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Sagi L, Price J, Lachowycz K, Starr Z, Major R, Keeliher C, Finbow B, McLachlan S, Moncur L, Steel A, Sherren PB, Barnard EBG. Critical hypertension in trauma patients following prehospital emergency anaesthesia: a multi-centre retrospective observational study. Scand J Trauma Resusc Emerg Med 2023; 31:104. [PMID: 38124103 PMCID: PMC10731700 DOI: 10.1186/s13049-023-01167-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Critical hypertension in major trauma patients is associated with increased mortality. Prehospital emergency anaesthesia (PHEA) is performed for 10% of the most seriously injured patients. Optimising oxygenation, ventilation, and cerebral perfusion, whilst avoiding extreme haemodynamic fluctuations are the cornerstones of reducing secondary brain injury. The aim of this study was to report the differential determinants of post-PHEA critical hypertension in a large regional dataset of trauma patients across three Helicopter Emergency Medical Service (HEMS) organisations. METHODS A multi-centre retrospective observational study of consecutive adult trauma patients undergoing PHEA across three HEMS in the United Kingdom; 2015-2022. Critical hypertension was defined as a new systolic blood pressure (SBP) > 180mmHg within 10 min of induction of anaesthesia, or > 10% increase if the baseline SBP was > 180mmHg prior to induction. Purposeful logistical regression was used to explore variables associated with post-PHEA critical hypertension in a multivariable model. Data are reported as number (percentage), and odds ratio (OR) with 95% confidence interval (95%CI). RESULTS 30,744 patients were attended by HEMS during the study period; 2161 received PHEA and 1355 patients were included in the final analysis. 161 (11.9%) patients had one or more new episode(s) of critical hypertension ≤ 10 min post-PHEA. Increasing age (compared with 16-34 years): 35-54 years (OR 1.76, 95%CI 1.03-3.06); 55-74 years (OR 2.00, 95%CI 1.19-3.44); ≥75 years (OR 2.38, 95%CI 1.31-4.35), pre-PHEA Glasgow Coma Scale (GCS) motor score four (OR 2.17, 95%CI 1.19-4.01) and five (OR 2.82, 95%CI 1.60-7.09), patients with a pre-PHEA SBP > 140mmHg (OR 6.72, 95%CI 4.38-10.54), and more than one intubation attempt (OR 1.75, 95%CI 1.01-2.96) were associated with post-PHEA critical hypertension. CONCLUSION Delivery of PHEA to seriously injured trauma patients risks haemodynamic fluctuation. In adult trauma patients undergoing PHEA, 11.9% of patients experienced post-PHEA critical hypertension. Increasing age, pre-PHEA GCS motor score four and five, patients with a pre-PHEA SBP > 140mmHg, and more than intubation attempt were independently associated with post-PHEA critical hypertension.
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Affiliation(s)
- Liam Sagi
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK.
| | - James Price
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Lachowycz
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Zachary Starr
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | - Rob Major
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
| | | | | | - Sarah McLachlan
- Essex and Herts Air Ambulance, Earls Colne, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Lyle Moncur
- Essex and Herts Air Ambulance, Earls Colne, UK
| | | | - Peter B Sherren
- Essex and Herts Air Ambulance, Earls Colne, UK
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ed B G Barnard
- Department of Research, Audit, Innovation, and Development, East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
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McGuinness MJ, Isles S, Xu W, Harmston C. Incidence and outcomes of major trauma patients with thoracic injuries and rib fractures in Aotearoa New Zealand. Injury 2023; 54:110787. [PMID: 37150724 DOI: 10.1016/j.injury.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 04/09/2023] [Accepted: 05/02/2023] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Thoracic trauma represents a significant burden of disease in Aotearoa, New Zealand (AoNZ). To date, no study has examined the incidence or outcomes of patients suffering major thoracic trauma, or major trauma and rib fractures in AoNZ. METHODS A 6 year retrospective study of all major trauma (Injury Severity Score >12) patients in AoNZ was performed. The National Trauma Registry was searched to identify patients. The National Minimum Data Set was searched for all ICD-10 codes associated with surgical stabilisation of rib fractures (SSRF). Poisson regression was used to determine the change in incidence rate over the study period adjusted for age with the logarithm of population size as the offset variable. The incidence rate ratios (IRR) with 95% confidence intervals (CI) were reported. RESULTS 12,218 patients sustained major trauma. 7,059 (57.8%) of these patients sustained thoracic injuries. Of these patients, 5,585 (79.1%) sustained rib fractures, and 180 (3.2%) proceeded to SSRF. A flail segment was observed in 16% of patients with rib fractures. Transport was the mechanism of injury in 53% of patients. During the study the incidence (cases per 100,000 people per year) of major trauma increased from 39.5 to 49.3 (IRR 1.05, 95%CI 1.04 to 1.07, <0.001), the incidence of thoracic injuries from 21.3 to 28.7 (1.07, 95% CI 1.05 to 1.08, <0.001) and the incidence of rib fractures from 16.0 to 22.9 (1.08, 95% CI 1.06 to 1.09, <0.001). SSRF was performed in 3.2% of patients with rib fractures and increased from 0.2 to 0.8 cases per 100,000 people per year (1.27, 95% CI 1.15 to 1.41, <0.001) during the study. CONCLUSION This study reports the incidence of major trauma patients with thoracic injury, major trauma patients with rib fractures and the incidence of SSRF in AoNZ. Transport related injuries are the predominant mechanism of injury. The incidence of SSRF was low across AoNZ. To improve the quality of care in AoNZ for major trauma patients with rib fractures, consideration should be made to create national guidelines and robust referral pathways to specialist centres that provide multidisciplinary care including performing SSRF.
