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Barbieri G, Cipriano A, Coccolini F, Pini S, Dell'Agnello D, Ranalli A, Cremonini C, Santini M, Ghiadoni L, Chiarugi M. Trauma Center model application in the University Hospital of Pisa: a single-center comparative study. Intern Emerg Med 2024:10.1007/s11739-024-03644-1. [PMID: 38940990 DOI: 10.1007/s11739-024-03644-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 05/09/2024] [Indexed: 06/29/2024]
Abstract
The Trauma Center, Hub, is a highly specialized hospital indicated for complex major trauma management after stabilization at a 1st level hospital, Spoke. Although in the United States this organization demonstrated its effectiveness in mortality, in the Italian context, data available are limited. On 30 September 2018, the University Hospital of Pisa formalized the introduction of the Trauma Center, optimizing Emergency Department (ED) organization to guarantee the highest standard of care. The aim of this study was to demonstrate that the new model led better outcomes. We conducted a comparative retrospective study on 1154 major traumas over 24 months: the first 12 months (576 patients) correspond to the period before Trauma Center introduction, and the following 12 (457 patients) to the subsequent period. Results showed increase in greater dynamics and primary centralization by helicopter (p < 0.001, p 0.006). A systematic assessment with ABCDE algorithm was performed in a higher number of patients in the most recent period, from 38.4% to 80.3% (p < 0.001). Focused Assessment with Sonography for Trauma (FAST) performed by the emergency doctor increased after Trauma Center introduction, p value < 0.001. The data show an increase of ATLS certification among staff from 51.9 to 71.4% and a reduction in early and late mortality after the Trauma Center introduction (p value 0.05 and < 0.01). Fewer patients required intensive and surgical treatments, with a shorter hospital stay. The results demonstrate the advantage in terms of outcomes in the organization of the Trauma Center in the Italian context.
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Affiliation(s)
- Greta Barbieri
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy.
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Via Savi, 10, 56126, Pisa, Italy.
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Silvia Pini
- Department of Anaesthesia and Critical Care Medicine, Pisa University Hospital, Pisa, Italy
| | | | | | - Camilla Cremonini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Via Savi, 10, 56126, Pisa, Italy
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Massimo Santini
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Massimo Chiarugi
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Via Savi, 10, 56126, Pisa, Italy
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
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Newberry RK, Paredes RM, Barnard EBG, Redman TT, Arana AA, Maddry JK, Glaser JJ, Rall JM. The Efficacy of Whole Blood Resuscitation During Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Mitigate Post-occlusion Circulatory Collapse: A Translational Model in Large Swine. Mil Med 2024:usae305. [PMID: 38870040 DOI: 10.1093/milmed/usae305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/25/2024] [Accepted: 06/01/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Uncontrolled torso hemorrhage is the primary cause of potentially survivable deaths on the battlefield. Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), in conjunction with damage control resuscitation, may be an effective management strategy for these patients in the prehospital or austere phase of their care. However, the effect of whole blood (WB) transfusion during REBOA on post-occlusion circulatory collapse is not fully understood. MATERIALS AND METHODS Yorkshire male swine (n = 6 per group, 70-90 kg) underwent a 40% volume-controlled hemorrhage. After a 10-minute hemorrhagic shock period, a REBOA balloon was inflated in Zone 1. Fifteen minutes after inflation, 0, 1, or 3 units (450 mL/unit) of autologous WB was infused through the left jugular vein. Thirty minutes after initial balloon inflation, the balloon was deflated slowly over 3 minutes. Following deflation, normal saline was administered (up to 3,000 mL) and swine were observed for 2 hours. Survival (primary outcome), hemodynamics, and blood gas values were compared among groups. Statistical significance was determined by log-rank test, one-way ANOVA, and repeated measures ANOVA. RESULTS Survival rates were comparable between groups (P = .345) with 66% of control, 33% of the one-unit animals, and 50% of the 3-unit animals survived until the end of the study. Following WB infusion, both the 1-unit and the 3-unit groups had significantly higher blood pressure (P < .01), pulmonary artery pressure (P < .01), and carotid artery flow (P < .01) compared to the control group. CONCLUSIONS WB transfusion during Zone 1 REBOA was not associated with increased short-term survival in this large animal model of severe hemorrhage. We observed no signal that WB transfusion may mitigate post-occlusion circulatory collapse. However, there was evidence of supra-normal blood pressures during WB transfusion.
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Affiliation(s)
- Ryan K Newberry
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- En Route Care Research Center, United States Army Institute of Surgical Research, JBSA Fort Sam, TX 78234, USA
| | - R Madelaine Paredes
- Office of the Chief Scientist, 59th Medical Wing, San Antonio, TX 78236, USA
| | - Ed B G Barnard
- EUReCa, PACE Section, Department of Medicine, Cambridge University, Trinity Lane, Cambridge CB2 1TN, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Clinical Innovation), Birmingham B15 2SQ, UK
| | - Theodore T Redman
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Medical Directorate, Medical Director, F3EA, Inc., Savannah, GA 31404, USA
| | - Allyson A Arana
- En Route Care Research Center, United States Army Institute of Surgical Research, JBSA Fort Sam, TX 78234, USA
- Office of the Chief Scientist, 59th Medical Wing, San Antonio, TX 78236, USA
| | - Joseph K Maddry
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Office of the Chief Scientist, 59th Medical Wing, San Antonio, TX 78236, USA
- Department of Clinical Investigation, Brook Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Jacob J Glaser
- Acute Care Surgery , Providence Regional Medical Center, Everett, WA 98201, USA
| | - Jason M Rall
- Office of the Chief Scientist, 59th Medical Wing, San Antonio, TX 78236, USA
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Dixon J, de Vries S, Fleischer C, Bhaumik S, Dymond C, Jones A, Ross M, Finn J, Geduld H, Steyn E, Lategan H, Hodsdon L, Verster J, Mukonkole S, Doubell K, Baidwan N, Mould-Millman NK. Preventable trauma deaths in the Western Cape of South Africa: A consensus-based panel review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003122. [PMID: 38728269 PMCID: PMC11086906 DOI: 10.1371/journal.pgph.0003122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/27/2024] [Indexed: 05/12/2024]
Abstract
Injury causes 4.4 million deaths worldwide annually. 90% of all injury-related deaths occur in low-and-middle income countries. Findings from expert-led trauma death reviews can inform strategies to reduce trauma deaths. A cohort of trauma decedents was identified from an on-going study in the Western Cape Province of South Africa. For each case, demographics, injury characteristics, time and location of death and postmortem findings were collected. An expert multidisciplinary panel of reviewed each case, determined preventability and made recommendations for improvement. Analysis of preventable and non-preventable cases was performed using Chi-square, Fisher's exact, and Wilcoxon signed rank tests. A rapid qualitative analysis of recommendations was conducted and descriptively summarized. 138 deaths (48 deceased-on-scene and 90 pre- or in-hospital deaths) were presented to 23 panelists. Overall, 46 (33%) of deaths reviewed were considered preventable or potentially preventable. Of all pre- and in-hospital deaths, late deaths (>24 hours) were more frequently preventable (22, 56%) and due to multi-organ failure and sepsis, compared to early deaths (≤24 hours) with 32 (63%) that were non-preventable and due to central nervous system injury and haemorrhage. 45% of pre and in-hospital deaths were preventable or potentially preventable. The expert panel recommended strengthening community based primary prevention strategies for reducing interpersonal violence alongside health system improvements to facilitate high quality care. For the health system the panel's key recommendations included improving team-based care, adherence to trauma protocols, timely access to radiology, trauma specialists, operative and critical care.
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Affiliation(s)
- Julia Dixon
- University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Shaheem de Vries
- Western Cape Government Health and Wellness, Cape Town, South Africa
| | - Chelsie Fleischer
- University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Smitha Bhaumik
- University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Chelsea Dymond
- Colorado Permanente Medical Group, Denver, Colorado, United States of America
| | - Austin Jones
- University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Madeline Ross
- University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Julia Finn
- University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Heike Geduld
- Stellenbosch University, Cape Town, South Africa
| | - Elmin Steyn
- Stellenbosch University, Cape Town, South Africa
| | | | | | | | | | | | - Navneet Baidwan
- Department of Family and Community Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
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Femoral fractures are an indicator of increased severity of injury for road traffic collision victims: an autopsy-based case-control study on 4895 fatalities. Arch Orthop Trauma Surg 2022; 142:2645-2658. [PMID: 34196773 DOI: 10.1007/s00402-021-03997-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs. PATIENTS AND METHODS A case-control study based on forensic material from 4895 consecutive RTC-induced fatalities, between 1996 and 2005. Injuries were coded according to the Abbreviated Injury Scale-1990 Revision (AIS-90), and the Injury Severity Score (ISS) was calculated. Victims were divided according to the presence of femoral fractures in all possible anatomic locations or not. Univariate comparisons and logistic regression analysis for probabilities of association as odds ratios (OR) were performed. RESULTS The FFx group comprised 788 (16.1%) victims. The remaining 4107 victims constituted the controls. The FFx group demonstrated higher ISS (median 48 vs 36, p < 0.001) and shorter post-injury survival times (median 60 vs 85 min, p < 0.001). Presence of bilateral fractures (15.5%) potentiated this effect (median ISS 50 vs 43, p = 0.006; median survival time 40 vs 65, p = 0.0025; compared to unilateral fractures). Statistically significant associations of FFx were identified with AIS2-5 thoracic trauma (OR 1.43), AIS2-5 abdominal visceral injuries (OR 1.89), AIS1-3 skeletal injuries of the upper (OR 2.7) and lower limbs (OR 3.99) and AIS2-5 of the pelvis (OR 2.75) (p < 0.001). In the FFx group, 218 (27.7%) victims survived past the emergency department and 116 (53.2%) underwent at least one surgical procedure. Complications occurred in 45.4% of hospitalized victims, the most common being pneumonia (34.8%). CONCLUSION This study has documented that femoral fractures are associated with increased severity of injury, shorter survival times and higher incidence of associated thoracic, abdominal and skeletal extremity injuries, compared to controls. These findings should be considered for an evidence-based upgrading of trauma care.
