multiple trauma, and is associated with significant morbidity and mortality. Multislice computed tomography (MSCT), allowing for multiplanar reconstructions and three-dimensional images, has become the imaging modality of choice for these patients. MSCT is indicated in all haemodynamically stable patients with suspected blunt abdominal trauma. A `focussed CT' algorithm, as recommended by the Advanced Trauma Life Support (ATLS®) program, may be useful for patients with isolated abdominal trauma who are conscious and cooperative. For unconscious patients with or without multiple trauma `unfocussed' whole-body MSCT algorithms should be used, as these lead to earlier as well as more accurate diagnosis. MSCT allows for rapid diagnosis of abdominal and retroperitoneal injuries and for grading of solid organ injuries. Active haemorrhage may be detected with accuracy similar to angiography. Even bowel, diaphragmatic and bladder injuries, where CT used to miss a significant number of injuries, can be diagnosed with high accuracy by the new generation of MSCT scanners.

Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room

INTRODUCTION

Successful management of emergency patients with multiple trauma in the hospital resuscitation room depends on the immediate diagnosis and rapid treatment of the most life-threatening injuries. In order to reduce the time spent in the resuscitation room, an in-hospital algorithm was developed in an interdisciplinary team approach with respect to local structures. The aim of the study was to analyse whether this algorithm affects the interval between hospital admission and the completion of diagnostic procedures and the start of life-saving interventions. Moreover, in-hospital mortality was investigated before and after the algorithm was introduced.

MATERIAL AND METHODS

In this prospective study, all consecutive trauma patients in the resuscitation room were investigated before (group I, 01/04-10/04) and after (group II, 01/05-11/05) introduction of the algorithm. The times between hospital admission and the end of the diagnostic procedures (ultrasound [sono], chest X-ray [CF], and cranial computed tomography [CCT]), and between hospital admission and the start of life-saving interventions were registered and in-hospital mortality analysed.

RESULTS

In the study period, 170 patients in group I and 199 patients in group II were investigated. Injury severity score (ISS) were comparable between the two groups. The intervals between admission and completion of diagnostic procedures were significantly lower after the algorithm was introduced (mean+/-S.D.): sono (11 +/- 10 min versus 7 +/- 6 min, p < 0.05), CF (21 +/- 12 min versus 12 +/- 9 min, p < 0.01), and CCT (55 +/- 27 min versus 32 +/- 14 min, p < 0.01). Moreover, the interval to the start of life-saving interventions was significantly shorter (126 +/- 90 min versus 51 +/- 20 min, p < 0.01). After introducing the algorithm, in-hospital mortality was reduced significantly from 33.3% to 16.7% (p < 0.05) in the most severely injured patients (ISS>or=25).

CONCLUSION

The introduction of an algorithm for early management of emergency patients significantly reduced the time spent in the resuscitation room. The periods to completion of sono, CF, and CCT, respectively, and the start of life-saving interventions were significantly shorter after introduction of the algorithm. Moreover, introduction of the algorithm reduced mortality in the most severely injured patients. Although further investigations are needed to evaluate the effects of the Heidelberg treatment algorithm in terms of outcome and mortality, the time reduction in the resuscitation room seems to be beneficial.

New aspects in the emergency room management of critically injured patients: a multi-slice CT-oriented care algorithm

BACKGROUND

Time-critical care of seriously injured patients is gaining more and more significance. The availability of the multi-slice CT allows a complete diagnostic assessment of injured patients in 90-240 s, but is presently carried out only at the conclusion of basic diagnostics. We investigated the effects of a clinical algorithm using multi-slice CT scanning ahead of other measures in the clinical care of seriously injured patients.

METHODS

Availability of a trauma admitting room with integrated multi-slice CT scanner enabled a new algorithm for patient care. We prospectively examined the time taken to reach established benchmarks in clinical care (completion of diagnosis, completion of resuscitation, exit from the trauma room) under this new approach. Data were collected for consecutive patients with serious injury (estimated injury severity score >15), and compared to historical data from the previous 2 years.

RESULTS

The new algorithm was employed in 139 patients with a mean ISS of 26.93. CT scanning was initiated 8 min (S.D. 5.7) after patient arrival, and concluded 13 min (S.D. 8.4) after patient arrival. Stabilising measures (initial resuscitation) were completed an average of 36 min from patient arrival. The length of stay in the trauma room was reduced to an average of 38 min (S.D. 19.1). Four patients required life-saving interventions after admission to the trauma room but before CT scanning began.

CONCLUSIONS

A new algorithm for trauma patient care that integrates high resolution CT scanning into the early diagnostic protocol reduces the length of stay in the trauma room markedly, and will facilitate rapid therapeutic intervention in patients with unstable haemorrhagic shock or neurosurgical emergencies.

[Management of seriously injured patients without conventional radiography? Does a whole body MSCT scanner replace the conventional X-ray unit in the emergency room?]

BACKGROUND

[corrected] In the Wuerzburg University level one trauma centre, mobile whole-body multislice computed tomography (MSCT) is used as the primary diagnostic tool in multiple trauma patients. A conventional X-ray unit is not available directly in the resuscitation room of the trauma suite. Three cases are reported to discuss whether state-of-the-art trauma management can be done without conventional radiography.

METHODS

In each of the three cases reported here, an emergency situation has occurred in which the emergency diagnosis of the chest with the CT-scan was found to be difficult or impossible. These specific situations are described and discussed for each case and a conclusion is given at the end of this paper.

RESULTS

Three scenarios were identified in which conventional radiological diagnostics seemed to be necessary in the emergency room despite the availability of the MSCT. One is the patient undergoing cardiopulmonary resuscitation, the second is the patient that deteriorates after CT-diagnostic is completed and the third is technical problems with the CT-scanner.

CONCLUSION

Whole-body MSCT is not sufficient as the sole diagnostic tool in hemodynamically instable trauma patients requiring resuscitation and needs to be complemented by a conventional x-ray unit for emergency diagnosis of the chest.

[Treatment of the combined pelvic and thoracic trauma in the emergency room]

Priorities in the diagnosis and treatment of a multiple trauma with injuries to the thorax and pelvis are usually determined by the pattern and the severity of the injury sustained. In this case a haemodynamically unstable patient with severest pelvic trauma and a moderate thoracic trauma developed progressive haemodynamic instability during an intervention to the pelvis, resulting in a lethal outcome for the patient. The cause only became obvious when computed tomography of the thorax (CTT) was performed which was able to demonstrate venous pulmonary bleeding compressing the left atrium. In haemodynamically unstable patients with a major pelvic trauma combined with a moderate thoracic trauma, early CTT should therefore be a main priority in the initial management of such patients in the resuscitation room. The time spent on such a diagnostic procedure seems to be worth the information gained, which can significantly influence the initial choices and priorities in treatment.