Trauma: today's problems, tomorrow's answers

Equipos de trauma: realidad mundial e implementación en un país en desarrollo. Descripción narrativa

Introducción. El trauma es una de las entidades con mayor morbimortalidad en el mundo. Los equipos especializados en la atención del paciente traumatizado son llamados <<equipos de trauma>>. Dichos equipos surgieron de la necesidad de brindar tratamiento oportuno multidisciplinario a individuos con heridas que condicionan gran severidad en la guerra; sin embargo, con el paso del tiempo se trasladaron al ámbito civil, generando un impacto positivo en términos de tiempos de atención, mortalidad y morbilidad. El objetivo de este estudio fue describir el proceso de desarrollo de los equipos de trauma a nivel mundial y la experiencia en nuestra institución en el suroccidente colombiano. Métodos. Se realizó una búsqueda en la base de datos PUBMED, que incluyó revisiones sistemáticas, metaanálisis, revisiones de Cochrane, ensayos clínicos y series de casos. Resultados. Se incluyeron 41 estudios para esta revisión narrativa, y se observó que el tiempo de permanencia en el Emergencias, el tiempo de traslado a cirugía, la mortalidad y las complicaciones asociadas al trauma fueron menores cuando se implementan equipos de trauma. Discusión. El diseño de un sistema de atención y valoración horizontal de un paciente con traumatismos severos produce un impacto positivo en términos de tiempos de atención, mortalidad y morbilidad. Se hace necesario establecer los parámetros operativos necesarios en las instituciones de salud de alta y mediana complejidad en nuestro país para implementar dichos equipos de trabajo.

The Effect of Availability of Manpower on Trauma Resuscitation Times in a Tertiary Academic Hospital

BACKGROUND

For trauma patients, delays to assessment, resuscitation, and definitive care affect outcomes. We studied the effects of resuscitation area occupancy and trauma team size on trauma team resuscitation speed in an observational study at a tertiary academic institution in Singapore.

METHODS

From January 2014 to January 2015, resuscitation videos of trauma team activated patients with an Injury Severity Score of 9 or more were extracted for review within 14 days by independent reviewers. Exclusion criteria were patients dead on arrival, inter-hospital transfers, and up-triaged patients. Data captured included manpower availability (trauma team size and resuscitation area occupancy), assessment (airway, breathing, circulation, logroll), interventions (vascular access, imaging), and process-of-care time intervals (time to assessment/intervention/adjuncts, time to imaging, and total time in the emergency department). Clinical data were obtained by chart review and from the trauma registry.

RESULTS

Videos of 70 patients were reviewed over a 13-month period. The median time spent in the emergency department was 154.9 minutes (IQR 130.7-207.5) and the median resuscitation team size was 7, with larger team sizes correlating with faster process-of-care time intervals: time to airway assessment (p = 0.08) and time to disposition (p = 0.04). The mean resuscitation area occupancy rate (RAOR) was 1.89±2.49, and the RAOR was positively correlated with time spent in the emergency department (p = 0.009).

CONCLUSION

Our results suggest that adequate staffing for trauma teams and resuscitation room occupancy are correlated with faster trauma resuscitation and reduced time spent in the emergency department.

What is optimal timing for trauma team alerts? A retrospective observational study of alert timing effects on the initial management of trauma patients

Background

Trauma teams improve the initial management of trauma patients. Optimal timing of trauma alerts could improve team preparedness and performance while also limiting adverse ripple effects throughout the hospital. The purpose of this study was to evaluate how timing of trauma team activation and notification affects initial in-hospital management of trauma patients.

Methods

Data from a single hospital trauma care quality registry were matched with data from a trauma team alert log. The time from patient arrival to chest X-ray, and the emergency department length of stay were compared with the timing of trauma team activations and whether or not trauma team members received a preactivation notification.