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Differences in characteristics between patients ≥ 65 and < 65 years of age with orthopaedic injuries after severe trauma. Scand J Trauma Resusc Emerg Med 2022; 30:51. [PMID: 36153545 PMCID: PMC9509558 DOI: 10.1186/s13049-022-01038-w] [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] [Received: 03/30/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Aim
Many trauma patients have associated orthopaedic injuries at admission. The existing literature regarding orthopaedic trauma often focuses on single injuries, but there is a paucity of information that gives an overview of this group of patients. Our aim was to describe the differences in characteristics between polytrauma patients ≥ 65 and < 65 years of age suffering orthopaedic injuries.
Methods
Patients registered in the Norwegian Trauma Registry (NTR) with an injury severity score (ISS) > 15 and orthopaedic injuries, who were admitted to Haukeland University Hospital in 2016–2018, were included. Data retrieved from the patients’ hospital records and NTR were analysed. The patients were divided into two groups based on age.
Results
The study comprised 175 patients, of which 128 (73%) and 47 (27%) were aged < 65 (Group 1) and ≥ 65 years (Group 2), respectively. The ISS and the new injury severity score (NISS) were similar in both groups. The dominating injury mechanism was traffic-related and thoracic injury was the most common location of main injury in both groups. The groups suffered a similar number of orthopaedic injuries. A significantly higher proportion of Group 1 underwent operative treatment for their orthopaedic injuries than in Group 2 (74% vs. 53%). The mortality in Group 2 was significantly higher than that in Group 1 (15% vs. 3%). In Group 2 most deaths were related to traffic injuries (71%). High energy falls and traffic-related incidents caused the same number of deaths in Group 1. In Group 1 abdominal injuries resulted in most deaths, while head injuries was the primary reason for deaths in Group 2.
Conclusions
Although the ISS and NISS were similar, mortality was significantly higher among patients aged ≥ 65 years compared to patients < 65 years of age. The younger age group underwent more frequently surgery for orthopaedic injuries than the elderly. There may be multiple reasons for this difference, but our study does not have sufficient data to draw any conclusions. Future studies may provide a deeper understanding of what causes treatment variation between age groups, which would hopefully help to further develop strategies to improve outcome for the elderly polytrauma patient.
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Characteristics of Prehospital Death in Trauma Victims. J Clin Med 2021; 10:jcm10204765. [PMID: 34682888 PMCID: PMC8540414 DOI: 10.3390/jcm10204765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Using Injury Severity Score (ISS) data, this study aimed to give an overview of trauma mechanisms, causes of death, injury patterns, and potential survivability in prehospital trauma victims. Methods: Age, gender, trauma mechanism, cause of death, and ISS data were recorded regarding forensic autopsies and whole-body postmortem CT. Characteristics were analyzed for injuries considered potentially survivable at cutoffs of (I) ISS ≤ 75 vs. ISS = 75, (II) ISS ≤ 49 vs. ISS ≥ 50, and (III) ISS < lethal dose 50% (LD50) vs. ISS > LD50 according to Bull’s probit model. Results: In n = 130 prehospital trauma victims (45.3 ± 19.5 years), median ISS was 66. Severity of injuries to the head/neck and chest was greater compared to other regions (p < 0.001). 52% died from central nervous system (CNS) injury. Increasing injury severity in head/neck region was associated with CNS-injury related death (odds ratio (OR) 2.7, confidence interval (CI) 1.8–4.4). Potentially survivable trauma was identified in (I) 56%, (II) 22%, and (III) 9%. Victims with ISS ≤ 75, ISS ≤ 49, and ISS < LD50 had lower injury severity across most ISS body regions compared to their respective counterparts (p < 0.05). Conclusion: In prehospital trauma victims, injury severity is high. Lethal injuries predominate in the head/neck and chest regions and are associated with CNS-related death. The appreciable amount (9–56%) of victims dying at presumably survivable injury severity encourages perpetual efforts for improvement in the rescue of highly traumatized patients.
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Selective aortic arch perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of noncompressible torso hemorrhage. J Trauma Acute Care Surg 2020; 87:263-273. [PMID: 31348400 DOI: 10.1097/ta.0000000000002315] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhage-induced traumatic cardiac arrest (HiTCA) has a dismal survival rate. Previous studies demonstrated selective aortic arch perfusion (SAAP) with fresh whole blood (FWB) improved the rate of return of spontaneous circulation (ROSC) after HiTCA, compared with resuscitative endovascular balloon occlusion of the aorta and cardiopulmonary resuscitation (CPR). Hemoglobin-based oxygen carriers, such as hemoglobin-based oxygen carrier (HBOC)-201, may alleviate the logistical constraints of using FWB in a prehospital setting. It is unknown whether SAAP with HBOC-201 is equivalent in efficacy to FWB, whether conversion from SAAP to extracorporeal life support (ECLS) is feasible, and whether physiologic derangement post-SAAP therapy is reversible. METHODS Twenty-six swine (79 ± 4 kg) were anesthetized and underwent HiTCA which was induced via liver injury and controlled hemorrhage. Following arrest, swine were randomly allocated to resuscitation using SAAP with FWB (n = 12) or HBOC-201 (n = 14). After SAAP was initiated, animals were monitored for a 20-minute prehospital period prior to a 40-minute damage control surgery and resuscitation phase, followed by 260 minutes of critical care. Primary outcomes included rate of ROSC, survival, conversion to ECLS, and correction of physiology. RESULTS Baseline physiologic measurements were similar between groups. ROSC was achieved in 100% of the FWB animals and 86% of the HBOC-201 animals (p = 0.483). Survival (t = 320 minutes) was 92% (11/12) in the FWB group and 67% (8/12) in the HBOC-201 group (p = 0.120). Conversion to ECLS was successful in 100% of both groups. Lactate peaked at 80 minutes in both groups, and significantly improved by the end of the experiment in the HBOC-201 group (p = 0.001) but not in the FWB group (p = 0.104). There was no significant difference in peak or end lactate between groups. CONCLUSION Selective aortic arch perfusion is effective in eliciting ROSC after HiTCA in a swine model, using either FWB or HBOC-201. Transition from SAAP to ECLS after definitive hemorrhage control is feasible, resulting in high overall survival and improvement in lactic acidosis over the study period.
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Oteng RA, Osei-Kwame D, Forson-Adae MSE, Ekremet K, Yakubu H, Arhin B, Maio RF. The preventability of trauma-related death at a tertiary hospital in Ghana: a multidisciplinary panel review approach. Afr J Emerg Med 2019; 9:202-206. [PMID: 31890485 PMCID: PMC6933155 DOI: 10.1016/j.afjem.2019.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/05/2019] [Accepted: 08/26/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction The purpose of the study was to determine the preventable trauma-related death rate (PDR) at Komfo Anokye Teaching Hospital in Kumasi, Ghana three years after initiation of an Emergency Medicine (EM) residency Method This was a retrospective, cross-sectional study. A multidisciplinary panel of physicians completed a structured implicit review of clinical data for trauma patients who died during the period 2011 to 2012. The panel judged the preventability of each death and the nature of inappropriate care. Categories were definitely preventable (DP), possibly preventable (PP), and not preventable (NP). Results 1) The total number of cases was forty-five; 36 cases had adequate data for review. Subjects were predominately male; road traffic injury (RTI) was the leading mechanism of injury. Four cases (11.1%) were DP, 14 cases (38.9%) were PP and 18 (50%) were NP. Hemorrhage was the leading cause of death (39%). Among DP/PP deaths there were 37 instances of inappropriate care. Delay in surgical intervention was the predominate event (50%). 2) The PDR for this study was 50% (0.95 CI, 33.7%–66.3%) Conclusion Fifty percent of trauma deaths were DP/PP. Multiple episodes of varying types of inappropriate care occurred. More efficient surgical evaluation and appropriate treatment of hemorrhage could reduce trauma morality. Large amounts of missing and incomplete clinical data suggest considerable selection bias. A major implication of this study is the importance of having a robust, prospective trauma registry to collect clinical information to increase the number of cases for review. Correcting delays in surgical care and inappropriate treatment of hemorrhage may improve trauma outcomes. Inadequacy of the clinical records within many low-resource settings hampers retrospective research system The need for a robust, electronic trauma registry that collects detailed clinical information is apparent.
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Affiliation(s)
- Rockefeller A. Oteng
- Department of Emergency Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana
- Corresponding author at: Department of Emergency Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Daniel Osei-Kwame
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana
| | | | - Kwame Ekremet
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana
| | - Hussein Yakubu
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana
| | - Bernard Arhin
- Research and Development Unit, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana
| | - Ronald F. Maio
- Department of Emergency Medicine, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA
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Knapp J, Bernhard M, Haltmeier T, Bieler D, Hossfeld B, Kulla M. [Resuscitative endovascular balloon occlusion of the aorta : Option for incompressible trunk bleeding?]. Anaesthesist 2019; 67:280-292. [PMID: 29508015 DOI: 10.1007/s00101-018-0418-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hemorrhage is the single largest cause of avoidable death in trauma patients, whereby in civil emergency medicine in Europe most life-threatening hemorrhages occur in the abdomen and the pelvis. This is one reason why endovascular balloon occlusion of the aorta (EBOA), a procedure especially established in vascular surgery, is increasingly propagated for rapid bleeding control in these patients. This review article provides a comprehensive overview of the technique, indications, contraindications and complications of resuscitative endovascular balloon occlusion of the aorta (REBOA). Additionally, outcomes reported in in the currently available literature are summarized and discussed. From this practical and user-oriented consequences for future successful introduction of REBOA in the field of emergency medicine are deduced.
