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Beucler N, Sellier A, Joubert C, Lesquen HD, Schlienger G, Caubere A, Holay Q, Desse N, Esnault P, Dagain A. Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept. J Neurosci Rural Pract 2022; 13:585-607. [PMID: 36743747 PMCID: PMC9893946 DOI: 10.25259/jnrp-2022-1-38-r1-(2348)] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods A scoping review was conducted on Medline database from inception to September 2021. Results The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.
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Affiliation(s)
- Nathan Beucler
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
| | - Aurore Sellier
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Christophe Joubert
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Henri De Lesquen
- Department of Thoracic and Vascular Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Ghislain Schlienger
- Department of Visceral Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Alexandre Caubere
- Department of Orthopaedic Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Quentin Holay
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
- Department of Diagnostic and Interventional Radiology, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Nicolas Desse
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Pierre Esnault
- Department of Intensive care unit, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Arnaud Dagain
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
- Department of Val-de-Grâce Military Academy, Paris, France
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Beucler N, Sellier A, Joubert C, Bernard C, Desse N, Esnault P, Dagain A. Severe Trauma Patients Requiring Undelayable Combined Cranial and Extra-Cranial Surgery: A Proof-of-Concept Monocentric Study. Mil Med 2022; 187:1127-1135. [PMID: 35038725 DOI: 10.1093/milmed/usab555] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/06/2021] [Accepted: 12/23/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. MATERIALS AND METHODS We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. RESULTS The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). CONCLUSION Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, Ile-de-France 75230, France
| | - Aurore Sellier
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Christophe Joubert
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Cédric Bernard
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Nicolas Desse
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Pierre Esnault
- Intensive Care Unit, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
- Val-de-Grâce Military Academy, Paris, Ile-de-France 75230, France
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Alageel M. The CT scan is for the unstable medical patient. CAN J EMERG MED 2022; 24:95-96. [PMID: 34611782 DOI: 10.1007/s43678-021-00207-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 09/17/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Mohammed Alageel
- King Khalid University Hospital, Emergency medicine, Riyadh, Saudi Arabia.
- UBC Department of Emergency Medicine, Vancouver, BC, Canada.
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Thippeswamy PB, Rajasekaran RB. Imaging in polytrauma - Principles and current concepts. J Clin Orthop Trauma 2020; 16:106-113. [PMID: 33717944 PMCID: PMC7920130 DOI: 10.1016/j.jcot.2020.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/22/2022] Open
Abstract
Imaging forms a crucial component in reducing mortality of polytraumatized patients by aiding appropriate diagnosis and guiding the emergency and definitive treatment. With the exponential expansion in the radiological armamentarium and introduction of protocols like Extended focused assessment with sonography for trauma (EFAST) and Whole body Computed tomography (WBCT), the role of imaging has considerably increased. Emergency imaging protocols should be done for rapid diagnosis of life-threatening injuries allowing simultaneous evaluation and resuscitation. Subsequent comprehensive imaging is essential to diagnose the often clinically missed injuries to reduce the overall morbidity. Imaging protocols must adapt to the patient's clinical scenario, which can be dynamically changing. Each trauma team should devise clear guidelines, protocols, and algorithms suitable for their center depending on the local availability of types of equipment and expertise. Radiologists must efficiently communicate and adopt patient-centered approach to ensure early appropriate care to these severely injured patients. Future research should involve multicentre studies to formulate the most appropriate imaging protocol in polytrauma to increase diagnostic accuracy and thereby reduce patient mortality.
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Affiliation(s)
- Pushpa Bhari Thippeswamy
- Department of Radiology, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India,Corresponding author. Department of Radiology, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, 641043, India.