Results

In 2009, the trauma team was activated 352 times; 269 times met the inclusion criteria. There were statistically significant differences in time to chest X-ray for differently timed trauma team activations (P = 0.003). Median time to chest X-ray for teams activated 15–20 minutes prearrival was 5 minutes, and 8 minutes for teams activated <5 minutes before patient arrival. Timing had no effect on length of stay in the emergency department (P = 0.694). We found no effect of preactivation notification on time to chest X-ray (P = 0.474) or length of stay (P = 0.684).

Conclusion

Proactive trauma team activation improved the initial management of trauma patients. Trauma teams should be activated prior to patient arrival.

Dobutamine stress echocardiography assessment of myocardial contusion due to blunt impact in dogs

We sought to investigate the role of two-dimensional stress echocardiography in the early assessment of myocardial contusion. For this purpose, 12 dogs, weighing 11.36 ± 1.50 kg, were selected and the myocardial contusion was experimentally induced. Two-dimensional dobutamine stress echocardiography (DSE) was used to detect abnormal myocardial motions segments at time phases of baseline and 0.5, 2, 4, and 8 h post-wounding. Finally, the above results were compared with pathological findings. The data show that after the dogs were induced to have severe myocardial contusion, 122 segments were found with abnormal myocardial wall motions at 0.5 h post-wounding, 133 segments at 2 h post-wounding, and 142 segments, each, at 4 h and 8 h post-wounding. The wall motion score (WMS) and wall motion score index (WMSI) increased (P < 0.001) as compared with the pre-impaction values. Considering the left ventricular axis view as the standard section, in the 60 segments examined by echocardiography, 54 segments were found to have wall motion abnormalities. Comparing with the results of pathological TTC staining, the sensitivity and specificity were found to be 100 and 66.6%, respectively. It was, therefore, concluded that two-dimensional DSE was a valuable technique in the early diagnosis of myocardial contusion due to its better sensitivity and specificity.

Predicting outcome after multiple trauma: which scoring system?

We have undertaken a review of the commonly used scoring systems to identify advantages and possible pitfalls involved in their use. Currently, there is a variety of systems available for scoring trauma severity. Some of them are based on the anatomical description of the injuries, whilst others are based on physiological parameters. The most widely used systems for the purpose of predicting outcome after trauma are based on combined anatomical and physiological parameters. Systems such as the Injury Severity Score (ISS) and the Trauma Injury Severity Score (TRISS) have served some useful purposes and have proved popular over time, but it now seems that there is no ideal scoring system available. The task of incorporating various factors such as pre-existing morbidity, age, immunological differences and different genetic predispositions has made the prospect of creating a universally acceptable and applicable trauma-scoring system extremely arduous, if not impossible. Therefore caution should be exercised when using any of the existing scoring systems until an ideal one becomes available.

Trauma teams

Although the value of a team approach in the resuscitation of the trauma patient has been recognized for more than 30 years, the integration of teams into United Kingdom (UK) hospitals has been slow. The multidisciplinary trauma team needs to be horizontally organized and the members require precise role allocation and practice so that they work together efficiently. To ensure that the trauma team is activated appropriately, criteria need to be defined. The role of the team leader is paramount in effective team-based resuscitation.

Reflections on technology: increasing the science but diminishing the art of nursing?

Technology has had a huge impact on the delivery of health care over the last 10-20 years and although this has been, in general, in the Intensive Care (ICU) environment, the Accident and Emergency (A & E) department has not been immune from technical developments and innovations, a trend that looks destined to continue. The impact of technological developments has given rise to much nursing literature relating to the effects technology has had in 'dehumanizing' the patients in their care, as critical care nurses in all fields endeavour to balance the need for technical competence with the traditional and still important traditional arts of nursing. This paper explores some of the definitions and terminology surrounding technology, nursing, art and science in an attempt to illustrate that technical proficiency, scientific knowledge and nursing artistry can be combined by skilled nurses to achieve a balance of care which preserves the humanity and dignity of patients and their relatives in a critical care environment.