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Affiliation(s)
- J Knapp
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Universitätsspital Bern, Freiburgstrasse 8, Bern, Schweiz.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - T Haltmeier
- Universitätsklinik für Viszerale Chirurgie und Medizin, Universitätsspital Bern, Bern, Schweiz
| | - D Bieler
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - B Hossfeld
- Klinik für Anästhesiologie und Intensivmedizin/Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - M Kulla
- Klinik für Anästhesiologie und Intensivmedizin/Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
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Pfeifer R, Halvachizadeh S, Schick S, Sprengel K, Jensen KO, Teuben M, Mica L, Neuhaus V, Pape HC. Are Pre-hospital Trauma Deaths Preventable? A Systematic Literature Review. World J Surg 2019; 43:2438-2446. [PMID: 31214829 DOI: 10.1007/s00268-019-05056-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The first and largest peak of trauma mortality is encountered on the trauma site. The aim of this study was to determine whether these trauma-related deaths are preventable. We performed a systematic literature review with a focus on pre-hospital preventable deaths in severely injured patients and their causes. METHODS Studies published in a peer-reviewed journal between January 1, 1990 and January 10, 2018 were included. Parameters of interest: country of publication, number of patients included, preventable death rate (PP = potentially preventable and DP = definitely preventable), inclusion criteria within studies (pre-hospital only, pre-hospital and hospital deaths), definition of preventability used in each study, type of trauma (blunt versus penetrating), study design (prospective versus retrospective) and causes for preventability mentioned within the study. RESULTS After a systematic literature search, 19 papers (total 7235 death) were included in this literature review. The majority (63.1%) of studies used autopsies combined with an expert panel to assess the preventability of death in the patients. Pre-hospital death rates range from 14.6 to 47.6%, in which 4.9-11.3% were definitely preventable and 25.8-42.7% were potentially preventable. The most common (27-58%) reason was a delayed treatment of the trauma victims, followed by management (40-60%) and treatment errors (50-76.6%). CONCLUSION According to our systematic review, a relevant amount of the observed mortality was described as preventable due to delays in treatment and management/treatment errors. Standards in the pre-hospital trauma system and management should be discussed in order to find strategies to reduce mortality.
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Affiliation(s)
- Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sylvia Schick
- Institute of Legal Medicine, Ludwig-Maximillians-Universität (LMU) Munich, Munich, Germany
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Ladislav Mica
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Valentin Neuhaus
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Grigorian A, Albertson S, Delaplain PT, Gabriel V, Maithel S, Dosch A, Schubl S, Joe V, Nahmias J. Cirrhosis increases complication rate and overall mortality in patients with traumatic lung injury. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618774577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Spencer Albertson
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Patrick T Delaplain
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Viktor Gabriel
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Shelley Maithel
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Austin Dosch
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Sebastian Schubl
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Victor Joe
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
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Grigorian A, Schubl S, Gabriel V, Dosch A, Joe V, Bernal N, Dogar T, Nahmias J. Analysis of trauma patients with unplanned returns to the operating room. Turk J Surg 2019; 35:54-61. [PMID: 32550304 DOI: 10.5578/turkjsurg.4182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/08/2018] [Indexed: 11/15/2022]
Abstract
Objectives Trauma patients undergoing damage-control surgery may have a planned return to the operating room. In contrast, little is known about unplanned returns to the operating room (uROR) in trauma. The aim of this study was to identify risk factors for uROR in trauma patients. It is hypothesized that blunt trauma patients with uROR have higher mortality when compared to penetrating trauma patients with uROR. Additionally, it is hypothesized that trauma patients with uROR after thoracotomy have higher mortality than patients with uROR after laparotomy. Material and Methods A retrospective analysis of the National Trauma Data Bank from 2011-2015 including any adult patient with an uROR was performed. Results From 3.447.320 patients, 9.269 (0.2%) were identified to have uROR. In a multivariable logistic regression analysis, 27 independent predictors were identified for risk of uROR with the strongest independent risk factor being compartment syndrome (OR= 10.50, CI= 9.35-11.78, p <0.001). Blunt (compared to penetrating) mechanism was associated with higher risk for mortality in patents with uROR (OR= 1.69, CI= 1.14-2.51, p <0.001) as was re-incision thoracotomy (RT) compared to re-incision laparotomy (RL) (OR= 2.22, CI= 1.29-3.84, p <0.001). Conclusion The strongest risk factor for uROR in trauma is compartment syndrome. Both a blunt (compared to penetrating) mechanism and RT (compared to RL) are independent risk factors for mortality in patients undergoing an uROR.
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Affiliation(s)
| | | | | | - Austin Dosch
- California Üniversitesi, Irvine, Surgery, Orange, ABD
| | - Victor Joe
- California Üniversitesi, Irvine, Surgery, Orange, ABD
| | - Nicole Bernal
- California Üniversitesi, Irvine, Surgery, Orange, ABD
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Abstract
BACKGROUND Earlier studies assessing mortality in polytrauma patients have focused on improving trauma care and reducing complications during hospital stay. The same studies have shown that the complication rate in these patients is high, often resulting in death. The aim of this study was to assess the incidence and causes of mortality in polytrauma patients in our institute. Secondarily, we assessed the donation and autopsy rates and outcome in these patients. PATIENTS AND METHODS All polytrauma patients (injury severity score≥16) transported to and treated in our institute during a period of 6 years were retrospectively analyzed. We included all patients who died during hospital stay. Prehospital and in-hospital data were collected on patients' condition, diagnostics, and treatment. The chance of survival was calculated according to the TRISS methodology. Patients were categorized according to the complications during treatment and causes of death. Logistic regression analysis was used to design a prediction model for mortality in major trauma. A statistical analysis was carried out. RESULTS Of the 1073 polytrauma patients who were treated in our institute during the study period, 205 (19.1%) died during hospital stay. The median age of the deceased patients was 58.8 years and 125 patients were men. Their mean injury severity score was 30.4. The most common mechanism of injury involved fall from height, followed by bicycle accidents. Almost 50% of the patients underwent an emergency intervention. Almost 92% of the total population died because of the effects of the accident (primary trauma). Of these, 24% died during primary assessment in the emergency department. Most patients died because of the effects of severe head injury (63.4%), followed by exsanguination (17.6%). The most common type of complications causing death during treatment was respiratory failure (6.3%), followed by multiple organ failure (1.5%). Autopsy was performed in 10.4%. Organ donation procedure was performed in 14.5%. Permission for donation was not provided in almost 20% of the population. CONCLUSION The mortality rate in polytrauma patients in our institute is considerable and comparable with the international literature. Most patients die because of the effects of the accident (primary trauma). Autopsy and organ donation rates are low in our institution and leave room for substantial improvements in the future.
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Analysis of Injury and Mortality Patterns in Deceased Patients with Road Traffic Injuries: An Autopsy Study. World J Surg 2017; 41:3111-3119. [DOI: 10.1007/s00268-017-4122-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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A comparison of Selective Aortic Arch Perfusion and Resuscitative Endovascular Balloon Occlusion of the Aorta for the management of hemorrhage-induced traumatic cardiac arrest: A translational model in large swine. PLoS Med 2017; 14:e1002349. [PMID: 28742797 PMCID: PMC5526509 DOI: 10.1371/journal.pmed.1002349] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/08/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Survival rates remain low after hemorrhage-induced traumatic cardiac arrest (TCA). Noncompressible torso hemorrhage (NCTH) is a major cause of potentially survivable trauma death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) at the thoracic aorta (Zone 1) can limit subdiaphragmatic blood loss and allow for IV fluid resuscitation when intrinsic cardiac activity is still present. Selective Aortic Arch Perfusion (SAAP) combines thoracic aortic balloon hemorrhage control with intra-aortic oxygenated perfusion to achieve return of spontaneous circulation (ROSC) when cardiac arrest has occurred. METHODS AND FINDINGS Male Yorkshire Landrace cross swine (80.0 ± 6.0 kg) underwent anesthesia, instrumentation for monitoring, and splenectomy. TCA was induced by laparoscopic liver lobe resection combined with arterial catheter blood withdrawal to achieve a sustained systolic blood pressure <10 mmHg, cardiac arrest. After 3 min of arrest, swine were allocated to one of three interventions: (1) REBOA plus 4 units of IV fresh whole blood (FWB), (2) SAAP with oxygenated lactated Ringer's (LR), 1,600 mL/2 min, or (3) SAAP with oxygenated FWB 1,600 mL/2 min. Primary endpoint was survival to the end of 60 min of resuscitation, a simulated prehospital phase. Thirty animals were allocated to 3 groups (10 per group)-5 protocol exclusions resulted in a total of 35 animals being used. Baseline measurements and time to cardiac arrest were not different amongst groups. ROSC was achieved in 0/10 (0%, 95% CI 0.00-30.9) REBOA, 6/10 (60%, 95% CI 26.2-87.8) SAAP-LR and 10/10 (100%, 95% CI 69.2-100.0) SAAP-FWB animals, p < 0.001. Survival to end of simulated 60-minute prehospital resuscitation was 0/10 (0%, 95% CI 0.00-30.9) for REBOA, 1/10 (10%, 95% CI 0.25-44.5) for SAAP-LR and 9/10 (90%, 95% CI 55.5-99.7) for SAAP-FWB, p < 0.001. Total FWB infusion volume was similar for REBOA (2,452 ± 0 mL) and SAAP-FWB (2,250 ± 594 mL). This study was undertaken in laboratory conditions, and as such may have practical limitations when applied clinically. Cardiac arrest in this study was defined by intra-aortic pressure monitoring that is not feasible in clinical practice, and as such limits the generalizability of findings. Clinical trials are needed to determine if the beneficial effects of SAAP-FWB observed in this laboratory study will translate into improved survival in clinical practice. CONCLUSIONS SAAP conferred a superior short-term survival over REBOA in this large animal model of hemorrhage-induced traumatic cardiac arrest with NCTH. SAAP using an oxygen-carrying perfusate was more effective in this study than non-oxygen carrying solutions in TCA. SAAP can effect ROSC from hemorrhage-induced electrocardiographic asystole in large swine.
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Heinrich D, Holzmann C, Wagner A, Fischer A, Pfeifer R, Graw M, Schick S. What are the differences in injury patterns of young and elderly traffic accident fatalities considering death on scene and death in hospital? Int J Legal Med 2017; 131:1023-1037. [PMID: 28180986 DOI: 10.1007/s00414-017-1531-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 01/03/2017] [Indexed: 11/28/2022]
Abstract
Older traffic participants have higher risks of injury than the population up to 65 years in case of comparable road traffic accidents and further, higher mortality rates at comparable injury severities. Rib fractures as risk factors are currently discussed. However, death on scene is associated with hardly survivable injuries and might not be a matter of neither rib fractures nor age. As 60% of traffic accident fatalities are estimated to die on scene, they are not captured in hospital-based trauma registries and injury patterns remain unknown. Our database comprises 309 road traffic fatalities, autopsied at the Institute of Legal Medicine Munich in 2004 and 2005. Injuries are coded according to Abbreviated Injury Scale, AIS© 2005 update 2008 [1]. Data used for this analysis are age, sex, site of death, site of accident, traffic participation mode, measures of injury severity, and rib fractures. The injury patterns of elderly, aged 65+ years, are compared to the younger ones divided by their site of death. Elderly with death on scene more often show serious thorax injuries and pelvic fractures than the younger. Some hints point towards older fatalities showing less frequently serious abdominal injuries. In hospital, elderly fatalities show lower Injury Severity Scores (ISSs) compared to the younger. The number of rib fractures is significantly higher for the elderly but is not the reason for death. Results show that young and old fatalities have different injury patterns and reveal first hints towards the need to analyze death on scene more in-depth.