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Luft A, Pasquier P, Soucanye de Landevoisin E, Morel-Stum N, Baillon A, Louis S, Menini W, Sagalle Y, Gintte J, Bouquet A, Avaro JP. The Damage Control Resuscitation and Surgical Team: The New French Paradigm for Management of Combat Casualties. Mil Med 2020; 187:e275-e281. [PMID: 33242064 DOI: 10.1093/milmed/usaa322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/15/2020] [Accepted: 08/20/2020] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The aim of this work was to introduce the new French forward resuscitation and surgical unit. It's also to discuss the choices and waivers granted to fit the tactical context of modern conflicts and the current epidemiology of combat casualties. MATERIALS AND METHODS A multidisciplinary task force of 11 people proceeded to the conception and the creation of a new military resuscitation and surgical unit. The preliminary work included a scoping review of the combat casualties' epidemiology in modern conflicts and an analysis of the recent French medical-surgical treatment facilities lessons learned. In April 2019, a technical-operational evaluation was conducted to confirm all the technical, ergonomic, and organizational choices made during the design phase. RESULTS The multidisciplinary task force resulted in the creation of the Damage Control Resuscitation and Surgical Team (DCRST). The DCRST focused on the resuscitation strategy, including transfusion of blood products, and the life-saving surgical procedures to be performed as close as possible to the point of injury. It was designed for the resuscitation of two patients: the life-saving surgery of two patients and the very short-term intensive care (<12 hours) of four patients at the same time. The DCRST provided sufficient autonomy to provide take care of four T1 and four T2 or T3 casualties per day for 48 hours. It was armed with 23 soldiers. The technical equipment represented 5,300 kg and 27 m3. All the technical medical equipment could be stored in two 20-foot containers. CONCLUSION The DCRST represents a new paradigm in medical support of French military operations. It offers the advantage of two combat casualties' surgical management at the same time, as close as possible to the combat zone. It responds to a 2-fold epidemiological and logistical challenge.
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Affiliation(s)
- Antoine Luft
- French Military Medical Service - Surgeon General Office, 75509 Paris Cedex 15, France.,French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | - Pierre Pasquier
- French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | | | - Nelly Morel-Stum
- French Military Medical Service- Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - Arthur Baillon
- French Military Medical Service - Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - Serge Louis
- French Military Medical Service - Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - William Menini
- French Military Medical Service - Sainte Anne military training hospital, 83000 Toulon, France
| | - Yannick Sagalle
- French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | - Julie Gintte
- French Military Medical Service - 12th Military Medical Center, 33068 Bordeaux CEDEX, France
| | - Antoine Bouquet
- French Military Medical Service - Surgeon General Office, 60 boulevard du Général Valin CS 21623, 75509 Paris Cedex 15, France
| | - Jean-Philippe Avaro
- French Military Medical Service - Sainte Anne Military Training Hospital, 83000 Toulon, France
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Abstract
Embedding physiological markers into treatment algorithms has helped trauma teams rationalise interventions safely and signifies a departure from the dichotomy of damage control orthopaedics (DCO) and early total care (ETC) to early appropriate care (EAC). This has been shown to reduce length of stay and cost to treating centres. This article seeks to provide a clear summary of current concepts for managing orthopaedic injuries in the multiply injured patient.
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Progress on combat damage control resuscitation/surgery and its application in the Chinese People's Liberation Army. J Trauma Acute Care Surg 2020; 87:954-960. [PMID: 31574061 DOI: 10.1097/ta.0000000000002344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Damage control resuscitation (DCR) and damage control surgery (DCS) has now been developed as a well-established standard of care for severely injured civilian patients worldwide. On the other hand, the application of combat DCR/DCS has saved the lives of thousands of severely injured casualties in several wars during the last two decades. This article describes the great progress on DCR/DCS in the last two decades and its application in the Chinese People's Liberation Army (PLA). The main development of the advanced theories of combat DCR/DCS including the global integration of DCR/DCS, application of remote battlefield DCR, balanced hemostatic resuscitation in combat hospitals and enhancement of en route DCR. There are two key factors that determine the feasibility of combat DCR: one is the availability of resources and supplies to implement the advanced theories of combat DCR/DCS, the other is the availability of qualified personnel who master the skills needed for the implementation of DCR/DCS. In the PLA, the advanced theories of combat DCR/DCS have now been widely accepted, and some of related advanced products, such as fresh-frozen plasma, packed red blood cells, and platelets, have been available in Level III medical facilities. In conclusion, great progress in combat DCR/DCS has been achieved in recent years, and the Chinese PLA is keeping good pace with this development, although there is still room for improvement.