The trauma team--a system of initial trauma care

Trauma remains the leading cause of death under the age of 35 years. England and Wales lost 252,000 working years from accidental deaths, including poison, in 1992. In this country, preventable deaths from trauma are inappropriately high. In many hospitals there are not enough personnel; in the majority, there are no recognisable trauma care systems, which can reduce preventable deaths to a minimum. The appropriateness of trauma centres for this country is being assessed in Stoke-on-Trent, and a report is due out later this year. Even if the recommendation is made to establish such centres, it is unlikely that many will be set up. Consequently most hospitals will have to rely on their own resources to set up and run a trauma team. This type of trauma care system is the subject of this article.

Trauma care in China: challenge and development

The People's Republic of China has significantly improved the general health of its people by a concerted effort in primary health care but trauma care and its prevention remains a problem. This paper provides an overview of the strengths and weaknesses of the trauma-care system in China and proposes a strategy for its future development. This includes public-health legislation, the integration of military and civilian practice to provide comprehensive care from the scene of the incident through to rehabilitation, medical audit, the introduction of postgraduate trauma-management training courses and international academic exchanges.

Selected topics in chest trauma

Trauma is the leading cause of death of young adults in the United States, and chest trauma is one of the leading causes of trauma-related fatalities. This article presents an approach to the radiological evaluation and diagnosis of pneumothorax, pneumomediastinum, traumatic aortic rupture, and thoracic spine injuries. Also discussed is the radiological assessment of vascular catheters, endotracheal tubes, and thoracostomy tubes.

A trauma centre in the UK: the Stoke experience

This paper outlines the development of a pilot trauma centre in Stoke on Trent, UK, as part of the Department of Health Trauma Centre Evaluation Project. A historical background to the Evaluation Project is included along with details of the evolution of trauma services in North Staffordshire, UK. The authors draw upon their personal experiences of working in the pilot centre and provide an insight into how the Emergency Department, in particular, met the challenge.

A prospective study of the performance of the trauma team leader

This study assessed the performance of the trauma team leader in 50 consecutive trauma resuscitations at Liverpool Hospital over a two-month period. The trauma team consists of intensive care (ICU), emergency, and surgical registrars, three nurses, a wardsman, a radiographer, and a social worker. The team leader position alternates between the ICU and emergency registrar on a fortnightly roster. A panel of specialists experienced in trauma management evaluated 38 aspects of the initial resuscitation. Individual variables received different weightings. The maximum possible score for team leader performance was 80. The mean team leader score was 70.4 +/- 8 (SD). The main deficiencies in the team leader's performances were in their interpersonal communications and in the adequacy of documentation of the history of the injury. In 20% of resuscitations there were failures to completely expose the patient. Medical skills were uniformly well performed. Poor communication with other team members were the main pitfall of the team leader in this study. The team leader score may prove a useful tool in improving the quality of the trauma team.

Trauma teams vs non-trauma teams

This paper gives an overview of research which analysed the nurse's role in the UK trauma team. A prospective study was carried out of 100 trauma patients in 6 UK Accident and Emergency (A & E) departments. The patients were observed throughout their time in the department and the time taken to assess and resuscitate them was monitored along with the structure and organisation of the team. The results revealed that in departments where no trauma teams were present 25% of the patients did not have a secure airway during their stay in the A & E department, and 18% of patients did not have any intravenous access. In comparison, departments with teams secured the airway and obtained intravenous access in 100% of the cases observed. The results highlighted that a structured organised team, with predetermined roles and responsibilities for both nursing and medical staff, has a direct bearing on patient outcome.

Helicopter transfer of trauma patients: the Isle of Man experience

A 10-year study of the helicopter transfer of motorcyclists injured during the International Motorcycle Tourist Trophy races (TT) and the amateur Manx Grand Prix (MGP) is reported. A total of 266 riders was transferred from the scene of the accident to hospital by air. The overall mortality rate for those riders airlifted was 3.38 per cent. The figures are compared with similar emergency helicopter services.