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Affiliation(s)
- Daniela Heinrich
- Ludwig-Maximilians-University (LMU) Munich, Institute of Legal Medicine, Nussbaumstrasse 26, D-80336, Munich, Germany.
| | - Christopher Holzmann
- Department of Accident and Reconstructive Surgery, Hospital of the RWTH University Aachen, Pauwelsstrasse 30, D-52074, Aachen, Germany
| | - Anja Wagner
- Ludwig-Maximilians-University (LMU) Munich, Institute of Legal Medicine, Nussbaumstrasse 26, D-80336, Munich, Germany
| | - Anja Fischer
- Ludwig-Maximilians-University (LMU) Munich, Institute of Legal Medicine, Nussbaumstrasse 26, D-80336, Munich, Germany
| | - Roman Pfeifer
- Department of Accident and Reconstructive Surgery, Hospital of the RWTH University Aachen, Pauwelsstrasse 30, D-52074, Aachen, Germany
| | - Matthias Graw
- Ludwig-Maximilians-University (LMU) Munich, Head of the Institute of Legal Medicine, Nussbaumstrasse 26, D-80336, Munich, Germany
| | - Sylvia Schick
- Ludwig-Maximilians-University (LMU) Munich, Institute of Legal Medicine, Nussbaumstrasse 26, D-80336, Munich, Germany
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Barnard EBG, Morrison JJ, Madureira RM, Lendrum R, Fragoso-Iñiguez M, Edwards A, Lecky F, Bouamra O, Lawrence T, Jansen JO. Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales. Emerg Med J 2016; 32:926-32. [PMID: 26598631 PMCID: PMC4717355 DOI: 10.1136/emermed-2015-205217] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Introduction Non-compressible torso haemorrhage (NCTH) carries a high mortality in trauma as many patients exsanguinate prior to definitive haemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct that has the potential to bridge patients to definitive haemostasis. However, the proportion of trauma patients in whom REBOA may be utilised is unknown. Methods We conducted a population based analysis of 2012–2013 Trauma Audit and Research Network (TARN) data. We identified the number of patients in whom REBOA may have been utilised, defined by an Abbreviated Injury Scale score ≥3 to abdominal solid organs, abdominal or pelvic vasculature, pelvic fracture with ring disruption or proximal traumatic lower limb amputation, together with a systolic blood pressure <90 mm Hg. Patients with non-compressible haemorrhage in the mediastinum, axilla, face or neck were excluded. Results During 2012–2013, 72 677 adult trauma patients admitted to hospitals in England and Wales were identified. 397 patients had an indication(s) and no contraindications for REBOA with evidence of haemorrhagic shock: 69% men, median age 43 years and median Injury Severity Score 32. Overall mortality was 32%. Major trauma centres (MTCs) received the highest concentration of potential REBOA patients, and would be anticipated to receive a patient in whom REBOA may be utilised every 95 days, increasing to every 46 days in the 10 MTCs with the highest attendance of this injury type. Conclusions This TARN database analysis has identified a small group of severely injured, resource intensive patients with a highly lethal injury that is theoretically amenable to REBOA. The highest density of these patients is seen at MTCs, and as such a planned evaluation of REBOA should be further considered in these hospitals.
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Affiliation(s)
- Edward Benjamin Graham Barnard
- Institute of Naval Medicine, Gosport, Hampshire, UK Office of the Chief Scientist, 59th Medical Wing, Joint Base San Antonio, United States Air Force, San Antonio, Texas, USA
| | - Jonathan James Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Robbie Lendrum
- Department of Anaesthetics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Fiona Lecky
- Trauma Audit and Research Network, Hope Hospital, Manchester, UK EMRiS Group, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Omar Bouamra
- Trauma Audit and Research Network, Hope Hospital, Manchester, UK
| | - Thomas Lawrence
- Trauma Audit and Research Network, Hope Hospital, Manchester, UK
| | - Jan Olaf Jansen
- Departments of Surgery and Intensive Care Medicine, Aberdeen Royal Infirmary, Aberdeen, UK Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Oliver GJ, Walter DP. A Call for Consensus on Methodology and Terminology to Improve Comparability in the Study of Preventable Prehospital Trauma Deaths: A Systematic Literature Review. Acad Emerg Med 2016; 23:503-10. [PMID: 26844807 DOI: 10.1111/acem.12932] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The study of preventable deaths is essential to trauma research for measuring service quality and highlighting avenues for improving care and as a performance indicator. However, variations in the terminology and methodology of studies on preventable prehospital trauma death limit the comparability and wider application of data. The objective of this study was to describe the heterogeneity in terminology and methodology. METHODS We performed a systematic literature review and report this using the PRISMA guidelines. Searches were conducted using PubMed (including Medline), Ovid, and Embase databases. Studies, with a full text available in English published between 1990 and 2015, meeting the following inclusion criteria were included: analysis of 1) deaths from trauma, 2) occurring in the prehospital phase of care, and 3) application of criteria to ascertain whether deaths were preventable. One author screened database results for relevance by title and abstract. The full text of identified papers was reviewed for inclusion. The reference list of included papers was screened for studies not identified by the database search. Data were extracted on predefined core elements relating to preventability reporting and definitions using a standardized form. RESULTS Twenty-seven studies meeting the inclusion criteria were identified: 12 studies used two categories to assess the preventability of death while 15 used three categories. Fifteen variations in the terminology of these categories and combination with death descriptors were found. Eleven different approaches were used in defining what constituted a preventable death. Twenty-one included survivability of injuries as a criterion. Methods used to determine survivability differed and eight variations in parameters for categorization of deaths were used. Nineteen used panel review in determining preventability with six implementing panel blinding. Panel composition varied greatly by expertise of personnel. Separation of prehospital deaths differed with 10 separating those dead at scene (DAS) and dead on arrival, three excluding those DAS, three excluding deaths prior to EMS arrival, and 11 not separating prehospital deaths. CONCLUSIONS The heterogeneity in methodology, terminology, and definitions of "preventable" between studies render data incomparable. To facilitate common understanding, comparability, and analysis, a commonly agreed ontology by the prehospital research community is required.
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Affiliation(s)
- Govind J. Oliver
- British Red Cross Research Fellow; London
- Humanitarian and Conflict Response Institute; University of Manchester; Manchester UK
| | - Darren P. Walter
- Humanitarian and Conflict Response Institute; University of Manchester; Manchester UK
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Mortality Patterns in Patients with Multiple Trauma: A Systematic Review of Autopsy Studies. PLoS One 2016; 11:e0148844. [PMID: 26871937 PMCID: PMC4752312 DOI: 10.1371/journal.pone.0148844] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/25/2016] [Indexed: 11/19/2022] Open
Abstract
PURPOSE A high percentage (50%-60%) of trauma patients die due to their injuries prior to arrival at the hospital. Studies on preclinical mortality including post-mortem examinations are rare. In this review, we summarized the literature focusing on clinical and preclinical mortality and studies included post-mortem examinations. METHODS A literature search was conducted using PubMed/Medline database for relevant medical literature in English or German language published within the last four decades (1980-2015). The following MeSH search terms were used in different combinations: "multiple trauma", "epidemiology", "mortality ", "cause of death", and "autopsy". References from available studies were searched as well. RESULTS Marked differences in demographic parameters and injury severity between studies were identified. Moreover, the incidence of penetrating injuries has shown a wide range (between 4% and 38%). Both unimodal and bimodal concepts of trauma mortality have been favored. Studies have shown a wide variation in time intervals used to analyze the distribution of death. Thus, it is difficult to say which distribution is correct. CONCLUSIONS We have identified variable results indicating bimodal or unimodal death distribution. Further more stundardized studies in this field are needed. We would like to encourage investigators to choose the inclusion criteria more critically and to consider factors affecting the pattern of mortality.
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Moon S, Lee SH, Ryoo HW, Kim JK, Ahn JY, Kim SJ, Jeon JC, Lee KW, Sung AJ, Kim YJ, Lee DR, Do BS, Park SR, Lee JS. Preventable trauma death rate in Daegu, South Korea. Clin Exp Emerg Med 2015; 2:236-243. [PMID: 27752603 PMCID: PMC5052913 DOI: 10.15441/ceem.15.085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 10/15/2015] [Accepted: 10/18/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study investigated the preventable death rate in Daegu, South Korea, and assessed affecting factors and preventable factors in order to improve the treatment of regional trauma patients. METHODS All traumatic deaths between January 2012 and December 2012 in 5 hospitals in Daegu were analyzed by panel review, which were classified into preventable and non-preventable deaths. We determined the factors affecting trauma deaths and the preventable factors during trauma care. RESULTS There were overall 358 traumatic deaths during the study period. Two hundred thirty four patients were selected for the final analysis after excluding cases of death on arrival, delayed death, and unknown causes. The number of preventable death was 59 (25.2%), which was significantly associated with mode of arrival, presence of head injury, date, and time of injury. A multivariate analysis revealed that preventable death was more likely when patients were secondly transferred from another hospital, visited hospital during non-office hour, and did not have head injuries. The panel discovered 145 preventable factors, which showed that majority of factors occurred in emergency departments (49.0%), and were related with system process (76.6%). CONCLUSION The preventable trauma death rate in Daegu was high, and mostly process-related.