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Affiliation(s)
| | | | | | - Christopher Harmston
- University of Auckland, New Zealand; Whangarei Hospital, Te Whatu Ora, New Zealand
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Demaçi S, Maliqi S, Çuperjani F, Behluli A, Selimi F, Gradica F, Bruçi B, Jukic T, Stubljar D, Aliu X. Influence of Severe Thoracic Trauma on Choosing the Correct Surgical Strategy in Patients with Polytrauma from Kosovo. Med Sci Monit Basic Res 2021; 27:e932463. [PMID: 34421114 PMCID: PMC8394592 DOI: 10.12659/msmbr.932463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Severe thoracic trauma (TT) has a significant impact on the selection of treatment strategy in patients with polytrauma. Our aim was to assess the impact of severe TT on choosing the optimal surgical procedure to decrease mortality. Material/Methods Overall, 66 patients with polytrauma and significant TT were analyzed. Demographic data, trauma history, admittance imaging, injury details, injury severity scores, conservative treatment, surgical treatment, days of hospital stay, and mortality data were gathered. Frequencies of thoracic surgical procedures and other treatments were collected and compared with those in the literature. Results All patients had Abbreviated Injury Scale (AIS) scores of thorax >3. Injuries to extremities and/or the osseous pelvis accounted for 50% of injuries; 47.0% included the head and/or neck; 45.5% were external injuries; and 27.3% were abdominal injuries or included pelvic organs and/or lumbar spine. Mean prehospital time was 40.3 min. Mean time from trauma occurrence to tertiary treatment was 125 min. Blunt TT (BTT) was recorded in 59 patients (89.4%), and penetrant TT (PTT) was recorded in 7 patients (10.6%). Thoracic drainage, urgent thoracotomy and laparotomy were recorded procedures. The mean Injury Severity Score (ISS) of all patients was 31.17. Nine patients died (13.6%) and had BTT with a mean ISS of 48.44. The Trauma Injury Severity Score for BTT injuries was 77.08% and for PTT, 85.6%. Conclusions Factors that decreased hospital stay and mortality and increased survival included arriving in time after injury, aggressive reanimation/intensive care, and mandatory thoracic surgical procedure combined with laparotomy.