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O'Neill SB, Hamid S, Nicolaou S, Qamar SR. Changes in Approach to Solid Organ Injury: What the Radiologist Needs to Know. Can Assoc Radiol J 2020; 71:352-361. [PMID: 32166970 DOI: 10.1177/0846537120908069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review aims to examine the challenges facing radiologists interpreting trauma computed tomography (CT) images in this era of a changing approach to management of solid organ trauma. After reviewing the pearls and pitfalls of CT imaging protocols for detection of traumatic solid organ injuries, we describe the key changes in the 2018 American Association for the Surgery of Trauma Organ Injury Scales for liver, spleen, and kidney and their implications for management strategies. We then focus on the important imaging findings in observed in patients who undergo nonoperative management and patients who are imaged post damage control surgery.
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Affiliation(s)
- Siobhán B O'Neill
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Saira Hamid
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Savvas Nicolaou
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Sadia R Qamar
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
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[The TraumaRegister DGU® dataset, its development over 25 years and advances in the care of severely injured patients]. Unfallchirurg 2019; 121:794-801. [PMID: 30225633 DOI: 10.1007/s00113-018-0555-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Since the publication in 1993, the dataset and documentation form of the TraumaRegister DGU® (TR-DGU) have continuously evolved. On the occasion of the 25th anniversary the authors have analyzed this evolution in order to reflect it in the light of medical progress in the treatment of the severely injured. MATERIAL AND METHODS Enrolled in the study were 5 reference data entry sheets from the years 1993, 1996, 2002, 2009 and 2016. Every piece of information (item) queried therein was entered into the study database, was categorized by topic and counted for further analysis. RESULTS The arrangement of the 4‑page data entry form has remained practically unchanged since 1993 and includes an average of 212 items. A total of 491 items were identified of which 64 were present throughout every dataset. Based on the average extent of the form this equals a proportion of approximately 30%. The dataset actually shows much more consistency than this number suggests because many changes can be traced back to a smarter design of the data entry form. Most items fell into the categories "results/diagnosis" (143 items/29.1%), "coagulation" (104/21.2%) and "surgical approach" (40/8.1%). Many items serve as raw data for the calculation of prognostic risk scores, such as the trauma and injury severity score (TRISS), the revised injury severity classification II (RISC II) and the trauma associated severe hemorrhage (TASH) score. Currently, nine scores can be calculated from the dataset. CONCLUSION The members of the working group TraumaRegister all actively participate in the treatment of severely injured patients. For 25 years this group has managed to unify the latest medical developments and well-established parameters within the TR-DGU dataset at a relatively constant degree of effort for documentation. Practice in place of theory is the driving force behind this development that serves quality assurance and research in the treatment of severely injured patients.
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González Posada MA, Biarnés Suñe A, Naya Sieiro JM, Salvadores de Arzuaga CI, Colomina Soler MJ. Damage Control Resuscitation in polytrauma patient. ACTA ACUST UNITED AC 2019; 66:394-404. [PMID: 31031044 DOI: 10.1016/j.redar.2019.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/13/2019] [Accepted: 03/18/2019] [Indexed: 11/30/2022]
Abstract
Haemorrhagic shock is one of the main causes of mortality in severe polytrauma patients. To increase the survival rates, a combined strategy of treatment known as Damage Control has been developed. The aims of this article are to analyse the actual concept of Damage Control Resuscitation and its three treatment levels, describe the best transfusion strategy, and approach the acute coagulopathy of the traumatic patient as an entity. The potential changes of this therapeutic strategy over the coming years are also described.
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Affiliation(s)
- M A González Posada
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España.
| | - A Biarnés Suñe
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España
| | - J M Naya Sieiro
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | | | - M J Colomina Soler
- Servicio de Anestesiología y Reanimación, Hospital Universitario de Bellvitge, l'Hospitalet de Llobregat, Barcelona, España; Universidad Barcelona, Barcelona, España
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Hugenschmitt D, Cesareo É, Claret PG, Lefort H. [Not Available]. SOINS; LA REVUE DE REFERENCE INFIRMIERE 2018; 63:59-61. [PMID: 30366707 DOI: 10.1016/j.soin.2018.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Delphine Hugenschmitt
- Samu-Smur 69, CHU Édouard-Herriot, Hospices Civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - Éric Cesareo
- Pôle anesthésie-réanimation douleur urgences, CHU de Nîmes, F-30000 Nîmes, France
| | - Pierre-Géraud Claret
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57000 Metz, France
| | - Hugues Lefort
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57000 Metz, France.