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Affiliation(s)
- Sungbae Moon
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Suk Hee Lee
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jong Kun Kim
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae Yun Ahn
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sung Jin Kim
- Department of Emergency Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Cheon Jeon
- Department of Emergency Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung Woo Lee
- Department of Emergency Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Ae Jin Sung
- Department of Emergency Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Yun Jeong Kim
- Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Dae Ro Lee
- Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Byung Soo Do
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sin Ryul Park
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jin-Seok Lee
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Pre-hospital care is emergency medical care given to patients before arrival in hospital after activation of emergency medical services. It traditionally incorporated a breadth of care from bystander resuscitation to statutory emergency medical services treatment and transfer. New concepts of care including community paramedicine, novel roles such as emergency care practitioners, and physician delivered pre-hospital emergency medicine are re-defining the scope of pre-hospital care. For severely ill or injured patients, acting quickly in the pre-hospital period is crucial with decisions and interventions greatly affecting outcomes. The transfer of skills and procedures from hospital care to pre-hospital medicine enables early advanced care across a range of disciplines. The variety of possible pathologies, challenges of environmental factors, and hazardous situations requires management that is tailored to the patient's clinical need and setting. Pre-hospital clinicians should be generalists with a broad understanding of medical, surgical, and trauma pathologies, who will often work from locally developed standard operating procedures, but who are able to revert to core principles. Pre-hospital emergency medicine consists of not only clinical care, but also logistics, rescue competencies, and scene management skills (especially in major incidents, which have their own set of management principles). Traditionally, research into the hyper-acute phase (the first hour) of disease has been difficult, largely because physicians are rarely present and issues of consent, transport expediency, and resourcing of research. However, the pre-hospital phase is acknowledged as a crucial period, when irreversible pathology and secondary injury to neuronal and cardiac tissue can be prevented. The development of pre-hospital emergency medicine into a sub-specialty in its own right should bring focus to this period of care.
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Affiliation(s)
- Mark H Wilson
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK; St Mary's Major Trauma Centre, Imperial College, London, UK.
| | - Karel Habig
- Greater Sydney HEMS Service, Sydney, Australia
| | | | - Amy Hughes
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK
| | - Gareth Davies
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK
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Burden of injuries avertable by a basic surgical package in low- and middle-income regions: a systematic analysis from the Global Burden of Disease 2010 Study. World J Surg 2015; 39:1-9. [PMID: 25008243 PMCID: PMC4273085 DOI: 10.1007/s00268-014-2685-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Injuries accounted for 11 % of the global burden of disease in 2010. This study aimed to quantify the burden of injury in low- and middle-income countries (LMICs) that could be averted if basic surgical services were made available and accessible to the entire population. Methods We examined all causes of injury from the Global Burden of Disease 2010 Study. We split the disability-adjusted life years (DALYs) for these conditions between surgically “avertable” and “nonavertable” burdens. For estimating the avertable fatal burden, we applied the lowest fatality rates among the 21 epidemiologic regions to each LMIC region, assuming that the differences in death rates between each region and the lowest rates reflect the gap in surgical care. We adjusted for fatal cases that occur prior to reaching hospitals as they are not surgically avertable. Similarly, we applied the lowest nonfatal burden per case to each LMIC region. Results Overall, 21 % of the injury burden in LMICs was potentially avertable by basic surgical care (52.3 million DALYs). The avertable proportion was greater for deaths than for nonfatal burden (23 vs. 20 %), suggesting that surgical services for injuries more effectively save lives than ameliorate disability. Sub-Saharan Africa had the largest proportion of potentially avertable burden (25 %). South Asia had the highest total avertable DALYs (17.4 million). Road injury comprised the largest total avertable burden in LMICs (16.1 million DALYs). Conclusions Basic surgical care has the potential to play a major role in reducing the injury-related burden in LMICs. Electronic supplementary material The online version of this article (doi:10.1007/s00268-014-2685-x) contains supplementary material, which is available to authorized users.
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Yeboah D, Mock C, Karikari P, Agyei-Baffour P, Donkor P, Ebel B. Minimizing preventable trauma deaths in a limited-resource setting: a test-case of a multidisciplinary panel review approach at the Komfo Anokye Teaching Hospital in Ghana. World J Surg 2015; 38:1707-12. [PMID: 24449414 DOI: 10.1007/s00268-014-2452-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Our objectives were to determine the proportion of preventable trauma deaths at a large trauma hospital in Kumasi, Ghana, and to identify opportunities for the improvement of trauma care. METHODS A multidisciplinary panel of experts evaluated pre-hospital, hospital, and postmortem data of consecutive trauma patients who died over a 5-month period in 2006-2007 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For preventable and potentially preventable deaths, deficiencies in care that contributed to their deaths were identified. RESULTS The panel reviewed 231 trauma deaths. Of these, 84 charts had sufficient information to review preventable factors. The panel determined that 23 % of trauma deaths were definitely preventable, 37 % were potentially preventable, and 40 % were not preventable. One main deficiency in care was identified for each of the 50 definitely preventable and potentially preventable deaths. The most common deficiencies were pre-hospital delays (44 % of the 50 deficiencies), delay in treatment (32 %), and inadequate fluid resuscitation (22 %). Among the 19 definitely preventable deaths, the most common cause of death was hemorrhage (47 %), and the most common deficiencies were inadequate fluid resuscitation (37 % of deficiencies in this group) and pre-hospital delay (37 %). CONCLUSIONS A high proportion of trauma fatalities might have been preventable by decreasing pre-hospital delays, adequate resuscitation in hospital, and earlier initiation of care, including definitive surgical management. The study also showed that preventable death panel reviews are a feasible and useful quality improvement method in the study setting.
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Affiliation(s)
- Dominic Yeboah
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana,
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Schueller G, Scaglione M, Linsenmaier U, Schueller-Weidekamm C, Andreoli C, De Vargas Macciucca M, Gualdi G. The key role of the radiologist in the management of polytrauma patients: indications for MDCT imaging in emergency radiology. Radiol Med 2015; 120:641-54. [PMID: 25634793 DOI: 10.1007/s11547-015-0500-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/13/2015] [Indexed: 12/15/2022]
Abstract
Trauma causes greater losses of life years and it is the most common cause of death for people under the age of 45. Time is one of the most relevant factors for the survival of injured patients, particularly the time elapsed from trauma until the resuscitation procedures. As a member of the trauma team, the radiologist contributes to the rapid diagnosis of traumatic disorders, with appropriate imaging modalities. Based on the evidence, the most appropriate diagnostic tool for severe/multiple trauma is computed tomography (CT). With the advent of multidetector CT (MDCT), radiologists are able to more effectively characterize life-threatening traumatic disorders within a few seconds in stable or stabilized patients. Considering the diagnostic potential of MDCT, conventional radiographs could be virtually abandoned in the diagnostic algorithms for adult polytraumatized patients. The radiologist helps to facilitate triage and to assess the optimal individual treatment for polytrauma patients, thus contributing to the improvement of patient outcomes. In this article, the indications for MDCT in the polytrauma setting are discussed.
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Abstract
BACKGROUND Hemorrhage persists as the leading cause of potentially preventable civilian and military death. Noncompressible torso hemorrhage (NCTH) is a particularly lethal injury complex, with few contemporary prehospital interventions available. Various porcine models of hemorrhage have been developed for civilian and military trauma research. However, the predominant contemporary models lack key physiologic characteristics including the natural tamponade provided by an intact abdominal wall.To improve physiologic and clinical relevance, we developed a laparoscopic model of NCTH. This approach maintains both the integrity of the peritoneum and the natural tamponade effect of an intact abdominal wall while preserving the intrinsic physiologic responses to hemorrhage. Furthermore, we present data quantifying the contribution of the swine contractile spleen in the context of uncontrolled hemorrhage. METHODS Anesthetized adult male Yorkshire swine underwent a laparoscopic Grade V liver injury, with or without open preinjury splenectomy. Animals were observed without intervention for a total of 120 minutes after injury to simulate point of injury, transport time, and arrival at hospital. RESULTS Shed blood-to-body weight ratio did not differ among groups; however, mortality was higher in splenectomized animals (67% vs. 33%). Cox regression modeling demonstrated a critical time point of 45 minutes and blood pressure as significant predictors of mortality. CONCLUSION This study describes a model of NCTH that reflects clinically relevant physiology in trauma and uncontrolled hemorrhage. In addition, it quantitatively assesses the role of the swine contractile spleen in the described model.
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Morrison JJ, Lendrum RA, Jansen JO. Resuscitative endovascular balloon occlusion of the aorta (REBOA): A bridge to definitive haemorrhage control for trauma patients in Scotland? Surgeon 2014; 12:119-20. [DOI: 10.1016/j.surge.2013.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 10/15/2013] [Indexed: 11/25/2022]
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Morrison JJ, Ross JD, Markov NP, Scott DJ, Spencer JR, Rasmussen TE. The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. J Surg Res 2014; 191:423-31. [PMID: 24836421 DOI: 10.1016/j.jss.2014.04.012] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 03/11/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a hemorrhage control and resuscitative adjunct that has been demonstrated to improve central perfusion during hemorrhagic shock. The aim of this study was to characterize the systemic inflammatory response associated and cardiopulmonary sequelae with 30, 60, and 90 min of balloon occlusion and shock on the release of interleukin 6 (IL-6) and tumor necrosis factor alpha. MATERIALS AND METHODS Anesthetized female Yorkshire swine (Sus scrofa, weight 70-90 kg) underwent a 35% blood volume-controlled hemorrhage followed by thoracic aortic balloon occlusion of 30 (30-REBOA, n = 6), 60 (60-REBOA, n = 8), and 90 min (90-REBOA, n = 6). This was followed by resuscitation with whole blood and crystalloid over 6 h. Animals then underwent 48 h of critical care with sedation, fluid, and vasopressor support. RESULTS All animals were successfully induced into hemorrhagic shock without mortality. All groups responded to aortic occlusion with a rise in blood pressure above baseline values. IL-6, as measured (picogram per milliliter) at 8 h, was significantly elevated from baseline values in the 60-REBOA and 90-REBOA groups: 289 ± 258 versus 10 ± 5; P = 0.018 and 630 ± 348; P = 0.007, respectively. There was a trend toward greater vasopressor use (P = 0.183) and increased incidence of acute respiratory distress syndrome (P = 0.052) across the groups. CONCLUSIONS REBOA is a useful adjunct in supporting central perfusion during hemorrhagic shock; however, increasing occlusion time and shock results in a greater IL-6 release. Clinicians must anticipate inflammation-mediated organ failure in post-REBOA use patients.
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Affiliation(s)
- Jonathan J Morrison
- The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom; The United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - James D Ross
- 59th Medical Wing, Joint Base San Antonio, Lackland, Texas
| | - Nickolay P Markov
- The United States Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Daniel J Scott
- The United States Army Institute of Surgical Research, Fort Sam Houston, Texas; 59th Medical Wing, Joint Base San Antonio, Lackland, Texas
| | | | - Todd E Rasmussen
- The United States Army Institute of Surgical Research, Fort Sam Houston, Texas; 59th Medical Wing, Joint Base San Antonio, Lackland, Texas; The Norman M. Rich Department of Surgery, the Uniformed Services University of the Health Sciences, Bethesda, Maryland.