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Affiliation(s)
| | | | | | - Avni Behluli
- University Clinical Center of Kosovo, Pristina, Kosovo
| | - Fitim Selimi
- University for Business and Technology, Pristina, Kosovo
| | | | - Burbuqe Bruçi
- University Clinical Center of Kosovo, Pristina, Kosovo
| | - Tomislav Jukic
- Department of Internal Medicine, History of Medicine and Medical Ethics, Faculty of Medicine, University Josip Juraj Strossmayer, Osijek, Croatia
| | | | - Xhevdet Aliu
- University for Business and Technology, Pristina, Kosovo
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O׳Keeffe M, Clark S, Khosa F, Mohammed MF, McLaughlin PD, Nicolaou S. Imaging Protocols for Trauma Patients: Trauma Series, Extended Focused Assessment With Sonography for Trauma, and Selective and Whole-body Computed Tomography. Semin Roentgenol 2016; 51:130-42. [DOI: 10.1053/j.ro.2016.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Weaver AE, Hunter-Dunn C, Lyon RM, Lockey D, Krogh CL. The effectiveness of a 'Code Red' transfusion request policy initiated by pre-hospital physicians. Injury 2016; 47:3-6. [PMID: 26239421 DOI: 10.1016/j.injury.2015.06.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/06/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Major trauma is a leading cause of mortality and serious morbidity. Recent approaches to life-threatening traumatic haemorrhage have emphasized the importance of early blood product transfusion. We have implemented a pre-hospital transfusion request policy where a pre-hospital physician can request the presence of a major transfusion pack on arrival at the destination trauma centre. OBJECTIVES This study was performed to establish whether three simple criteria (1) suspicion or evidence of active haemorrhage (2) systolic BP<90 mmHg (3) failure of blood pressure to respond to an intravenous fluid bolus) which were used to activate a pre-hospital 'Code Red' transfusion request accurately identified seriously injured patients who required transfusion on arrival at hospital. METHODS Prospective evaluation of all pre-hospital 'Code Red' requests over a 30-month period (August 2008-May 2011) was performed for patients transported to a major trauma centre. Mechanism of injury, Injury Severity Score, hospital mortality, and use of blood products were recorded. Patients were followed up to hospital discharge. RESULTS 176 'Code Red' activations were made in the study period. 129 patients were transported to the Trauma Centre. Mechanism of injury was penetrating trauma in 39 (30%) cases, road traffic collision in 58 (45%), falls in 18 (14%) and 'other' in 14 (10.8%). Complete data was available for 126 patients. Of the patients reaching hospital, 20 died in the emergency department or operating theatre, 22 died following admission and 84 survived to hospital discharge. Mean Injury Severity Score (ISS) was 29.1. (range 0-66). Overall, 115 (91%) of the patients declared 'Code Red' pre-hospital received blood product transfusion after arrival in hospital. Eleven patients did not receive any blood products following hospital admission. In patients declared 'Code Red' pre-hospital, mean packed red blood cell transfusion in the first 24-h was 10.4 unit (95% CI 8.4-12.3 unit). CONCLUSIONS The use of simple pre-hospital criteria allowed physicians to successfully identify trauma patients with severe injury and a requirement for blood product transfusion. This allowed blood products to be ready on the patient's arrival in a major trauma centre with the potential for earlier transfusion.
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Affiliation(s)
- Anne E Weaver
- Emergency Medicine & Pre-hospital Care, London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom.
| | - Ceri Hunter-Dunn
- Emergency Medicine, London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom.
| | - Richard M Lyon
- Emergency Medicine & Pre-hospital Care, London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom.
| | - David Lockey
- North Bristol NHS Trust, Bristol, United Kingdom; School of Clinical Sciences, University of Bristol, Bristol, United Kingdom; London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom.
| | - Charlotte L Krogh
- London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom.
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Khorsandi M, Skouras C, Prasad S, Shah R. Major cardiothoracic trauma: Eleven-year review of outcomes in the North West of England. Ann R Coll Surg Engl 2015; 97:298-303. [PMID: 26263939 PMCID: PMC4473869 DOI: 10.1308/003588415x14181254789169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Up to 15% of patients with cardiothoracic trauma require emergency surgery, and death can be prevented in a substantial proportion of this group. UK reports have emphasised the need for improvement in this field. We assessed major cardiothoracic trauma (MCT) outcomes in North West England over 11 years. METHODS The database from the Trauma Audit and Research Network was used to retrieve data for all patients who had suffered MCT between 2000 and 2011 in North West England and the findings analysed. Trauma that led to thoracotomy/thoracoscopy or sternotomy was defined as MCT. RESULTS A total of 146 patients were identified, and a considerable male predominance (88.4%) noted. A total of 54.1% had sustained penetrating cardiothoracic trauma. Also, 53.4% had been admitted to tertiary-care hospitals for trauma (TCHT) and 46.6% had been admitted to non-TCHT. Overall prevalence of mortality was 35.6%. No significant difference was found in mortality between TCHT vs non-TCHT. Prevalence of mortality was significantly higher in the subgroup of patients cared for exclusively in non-TCHT compared with patients transferred from non-TCHT to TCHT (41% vs 13.8%, p<0.05). CONCLUSIONS No significant difference was demonstrated in length of stay in hospital/length of stay in the intensive treatment unit and prevalence of mortality between patients originally presenting in TCHT and those presenting in non-TCHT. However, patients transferred from non-TCHT to TCHT had a lower prevalence of mortality. These findings may constitute a valuable benchmark for comparison with results arising after introduction of trauma centres in the UK.