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Otsuka H, Sato T, Sakurai K, Aoki H, Yamagiwa T, Iizuka S, Inokuchi S. Use of interventional radiology as initial hemorrhage control to improve outcomes for potentially lethal multiple blunt injuries. Injury 2018; 49:226-229. [PMID: 29221814 DOI: 10.1016/j.injury.2017.11.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recently, trauma management has been markedly improved with interventional radiology (IVR) and damage-control strategies. However, the indications for its use in hemodynamically unstable patients with severe trauma remains unclear. In some cases, IVR may be more effective than surgery for damage-control hemostasis; however, performing IVR in life-threatening trauma settings is challenging. To address this, we practiced and evaluated a trauma-management system with emergency physicians who trained for both severe trauma management, and techniques of surgery and IVR. MATERIALS AND METHODS Among the 1822 patients with severe trauma admitted between October 2014 and December 2016, 201 underwent emergency surgery or IVR. Among these, 16 patients whose systolic blood pressure was ≤90 mmHg, without improvement following primary resuscitation, and whose first intervention was IVR, were analyzed. We retrospectively evaluated the admission characteristics, IVR-related characteristics, and prognoses, and compared several parameters before and after IVR. RESULTS This study included 10 men and 6 women (median age: 46 years). IVR was performed for 10 pelvic fractures; five liver-, one splenic-, and one renal injury; and one transection each of the external carotid-, vertebral-, axillosubclavian-, intercostal-, and lumbar arteries. The mean times from the patient arrival, and diagnosis to the start of IVR were 56.3 ± 26.6 and 15.1 ± 3.8 min, respectively. The mean time spent in the angiography suite was 50 min. The systolic blood pressure, pulse rate, base excess/deficit, serum-lactate levels, and D-dimer values were significantly improved after IVR. Although two patients needed additional treatment for morbidities following IVR intervention, all achieved complete recovery. The mortality rate was 25.0%, and no preventable deaths were noted. Eight patients showed unexpected survival. CONCLUSIONS In some cases, IVR may be the best first measure for resuscitative hemostasis in potentially lethal multiple injuries, given efficient diagnoses/actions and the ability to deal with complications.
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Affiliation(s)
- Hiroyuki Otsuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Toshiki Sato
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Keiji Sakurai
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Hiromichi Aoki
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Takeshi Yamagiwa
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Shinichi Iizuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Sadaki Inokuchi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
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Inter-rater reliability in the radiological classification of renal injuries. World J Urol 2018; 36:489-496. [DOI: 10.1007/s00345-017-2166-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 12/26/2017] [Indexed: 11/25/2022] Open
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Otsuka H, Sato T, Sakurai K, Aoki H, Yamagiwa T, Iizuka S, Inokuchi S. Importance of the capability for complete resuscitative treatment combining surgery and interventional radiology for potentially lethal multiple injuries: A case report. Trauma Case Rep 2017; 11:13-17. [PMID: 29644270 PMCID: PMC5887058 DOI: 10.1016/j.tcr.2017.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2017] [Indexed: 10/31/2022] Open
Abstract
Background Recently, trauma management has been complicated owing to the introduction of damage-control strategies and interventional radiology. Here, we discuss important aspects regarding survival of patients with severe trauma. Case presentation A 74-year-old Japanese woman experienced a traffic accident on a highway. On arrival, paramedics were unable to measure her blood pressure, and her condition deteriorated. The patient was immediately transferred to our hospital in a physician-staffed emergency helicopter, during which she was administered emergency blood transfusions. On admission, her systolic blood pressure was 44 mmHg, and focused assessment with sonography for trauma yielded positive findings at the anterior mediastinum, right thoracic cavity, and intra-abdominal cavity. Plain radiography revealed a partial unstable-type pelvic fracture. Immediately, cardiac tamponade caused by the massive anterior mediastinal hematoma with internal thoracic vessel injuries was diagnosed through a median sternotomy, while a diaphragmatic rupture and hemorrhage from the intra-abdominal cavity were diagnosed through right anterior-lateral thoracotomy. Furthermore, massive bowel and mesenteric vessel injuries were diagnosed through laparotomy; all of these injuries were treated sequentially as a simplified process. The patient then underwent transcatheter arterial embolization for the retroperitoneal hematoma and the pelvic fracture. Reestablishing intestinal continuity was performed after intensive care. All procedures were seamlessly performed by trained emergency physicians, and the postoperative course was uneventful, with the patient recovering completely after rehabilitation. Conclusions The capability to perform complete resuscitative treatments that seamlessly combine surgery and interventional radiology in the appropriate order is important for the survival of patients with multiple traumatic injuries.