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Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Highly Lethal Model of Noncompressible Torso Hemorrhage. Shock 2014; 41:130-7. [DOI: 10.1097/shk.0000000000000085] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pooled preventable death rates in trauma patients. Eur J Trauma Emerg Surg 2014; 40:279-85. [DOI: 10.1007/s00068-013-0364-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 12/29/2013] [Indexed: 10/25/2022]
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Gitelman V, Auerbach K, Doveh E. Development of road safety performance indicators for trauma management in Europe. ACCIDENT; ANALYSIS AND PREVENTION 2013; 60:412-423. [PMID: 22938913 DOI: 10.1016/j.aap.2012.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 05/18/2012] [Accepted: 08/05/2012] [Indexed: 06/01/2023]
Abstract
Trauma management (TM) covers two types of medical treatment: the initial one provided by Emergency Medical Services (EMS) and a further one provided by permanent medical facilities. There is a consensus in the professional literature that to reduce the severity and the number of road crash victims, the TM system should provide rapid and adequate initial care of injury, combined with sufficient further treatment at a hospital or trauma centre. Recognizing the important role of TM for reducing road crash injury outcome, it was decided, within the EU funded SafetyNet project, to develop road safety performance indicators (SPIs) which would characterize the level of TM systems' performance in European countries and enable country comparisons. The concept of TM SPIs was developed based on a literature study of performance indicators in TM, a survey of available practices in Europe and data availability examinations. A set of TM SPIs was introduced including 14 indicators which characterize five issues such as: availability of EMS stations; availability and composition of EMS medical staff; availability and composition of EMS transportation units; characteristics of the EMS response time, and availability of trauma beds in permanent medical facilities. Basic information on the TM systems was collected in close cooperation with the national expert group. A dataset with TM SPIs for 21 countries was created. It was demonstrated that the countries can be compared using selected TM SPIs. Moreover, a more general comparison of the TM systems' performance in the countries is possible, using multiple ranking and statistical weighting techniques. By both methods, final estimates were received enabling the recognition of groups of countries with similar levels of the TM system's performance. The results of various trials were consistent as to the recognition of countries with high or low level of the TM systems' performance, where in grouping countries with intermediate levels of the TM system's performance some differences were observed. The SafetyNet project's practice demonstrated that data collection for estimating TM SPIs is not an easy task but is realizable for the majority of countries. The TM SPIs' message is currently limited to the availability of trauma care services. Further development of the TM SPIs should focus on characteristics of actual treatment supplied, based on combined police and medical road crash related databases.
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Affiliation(s)
- Victoria Gitelman
- Ran Naor Road Safety Research Center, Technion - Israel Institute of Technology, Technion City, Haifa 32000, Israel.
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Bajwa SJS, Kaur J, Singh A, Kapoor V, Bindra GS, Ghai GS. Clinical and critical care concerns of cranio-facial trauma: A retrospective study in a tertiary care institute. Natl J Maxillofac Surg 2013; 3:133-8. [PMID: 23833486 PMCID: PMC3700145 DOI: 10.4103/0975-5950.111343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: Maxillofacial trauma is commonly associated with other injuries, predominantly head injuries. The predictors of outcome in such concomitant injuries have been studied the least. The present study aims at the evaluation of types of injury, management and outcome of patients sustaining maxillofacial trauma and concomitant cranial injuries. Materials and Methods: A retrospective study was carried out in the department of anesthesiology and intensive care. A case series of 129 patients was evaluated who were admitted in ICU (Intensive Care Unit) with maxillofacial trauma and head injuries. The data was then compiled systematically and analyzed using SPSS windows and value of P < 0.05 was considered significant and P < 0.001 as highly significant. Results: Among the 129 patients, majority of them had roadside accidents (RSA > 90%) and male gender predominance with male to female ratio of 5: 1. Fracture maxilla and nasal bones were the most commonly encountered injuries (51.93%) followed by mandibular fractures (39.53%) and fracture of zygomatic bones (28.68%). Eighty five patients (65.90%) required mechanical ventilation, tracheostomy was needed in 29 (22.48%) patients and 81 (62.8%) patients were operated for head injuries as well. Majority of the victims were aged between 15 and 40 years. Conclusions: Maxillofacial trauma and cranial injuries are common among young males and so is the nature of injuries, that is, RSA. Besides facial injuries, head injuries are important determinant of outcome in such patients. Timely resuscitation and surgical interventions at specialized centers are of prime importance as far as a better prognosis is concerned in such injuries.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
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Kleber C, Giesecke MT, Tsokos M, Haas NP, Schaser KD, Stefan P, Buschmann CT. Overall distribution of trauma-related deaths in Berlin 2010: advancement or stagnation of German trauma management? World J Surg 2012; 36:2125-30. [PMID: 22610265 DOI: 10.1007/s00268-012-1650-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Trauma is the leading cause of death among children, adolescents, and young adults. The latest data from the German Trauma Registry reveals a constant decrease in trauma mortality, indicating that 11.6 % of all trauma patients in 2010 died in hospital. Notably, trauma casualties dying before admission to hospital have not been systematically surveyed and analyzed in Germany. METHODS We conducted a prospective observational study of all traumatic deaths in Berlin, recording demographic data, trauma mechanisms, and causes/localization and time of death after trauma. Inclusion criteria were all deaths following trauma from 1 January 2010 to 31 December 2010. RESULTS A total of 440 trauma fatalities were included in this study, with a mortality rate of 13/100,000 inhabitants; 78.6 % were blunt injuries, and fall from a height >3 m (32.7 %) was the leading trauma mechanism. 32.5 % died immediately, 23.9 % died within 60 min, 7.7 % died within 1-4 h, 16.8 % died within 4-48 h, 11.1 % died <1 week later, and 8 % died >1 week after trauma. The predominant causes of death were polytrauma (45.7 %), sTBI (38 %), exsanguination (9.5 %), and thoracic trauma (3.2 %). Death occurred on-scene in 58.7 % of these cases, in the intensive care unit in 33.2 %, and in 2.7 % of the cases, in the emergency department, the operating room, and the ward, respectively. CONCLUSIONS Polytrauma is the leading cause of death, followed by severe traumatic brain injury (sTBI). The temporal analysis of traumatic death indicates a shift from the classic "trimodal" distribution to a new "bimodal" distribution. Besides advances in road safety, prevention programs and improvement in trauma management-especially the pre-hospital phase-have the potential to significantly improve the survival rate after trauma.
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Affiliation(s)
- Christian Kleber
- Center for Musculoskeletal Surgery, AG Polytrauma, Charité-Universitätsmedizin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
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Bajwa SS, Kaur J, Bajwa SK, Kaur G, Singh A, Parmar SS, Kapoor V. Designing, managing and improving the operative and intensive care in polytrauma. J Emerg Trauma Shock 2012; 4:494-500. [PMID: 22090744 PMCID: PMC3214507 DOI: 10.4103/0974-2700.86642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 02/24/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND CONTEXT Polytrauma is a leading cause of mortality in the developing countries and efforts from various quarters are required to deal with this increasing menace. AIMS AND OBJECTIVES An attempt has been made by the coordinated efforts of the intensive care and trauma team of a newly established tertiary care institute in designing and improving the trauma care services to realign its functions with national policies by analyzing the profile of polytrauma victims and successfully managing them. MATERIALS AND METHODS A retrospective analysis was carried out among the 531 polytrauma admissions in the emergency department. The information pertaining to age and gender distribution, locality, time to trauma and initial resuscitation, cause of injury, type of injury, influence of alcohol, drug addiction, presenting clinical picture, Glasgow Coma score on admission and few other variables were also recorded. The indications for various operative interventions and intensive care unit (ICU) admissions were analyzed thoroughly with a concomitant improvement of our trauma care services and thereby augmenting the national policies and programs. A statistical analysis was carried out with chi-square and analysis of variance ANOVA tests, using SPSS software version 10.0 for windows. The value of P<0.05 was considered significant and P<0.0001 as highly significant. RESULTS Majority of the 531 polytrauma patients hailed from rural areas (63.65%), riding on the two wheelers (38.23%), and predominantly comprised young adult males. Fractures of long bones and head injury was the most common injury pattern (37.85%) and 51.41% of the patients presented with shock and hemorrhage. Airway management and intubation became necessary in 42.93% of the patients, whereas 52.16% of the patients were operated within the first 6 hours of admission for various indications. ICU admission was required for 45.76% of the patients because of their deteriorating clinical condition, and overall,ionotropic support was administered in 55.93% of the patients for successful resuscitation. CONCLUSIONS There is an urgent need for proper implementation ofpre-hospital and advanced trauma life support measures at grass-root level. Analyzing the profile of polytrauma victims at a national level and simultaneously improving the trauma care services at every health center are very essential to decrease the mortality and morbidity. The improvement can be augmented further by strengthening the rural health infrastructure, strict traffic rules, increasing public awareness and participation and coordination among the various public and private agencies in dealing with polytrauma.
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Affiliation(s)
- Sukhminderjit Singh Bajwa
- Department of Anaesthesiology & Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
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Osime OC, Ighedosa SU, Oludiran OO, Iribhogbe PE, Ehikhamenor E, Elusoji SO. Patterns of Trauma Deaths in an Accident and Emergency Unit. Prehosp Disaster Med 2012; 22:75-8. [PMID: 17484367 DOI: 10.1017/s1049023x00004374] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction:Trauma is a leading cause of death in most countries. Different patterns of trauma deaths are recorded in different countries. The purpose of this study was to evaluate retrospectively the pattern of trauma deaths in the emergency unit of a University Teaching Hospital in Nigeria.Methods:This is a descriptive, retrospective study. The data were obtained from patient case files and nurses'records. The data abstracted included age, sex, cause of trauma/death, parts of the body injured, time of death, andthe duration of stay in the Accident and Emergency Unit (AEU).Results:A total of 5,537 cases presented to the AEU of the University of Benin Teaching Hospital between 01 January 2001 and 31 December 2004. Of these, 5,446 were due to trauma (98.4%). A total of 127 patients died (case fatality rate: 2.3%). Of the deaths, 81.9% were males. Motor vehicle crashes were the most frequent cause (54.3%), and drowning was the least common cause of trauma (0.8%). The most frequently injured region of the body was the head and neck (53.4%). A total of 67.4% of the deaths occurred within six hours of presentation to the AEU.Conclusions:There is a great need for improved road safety, adequate pre-hospital medical care, and prompt transfer services for victims of trauma.