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Affiliation(s)
- M Khorsandi
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh
| | - C Skouras
- Department of Clinical Surgery, Edinburgh University, Edinburgh
| | - S Prasad
- Department of Cardio-Thoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh
| | - R Shah
- Department of Cardio-Thoracic Surgery, University Hospital of South Manchester (Wythenshawe hospital)
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Sedlic A, Chingkoe CM, Tso DK, Galea-Soler S, Nicolaou S. Rapid imaging protocol in trauma: a whole-body dual-source CT scan. Emerg Radiol 2013; 20:401-8. [PMID: 23793476 DOI: 10.1007/s10140-013-1139-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 06/04/2013] [Indexed: 11/27/2022]
Abstract
The purpose of this study is to determine whether a single acquisition whole-body trauma multi-detector CT scan is able to reduce resuscitation time, scan time, and effective radiation dose without compromising diagnostic quality in the setting of polytrauma. Retrospective analysis of 33 trauma patients undergoing single acquisition whole-body CT with injury severity scores of ≥ 16 was compared to 34 patients imaged with a segmented whole-body CT protocol. Time spent in the emergency department, effective radiation dose, image quality, and mortality rates were compared. The single acquisition group spent 53.7 % less time in the emergency department prior to imaging (p=0.0044) and decreased scanning time by 25 %. The protocol yielded a 24.5 % reduction in mean effective radiation dose (24.66 mSv vs. 32.67 mSv, p<0.0001). The image noise was similar in both groups. Standardized mortality ratios were comparable. The single acquisition protocol significantly reduces time spent in the emergency department by allowing faster imaging at a lower radiation dose while maintaining image quality. Other contributors to reduction in radiation dose include use of dual-source CT technology, removal of delayed CT intravenous pyelogram, and arm positioning.
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Affiliation(s)
- Anto Sedlic
- Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, Canada, V5Z 1M9,
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8
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Ávila Martínez RJ, Hernández Voth A, Marrón Fernández C, Hermoso Alarza F, Martínez Serna I, Mariscal de Alba A, Zuluaga Bedoya M, Trujillo MD, Meneses Pardo JC, Díaz Hellin V, Larru Cabrero E, Gámez García AP. Evolution and complications of chest trauma. Arch Bronconeumol 2013; 49:177-80. [PMID: 23415575 DOI: 10.1016/j.arbres.2012.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/02/2012] [Accepted: 12/18/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe the clinical characteristics and risk factors of patients with chest trauma, and to evaluate their correlation with the development of complications. METHODS Descriptive, prospective and analytical study of a patient cohort with chest trauma who underwent follow-up for a period of 30 days. Excluded from the study were those patients with moderate to severe traumatic brain injury, long-bone fractures, abdominal trauma and patients requiring mechanical ventilation. RESULTS A total of 376 patients met the inclusion criteria, 220 of whom were males (58.5%). The most frequent causes of trauma were falls (218 cases; 57.9%) and motor vehicle accidents (57 cases; 15.1%). The most frequent type of trauma was rib contusion (248 cases; 65.9%) and rib fractures (61 cases; 16.2%). Complications were observed in 43 patients (11.4%), mainly hemothorax (13 cases), pneumothorax (9 cases), pneumonia (6 cases) and acute renal failure (4 cases). Four patients died due to pneumonia and hemothorax. Thirty-three patients were hospitalized (8.7%) and 10 (2.6%) required later re-admittance. The risk for complications increased significantly in patients with more than 2 rib fractures, in those over the age of 85 and in the presence of certain comorbidities, such as COPD and pathologies requiring anticoagulation therapy. The risk for re-admittance is higher in patients over the age of 60. CONCLUSIONS Patients with chest trauma who present certain comorbidities, are over the age of 85 and have more than 2 rib fractures may present more complications. These factors should be contemplated in the evaluation, management and follow-up of these subjects.
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Abstract
A chest-trauma management system, tagged as the "Pécs model" in a tertiary referral center is described with extensive references to the state of the art in thoracic trauma. Chest drainage has utmost importance in primary therapy as well as in surgical decision making (diagnosis). Thoracotomy is a general surgical competence, just as damage control is. Definitive treatment and management of sequelae, however, requires competence in thoracic surgery. Multidisciplinarity is underscored.
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Affiliation(s)
- F Tamás Molnár
- Pécsi Tudományegyetem Klinikai Központ, Sebészeti Klinika, Mellkassebészeti Osztály.