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Affiliation(s)
- Hiroyuki Otsuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Japan
| | - Toshiki Sato
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Japan
| | - Keiji Sakurai
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Japan
| | - Hiromichi Aoki
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Japan
| | - Takeshi Yamagiwa
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Japan
| | - Shinichi Iizuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Japan
| | - Sadaki Inokuchi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Japan
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Malgras B, Prunet B, Lesaffre X, Boddaert G, Travers S, Cungi PJ, Hornez E, Barbier O, Lefort H, Beaume S, Bignand M, Cotte J, Esnault P, Daban JL, Bordes J, Meaudre E, Tourtier JP, Gaujoux S, Bonnet S. Damage control: Concept and implementation. J Visc Surg 2017; 154 Suppl 1:S19-S29. [PMID: 29055663 DOI: 10.1016/j.jviscsurg.2017.08.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.
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Affiliation(s)
- B Malgras
- Service de chirurgie viscérale, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75230 Paris cedex 05, France
| | - B Prunet
- Fédération anesthésie-réanimation-brûlés, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France
| | - X Lesaffre
- Brigade des sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France
| | - G Boddaert
- Service de chirurgie thoracique et vasculaire, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France
| | - S Travers
- Brigade des sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France
| | - P-J Cungi
- Fédération anesthésie-réanimation-brûlés, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France
| | - E Hornez
- Service de chirurgie viscérale et générale, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France
| | - O Barbier
- Service de chirurgie orthopédique et traumatologique, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - H Lefort
- Brigade des sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France
| | - S Beaume
- Fédération anesthésie-réanimation-brûlés, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France
| | - M Bignand
- Brigade des sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France
| | - J Cotte
- Fédération anesthésie-réanimation-brûlés, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France
| | - P Esnault
- Fédération anesthésie-réanimation-brûlés, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France
| | - J-L Daban
- Service d'anesthésie-réanimation, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France
| | - J Bordes
- Fédération anesthésie-réanimation-brûlés, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France
| | - E Meaudre
- Fédération anesthésie-réanimation-brûlés, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75230 Paris cedex 05, France
| | - J-P Tourtier
- Brigade des sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75230 Paris cedex 05, France
| | - S Gaujoux
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - S Bonnet
- Service de chirurgie viscérale et générale, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75230 Paris cedex 05, France.
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Mercer SJ. Using full immersive simulation to prepare trauma teams to work in a major trauma centre. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408616680384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A reconfiguration of trauma services in the UK has led to the development of trauma networks with major trauma centres. This article describes the use of fully immersive simulation to train whole trauma teams in both a traditional simulation centre setting and ‘in situ’ in the clinical environment. Carefully designed scenarios that are driven by experienced faculty allow modern trauma management concepts, such as damage control resuscitation and massive transfusion to be explored within a hospital’s own organisational structure. Human factors specific to the trauma team can also be explored as part of a video-assisted debrief.