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Affiliation(s)
- Odigie Clement Osime
- Department of Surgery, University of Benin Teaching Hospital, PMB 1111, Benin City, Nigeria.
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Settervall CHC, Domingues CDA, Sousa RMCD, Nogueira LDS. Preventable trauma deaths. Rev Saude Publica 2012; 46:367-75. [PMID: 22310649 DOI: 10.1590/s0034-89102012005000010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 09/15/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To describe methods of estimation and assess preventable deaths and types of errors related to health care. METHODS A systematic review of articles on preventable trauma deaths published between 2000 and 2009 was conducted. Lilacs, SciELO and Medline databases were searched using the keywords "trauma," "avoidable," "preventable," "interventions" and "complications" and the health sciences descriptors "death," "cause of death," and "hospitals." RESULTS A total of 29 articles published during the study period were selected. Most were retrospective studies (96.5%). The most common methods used to define avoidability of death were expert panel and injury severity scores. Deaths were categorized as follows: preventable; potentially preventable; and not preventable. The mean preventable death rate was 10.7% (SD 11.5%). The most commonly reported errors were inadequate care management of injured patients and evaluation and treatment errors. CONCLUSIONS Inconsistent terms were used to categorize deaths and related noncompliances. It is suggested to standardize the terminology for the classification of deaths and types of errors.
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Ringen AH, Hjortdahl M, Wisborg T. Norwegian trauma team leaders--training and experience: a national point prevalence study. Scand J Trauma Resusc Emerg Med 2011; 19:54. [PMID: 21975088 PMCID: PMC3197515 DOI: 10.1186/1757-7241-19-54] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 10/05/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The treatment of trauma victims is a complex multi-professional task in a stressful environment. We previously found that trauma team members perceive leadership as the most important human factor. The aim of the present study was to assess the experience and education of Norwegian trauma team leaders, and allow them to describe their perceived educational needs. METHODS We conducted an anonymous descriptive study using a point prevalence methodology based on written questionnaires. All 45 hospitals in Norway receiving severely injured trauma victims were contacted on a randomly selected weeknight during November 2009. Team leaders were asked to specify what trauma related training programs they had participated in, how much experience they had, and what further training they wished, if any. RESULTS Response rate was 82%. Slightly more than half of the team leaders were residents. The median working experience as a surgeon among team leaders was 7.5 years. Sixty-eight percent had participated in multi-professional training in non-technical skills, while 54% had passed the advanced trauma life support(ATLS) course. Fifty-one percent were trained in damage control surgery. A median of one course per team leader was needed to comply with the new proposed national standards. Team leaders considered training in damage control surgery the most needed educational objective. CONCLUSIONS Level of experience among team leaders was highly variable and their educational background insufficient according to international and proposed national standards. Proposed national standards should be urgently implemented to ensure equal access to high quality trauma care.
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Affiliation(s)
- Amund Hovengen Ringen
- The BEST Foundation: Better & Systematic Team Training, Hammerfest Hospital, Department of Anaesthesiology and Intensive Care, Finnmark Health Trust, Hammerfest, Norway.
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A Model of Personnel Mobilization during Mass-Casualty Incidents. Prehosp Disaster Med 2010. [DOI: 10.1017/s1049023x0002330x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Leadership is the essential non-technical skill in the trauma team--results of a qualitative study. Scand J Trauma Resusc Emerg Med 2009; 17:48. [PMID: 19781093 PMCID: PMC2764560 DOI: 10.1186/1757-7241-17-48] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Accepted: 09/26/2009] [Indexed: 11/18/2022] Open
Abstract
Background Trauma is the leading cause of death for young people in Norway. Studies indicate that several of these deaths are avoidable if the patient receives correct initial treatment. The trauma team is responsible for initial hospital treatment of traumatized patients, and team members have previously reported that non-technical skills as communication, leadership and cooperation are the major challenges. Better team function could improve patient outcome. The aim of this study was to obtain a deeper understanding of which non-technical skills are important to members of the trauma team during initial examination and treatment of trauma patients. Methods Twelve semi-structured interviews were conducted at four different hospitals of various sizes and with different trauma load. At each hospital a nurse, an anaesthesiologist and a team leader (surgeon) were interviewed. The conversations were transcribed and analyzed using systematic text condensation according to the principles of Giorgi's phenomenological analysis as modified by Malterud. Results and conclusion Leadership was perceived as an essential component in trauma management. The ideal leader should be an experienced surgeon, have extensive knowledge of trauma care, communicate clearly and radiate confidence. Team leaders were reported to have little trauma experience, and the team leaders interviewed requested more guidance and supervision. The need for better training of trauma teams and especially team leaders requires further investigation and action.
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Chiara O, Pitidis A, Lispi L, Bruzzone S, Ceccolini C, Cacciatore P, Cimbanassi S, Taggi F. Epidemiology of Fatal Trauma in Italy in 2002 Using Population-Based Registries. Eur J Trauma Emerg Surg 2009; 36:157-63. [PMID: 26815691 DOI: 10.1007/s00068-009-9066-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 08/09/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Population-based registries have been proposed for epidemiologic studies and quality assessment in trauma care because they consider the entire population of a given geographic area. PATIENTS AND METHODS Trauma mortality in pre-hospital and in-hospital settings and death time from injury have been calculated for Italy during 2002 by cross-analyzing two national databases: the death certificates register (DCD) and the hospital discharge register (HDR). All diagnosis codes from 800.0 to 939.9 and from 950.0 to 959.9 in both the DCD and the HDR, with the exclusion of femur fractures (820.0 and 821.9) if older than 65, have been included. RESULTS The total number of people who died during 2002 as a consequence of trauma in Italy was 15,456; of these, 43.5% were older than age 64, and 35.9% belonged to the 15-44 age group. The overall incidence rate of trauma death was 27.23 per 100,000 inhabitants/ year, with a relative risk to men vs. women of 2.3. An analysis of the time distribution of the trauma deaths showed that 46.8% were pre-hospital mortalities, 18% of the deaths occurred within 48 h after hospital admission (acute mortality), 11.2% of the deaths occurred between three and seven days after admission (early mortality), and 24.0% of the patients died more than seven days after admission (late mortality). Patients who died before they arrived at hospital were younger and the proportion of men was higher than for the deaths that occurred after hospital arrival. CONCLUSION The use of population-based registries proved to be effective in our study because it allowed us to use currently available data to obtain information useful for trauma system planning and design.
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Affiliation(s)
- Osvaldo Chiara
- Trauma Team, Emergency Department, Ospedale Niguarda Ca'Granda, Milan, Italy.
- Trauma Team, Emergency Department, Ospedale Niguarda Ca'Granda, Milan, Italy.
| | - Alessio Pitidis
- Department of Environment and Primary Prevention, National Institute of Health, Rome, Italy
| | - Lucia Lispi
- General Directorate of Healthcare Planning, Ministry of Health, Rome, Italy
| | - Silvia Bruzzone
- Division for Statistics and Surveys on Social Institutions, Italian National Institute of Statistics, Rome, Italy
| | - Carla Ceccolini
- General Directorate of Healthcare Planning, Ministry of Health, Rome, Italy
| | - Paola Cacciatore
- Division for Statistics and Surveys on Social Institutions, Italian National Institute of Statistics, Rome, Italy
| | - Stefania Cimbanassi
- Trauma Team, Emergency Department, Ospedale Niguarda Ca'Granda, Milan, Italy
| | - Franco Taggi
- Department of Environment and Primary Prevention, National Institute of Health, Rome, Italy
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Pfeifer R, Tarkin IS, Rocos B, Pape HC. Patterns of mortality and causes of death in polytrauma patients--has anything changed? Injury 2009; 40:907-11. [PMID: 19540488 DOI: 10.1016/j.injury.2009.05.006] [Citation(s) in RCA: 285] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Revised: 05/01/2009] [Accepted: 05/06/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Numerous articles have examined the pattern of traumatic deaths. Most of these studies have aimed to improve trauma care and raise awareness of avoidable complications. The aim of the present review is to evaluate whether the distribution of complications and mortality has changed. MATERIALS AND METHODS A review of the published literature to identify studies examining patterns and causes of death following trauma treated in level 1 hospitals published between 1980 and 2008. PubMed was searched using the following terms: Trauma Epidemiology, Injury Pattern, Trauma Deaths, and Causes of Death. Three time periods were differentiated: (n=6, 1980-1989), (n=6, 1990-1999), and (n=10, 2000-2008). The results were limited to the English and/or German language. Manuscripts were analysed to identify the age, injury severity score (ISS), patterns and causes of death mentioned in studies. RESULTS Twenty-two publications fulfilled the inclusion criteria for the review. A decrease of haemorrhage-induced deaths (25-15%) has occurred within the last decade. No considerable changes in the incidence and pattern of death were found. The predominant cause of death after trauma continues to be central nervous system (CNS) injury (21.6-71.5%), followed by exsanguination (12.5-26.6%), while sepsis (3.1-17%) and multi-organ failure (MOF) (1.6-9%) continue to be predominant causes of late death. DISCUSSION Comparing manuscripts from the last three decades revealed a reduction in the mortality rate from exsanguination. Rates of the other causes of death appear to be unchanged. These improvements might be explained by developments in the availability of multislice CT, implementation of ATLS concepts and logistics of emergency rescue.
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Affiliation(s)
- Roman Pfeifer
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, Pittsburgh, PA 15213, USA.