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Harrison JE, Berry JG, Jamieson LM. Head and traumatic brain injuries among Australian youth and young adults, July 2000–June 2006. Brain Inj 2012; 26:996-1004. [DOI: 10.3109/02699052.2012.660515] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lippross S, Klueter T, Steubesand N, Oestern S, Mentlein R, Hildebrandt F, Podschun R, Pufe T, Seekamp A, Varoga D. Multiple trauma induces serum production of host defence peptides. Injury 2012; 43:137-42. [PMID: 21561617 DOI: 10.1016/j.injury.2011.03.044] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 03/15/2011] [Accepted: 03/21/2011] [Indexed: 02/02/2023]
Abstract
Today multiple trauma still is associated with a high mortality. Although severe open fractures and wounds can give rise to local infections and sepsis, the overall infection rate of multiply injured patients is surprisingly low. We have investigated serum of multiply injured patients with respect to antibacterial properties and screened for host defence peptides (HDP) that constitute a class of fast acting and rapidly available molecules preventing bacterial infection. Serum specimens were obtained from multiply injured patients. Radial diffusion assays were performed to investigate antimicrobial properties. Ultrafiltration and heat-inactivation were used to rule out antimicrobial activity of large proteins i.e. complement factors. ELISA was performed to analyse serum concentrations of the human beta-defensins 2 and 3 (hBD-2 and hBD-3), LL-37 and the proinflammatory cytokines interferon-gamma (IFN-γ) and interleukin-6 (IL-6). Serum of multiply injured patients showed greater zones of inhibition in antimicrobial testing against Gram negative und positive bacteria. This effect was mediated by proteins smaller than 10 kDa, inactivation of the complement system does not significantly reduce antibacterial action. hBD-2, hBD-3 and LL-37 concentrations were significantly elevated after trauma and followed different characteristic concentration curves. Similar patterns of concentration profiles were recorded for hBD-2/IL-6 and hBD-3/IFN-γ suggesting a stimulatory influence within their induction process. With this study we provide evidence, that serum of multiply injured patients has by far higher antibacterial capacity than that of healthy donors. As possible mediators we have detected the HDP hBD-2, hBD-3 and LL-37 and their inducers in serum of multiply injured patients.
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Affiliation(s)
- Sebastian Lippross
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany
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Russell RJ, Hodgetts TJ, McLeod J, Starkey K, Mahoney P, Harrison K, Bell E. The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services. Philos Trans R Soc Lond B Biol Sci 2011; 366:171-91. [PMID: 21149354 DOI: 10.1098/rstb.2010.0232] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This paper discusses mathematical models of expressing severity of injury and probability of survival following trauma and their use in establishing clinical governance of a trauma system. There are five sections: (i) Historical overview of scoring systems--anatomical, physiological and combined systems and the advantages and disadvantages of each. (ii) Definitions used in official statistics--definitions of 'killed in action' and other categories and the importance of casualty reporting rates and comparison across conflicts and nationalities. (iii) Current scoring systems and clinical governance--clinical governance of the trauma system in the Defence Medical Services (DMS) by using trauma scoring models to analyse injury and clinical patterns. (iv) Unexpected outcomes--unexpected outcomes focus clinical governance tools. Unexpected survivors signify good practice to be promulgated. Unexpected deaths pick up areas of weakness to be addressed. Seventy-five clinically validated unexpected survivors were identified over 2 years during contemporary combat operations. (v) Future developments--can the trauma scoring methods be improved? Trauma scoring systems use linear approaches and have significant weaknesses. Trauma and its treatment is a complex system. Nonlinear methods need to be investigated to determine whether these will produce a better approach to the analysis of the survival from major trauma.
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Affiliation(s)
- R J Russell
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK
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Sharpe DB, Barneby EM, Russell RJ. New approaches to the management of traumatic external haemorrhage. TRAUMA-ENGLAND 2011. [DOI: 10.1177/1460408610385739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Uncontrolled external haemorrhage, though rare in civilian practice, is responsible for up to 80% of pre-hospital deaths in military trauma. Data from recent conflicts shows that exsanguination before evacuation accounts for 50% of deaths. Severe haemorrhage leads to the lethal triad of acidosis, hypothermia and coagulopathy. A new treatment paradigm, <C>ABC (where <C> stands for ‘Control of catastrophic haemorrhage) has been used to prioritise management of external haemorrhage. This approach has been augmented by the use of elastic field dressings, tourniquets and haemostatic agents. A ‘ladder’ approach is used to ensure basic wound management techniques are adopted before more sophisticated ones. Early fluid replacement via intraosseous needles and using blood and other blood products in the pre-hospital environment are other strategies used to achieve early haemostasis.
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Affiliation(s)
- DB Sharpe
- Emergency Department, Peterborough District Hospital, UK
| | - EM Barneby
- Emergency Department, Peterborough District Hospital, UK
| | - RJ Russell
- Emergency Department, Peterborough District Hospital, UK, Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham Research Park, Birmingham, UK, ,
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