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Affiliation(s)
- Simon J Mercer
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Wulffeld S, Rasmussen LS, Højlund Bech B, Steinmetz J. The effect of CT scanners in the trauma room - an observational study. Acta Anaesthesiol Scand 2017. [PMID: 28635146 DOI: 10.1111/aas.12927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A CT scanner incorporated in the trauma resuscitation bay may benefit trauma patients by fastening work-up times; however, evidence in the area is still sparse. We assessed if time from admission to first CT scan was lower after incorporation of a CT scanner in the resuscitation bay. METHODS We included trauma patients admitted in two 1-year periods, before and after a major rebuilding of the trauma room. Beforehand, one CT scanner was located in an adjacent room. After the rebuilding, two mobile CT scanners were placed in the resuscitation bays, where a moving gantry was combined with a trauma resuscitation table. Subgroup analyses were performed on severely injured and patients with traumatic brain injury. RESULTS We included 784 patients before and 742 patients after the reconstruction. Case-mix differed between study periods as there was a higher proportion of severe injuries, traumatic brain injury and penetrating trauma in the after period. We found a minor increase in time to CT in the after period (20 vs. 21 min, P = 0.008). In a multivariate regression analysis adjusted for differences in case-mix and with time to CT as outcome, period was an insignificant explanatory variable [β (before vs. after): 0.96 min 95% CI: 0.9-1.02, P = 0.3]. In both subgroups, we found no significant difference in time to CT. CONCLUSION We found no reduction in time to CT scan, when comparing a period with mobile CT scanners incorporated in the resuscitation bay to an earlier period with a CT scanner next to the trauma room.
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Affiliation(s)
- S. Wulffeld
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - L. S. Rasmussen
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - B. Højlund Bech
- Department of Diagnostic Radiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - J. Steinmetz
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- Trauma Centre; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Grissom TE, Pierce B. Radiographic Imaging and Ultrasound in Early Trauma Management: Damage Control Radiology for the Anesthesiologist. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Initial Evaluation and Triage of the Injured Patient: Mechanisms of Injury and Triggers for Operating Room Versus Emergency Department Stabilization. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0148-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Anesthetic Considerations and Ventilation Strategies in Cardiothoracic Trauma. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0149-6] [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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Woodhams R. The role of interventional radiology in primary postpartum hemorrhage. HYPERTENSION RESEARCH IN PREGNANCY 2016. [DOI: 10.14390/jsshp.hrp2015-016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Reiko Woodhams
- Department of Diagnostic Radiology, Kitasato University School of Medicine
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Kataoka Y, Minehara H, Kashimi F, Hanajima T, Yamaya T, Nishimaki H, Asari Y. Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma. Injury 2016; 47:59-63. [PMID: 26508437 DOI: 10.1016/j.injury.2015.09.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 09/12/2015] [Accepted: 09/25/2015] [Indexed: 02/02/2023]
Abstract
OBJECT To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma. PATIENTS AND METHODS The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group). RESULTS Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n=12), thoracotomy (n=1), craniotomy (n=1), and haemostasis of the lower extremities (n=1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n=12), endovascular stent or stent-graft placement (n=2), and embolisation of a portal vein by laparotomy (n=2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72]min vs. 355 [SD 169]min; p=0.007). The mortality were 15 (95% CI 2-45) % in the intraoperative IVR group vs. 36 (95% CI 22-51) % in the control group. CONCLUSION Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.
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Affiliation(s)
- Yuichi Kataoka
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Hiroaki Minehara
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Fumie Kashimi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Tasuku Hanajima
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Tatsuhiro Yamaya
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Hiroshi Nishimaki
- Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Japan.
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
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Alted López E. Are the paradigms in trauma disease changing? Med Intensiva 2015; 39:382-9. [PMID: 26068224 DOI: 10.1016/j.medin.2015.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/23/2015] [Accepted: 03/29/2015] [Indexed: 11/26/2022]
Abstract
Despite an annual trauma mortality of 5 million people worldwide, resulting in countless physical disabilities and enormous expenses, there are no standardized guidelines on trauma organization and management. Over the last few decades there have been very notorious improvements in severe trauma care, though organizational and economical aspects such as research funding still need to be better engineered. Indeed, trauma lags behind other serious diseases in terms of research and organization. The rapid developments in trauma care have produced original models available for research projects, initial resuscitation protocols and radiological procedures such as CT for the initial management of trauma patients, among other advances. This progress underscores the need for a multidisciplinary approach to the initial management and follow-up of this complicated patient population, where intensivists play a major role in both the patient admission and subsequent care at the trauma unit.
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Affiliation(s)
- E Alted López
- Unidad de Cuidados Intensivos de Trauma, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España.
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