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Llullaku SS, Hyseni NS, Bytyçi CI, Rexhepi SK. Evaluation of trauma care using TRISS method: the role of adjusted misclassification rate and adjusted w-statistic. World J Emerg Surg 2009; 4:2. [PMID: 19146701 PMCID: PMC2633290 DOI: 10.1186/1749-7922-4-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2008] [Accepted: 01/15/2009] [Indexed: 11/16/2022] Open
Abstract
Background Major trauma is a leading cause of death worldwide. Evaluation of trauma care using Trauma Injury and Injury Severity Score (TRISS) method is focused in trauma outcome (deaths and survivors). For testing TRISS method TRISS misclassification rate is used. Calculating w-statistic, as a difference between observed and TRISS expected survivors, we compare our trauma care results with the TRISS standard. Aim The aim of this study is to analyze interaction between misclassification rate and w-statistic and to adjust these parameters to be closer to the truth. Materials and methods Analysis of components of TRISS misclassification rate and w-statistic and actual trauma outcome. Results The component of false negative (FN) (by TRISS method unexpected deaths) has two parts: preventable (Pd) and non-preventable (nonPd) trauma deaths. Pd represents inappropriate trauma care of an institution; otherwise nonpreventable trauma deaths represents errors in TRISS method. Removing patients with preventable trauma deaths we get an Adjusted misclassification rate: (FP + FN - Pd)/N or (b+c-Pd)/N. Substracting nonPd from FN value in w-statistic formula we get an Adjusted w-statistic: [FP-(FN - nonPd)]/N, respectively (FP-Pd)/N, or (b-Pd)/N). Conclusion Because adjusted formulas clean method from inappropriate trauma care, and clean trauma care from the methods error, TRISS adjusted misclassification rate and adjusted w-statistic gives more realistic results and may be used in researches of trauma outcome.
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Affiliation(s)
- Sadik S Llullaku
- University Clinical Centre of Kosova, Department of Paediatric Surgery, 10 000 Prishtina, Kosova
| | - Nexhmi Sh Hyseni
- University Clinical Centre of Kosova, Department of Paediatric Surgery, 10 000 Prishtina, Kosova
| | - Cen I Bytyçi
- University Clinical Centre of Kosova, Department of Orthopaedic and Trauma Surgery, 10 000 Prishtina, Kosova
| | - Sylejman K Rexhepi
- University Clinical Centre of Kosova, Department of Internal Diseases, 10 000 Prishtina, Kosova
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Li MD, Doong JL, Chang KK, Lu TH, Jeng MC. Differences in urban and rural accident characteristics and medical service utilization for traffic fatalities in less-motorized societies. JOURNAL OF SAFETY RESEARCH 2008; 39:623-630. [PMID: 19064048 DOI: 10.1016/j.jsr.2008.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Revised: 09/23/2008] [Accepted: 10/27/2008] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Fatalities from traffic accidents in less-motorized societies are an important global issue. We aimed to characterize the geographic differences of fatalities in such societies to facilitate the development of targeted interventions. METHOD This study linked police reports, hospital data, and vital registration data from Taiwan with special reference to accident factors in pre-hospital deaths and medical care in hospital deaths. RESULTS A higher percentage of pre-hospital deaths were observed following rural as compared to urban traffic accidents. The deaths due to rural accidents can be attributed to lower use of restraints (i.e., helmets or seat belts), lower percentage of motorcyclists, and more highway accidents. A higher percentage of victims in rural accidents were transported to distant medical centers rather than to local hospitals. CONCLUSION Specific interventions, such as intelligent emergency medical systems, campaigns for helmets and seat belt usage, enforcement of helmets and seat belt use, and speed control measures should be targeted to rural areas. IMPACT ON INDUSTRY Cooperation between the vehicle industry and emergency medical providers in rural traffic accident rescue teams may decrease the numbers of deaths in these regions.
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Affiliation(s)
- Ming-Der Li
- Department of Mechanical Engineering, National Central University, Taoyuan, Taiwan
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Cost-Drivers in Acute Treatment of Severe Trauma in Europe: A Systematic Review of Literature. Eur J Trauma Emerg Surg 2008; 35:61-6. [PMID: 26814534 DOI: 10.1007/s00068-008-8013-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 04/02/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Throughout the world, trauma is a leading cause of morbidity and mortality in the young and most active group of society. While specialist trauma centers play a critical role in the survival after severe trauma, the assessment of trauma-related costs, budgeting for adequate trauma capacity, and determining the cost-effectiveness of interventions in critical care are fraught with difficulties. Through a systematic review of the European literature on severe trauma, we aimed to identify the key elements that drive the costs of acute trauma care. METHODS A PubMed/MEDLINE search for articles relating the costs and economics of trauma was performed for the period January 1995 to July 2007. One hundred and seventy-three European publications were identified. Twelve publications were retrieved for complete review that provided original cost data, a breakdown of costs according to the different elements of trauma care, and focused on severe adult polytrauma. The identified publications presented studies from the UK (3), Germany (6), Italy (2), and Switzerland (1). RESULTS In all publications reviewed, length of stay in the intensive care unit (ICU; 60%) and requirements for surgical interventions (≤ 25%) were the key drivers of hospital costs. The cost of transfusion during the initial rescue therapy can also be substantial, and in fact represented a significant portion of the overall cost of emergency and ICU care. Multiple injuries often require multiple surgical interventions, and prolonged ICU and hospital stay, and across all studies a clear relationship was observed between the severity of polytrauma injuries observed and overall treatment costs. While significant differences existed in the absolute costs of trauma care across countries, the key drivers of costs were remarkably similar. CONCLUSIONS Irrespective of the idiosyncrasies of the national healthcare systems in Europe, severity of injury, length of stay in ICU, surgical interventions and transfusion requirements represent the key drivers of acute trauma care for severe injury.
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Critical Bleeding in Blunt Trauma Patients. Intensive Care Med 2007. [DOI: 10.1007/0-387-35096-9_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Giannoudis PV, Tosounidis TI, Kanakaris NK, Kontakis G. Quantification and characterisation of endothelial injury after trauma. Injury 2007; 38:1373-81. [PMID: 18054021 DOI: 10.1016/j.injury.2007.09.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Accepted: 09/19/2007] [Indexed: 02/02/2023]
Abstract
The microenvironment theory has become very popular for providing mechanisms which explain the development of often lethal posttraumatic complications such as systemic inflammatory response syndrome (SIRS), adult respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). With the recent advances in molecular biology and the ever-expanding understanding of trauma pathophysiology, immunomonitoring in trauma patients attempts to characterise and quantify novel molecules in order to predict patients at risk. This review article assesses the existing evidence on the biomarkers of endothelial injury and their potential utility as quantification parameters of endothelial dysfunction in trauma patients.
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Affiliation(s)
- Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, Leeds Teaching Hospitals, University of Leeds, UK.
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Abstract
Despite decades of studies and experiences, an evidence-based medicine consensus on the more appropriate treatment of trauma patients in the out-of-hospital setting has not yet been achieved. Different approaches exist and no one has been demonstrated clearly superior over the others for all circumstances and for all patients. A number of factors likely account for this finding.
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Affiliation(s)
- Giorgio Berlot
- Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara University Hospital, Trieste Medical School, Strada di Fiume 447, 34100 Trieste, Italy
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Rudra A, Chatterjee S, Sengupta S, Sirohia S, Wankhade R, Das T. Fluid resuscitation in trauma. Indian J Crit Care Med 2006. [DOI: 10.4103/0972-5229.29843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chiara O, Cimbanassi S, Pitidis A, Vesconi S. Preventable trauma deaths: from panel review to population based-studies. World J Emerg Surg 2006; 1:12. [PMID: 16759417 PMCID: PMC1475565 DOI: 10.1186/1749-7922-1-12] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2006] [Accepted: 04/11/2006] [Indexed: 12/02/2022] Open
Abstract
Preventable trauma deaths are defined as deaths which could be avoided if optimal care has been delivered. Studies on preventable trauma deaths have been accomplished initially with panel reviews of pre-hospital and hospital charts. However, several investigators questioned the reliability and validity of this method because of low reproducibility of implicit judgments when they are made by different experts. Nevertheless, number of studies were published all around the world and ultimately gained some credibility, particularly in regions where comparisons were made before and after trauma system implementation with a resultant fall in mortality. During the last decade of century the method of comparing observed survival with probability of survival calculated from large trauma registries has obtained popularity. Preventable trauma deaths were identified as deaths occurred notwithstanding a high calculated probability of survival. In recent years, preventable trauma deaths studies have been replaced by population-based studies, which use databases representative of overall population, therefore with high epidemiologic value. These databases contain readily available information which carry out the advantage of objectivity and large numbers. Nowadays, population-based researches provide the strongest evidence regarding the effectiveness of trauma systems and trauma centers on patient outcomes.
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Affiliation(s)
- Osvaldo Chiara
- Niguarda Ca'Granda Hospital, Trauma Team, Post-Graduate School of General Surgery, University of Milano, Italy
| | - Stefania Cimbanassi
- Niguarda Ca'Granda Hospital, Trauma Team, Post-Graduate School of General Surgery, University of Milano, Italy
| | - Alessio Pitidis
- National Institute of Health of the Ministry of Health, Rome, Italy
| | - Sergio Vesconi
- Niguarda Ca'Granda Hospital Division of Anesthesiology and Intensive Care, Post-Graduate School of Anesthesiology and Intensive Care, University of Milano, Italy
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Kompanje EJO, Bakker J, Slieker FJA, IJzermans JNM, Maas AIR. Organ donations and unused potential donations in traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage. Intensive Care Med 2006; 32:217-222. [PMID: 16432680 DOI: 10.1007/s00134-005-0001-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2004] [Accepted: 11/03/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To obtain insight into the occurrence of brain death and the potential for brain dead and controlled non-heart-beating organ donors (CNHB) in patients with traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) in a large neurosurgical serving area (2.1 million inhabitants). DESIGN Retrospective analysis of data concerning patients with TBI, SAH and ICH who died during the course of ICU treatment during 1999-2003. SETTING A 16-bed neuro-intensive care unit. PATIENTS Patients with TBI, SAH or ICH who died during the course of ICU treatment. MEASUREMENTS AND RESULTS The number of ICU deaths in patients with TBI, SAH and ICH declined from 111 in 1999 to 64 in 2003. In total, 476 deaths occurred. Of these, 177 patients were not included in the analysis. Two hundred ninety-nine (299) ventilated patients had two or more absent brainstem reflexes (ABSR) and a Glasgow Coma Score of 3-4 at the moment of treatment withdrawal and formed the potential for organ donation; 61 of these patients were treated until full brain death. Organs of 57 patients could be harvested. We analysed the reasons that organs were not procured in the 242 remaining patients. The most important reasons were family refusal (32%), medical contraindications (14%), and the treating physician not considering potential organ donation (20%). The missed potential is 162/299 (54%). CONCLUSIONS The number of actual and potential organ donors is declining, but a considerable number of potential CNHB donors exists. Refusal by relatives is the most important reason for failure to procure organs.
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Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Jan Bakker
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - François J A Slieker
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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