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Comparison of Mortality Due to Severe Multiple Trauma in Two Comprehensive Models of Emergency Care: Atlantic Pyrenees (France) and Navarra (Spain)
Abstract
Injury due to external causes is an important health problem in our society today. Emergency care systems based on the concept of "comprehensive care" can prevent deaths and disabilities as well as limit the severity and pain caused by trauma.
To investigate the frequency and characteristics of different mechanisms of injury and to estimate mortality, comparing two comprehensive emergency systems: Atlantic Pyrenees (AP) in France and Navarra (NA) in Spain.
A prospective cohort study of severe multiple-injury patients attended to by the comprehensive emergency care systems of AP and NA from April 1, 2001 to March 31, 2002. Data were collected from personal patient data, the emergency coordination center "112," pre-hospital and hospital health care levels, and discharge data. Bivariate statistical analysis and multivariate logistic regression models were employed for statistical management.
There were 614 severe multiple trauma patients recorded, 278 in AP and 336 in NA. Significant differences were observed in arrival time, pre-hospitalization care, pre-hospital Revised Trauma Score (RTS), Injury Severity Score (ISS) at the intensive care unit, and procedures used (intubation, administration of fluids, immobilization, and diagnostic methods). Logistic regression showed significant differences in patient death, age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.03), penetrating or accidental injuries, (OR 3.85, 95% CI 1.1-13.1), RTS (OR 0.58, 95% CI 0.5-0.7), and ISS score (OR 1.05, 95% CI 1.0-1.1).
Despite a more aggressive approach and employment of greater resources, the French comprehensive trauma system does not show greater survival rates among injured patients compared to Navarra, even when controlling for confounding factors like age, injury mechanism, RTS, ISS, and others.
... En nuestra comunidad contamos con datos de dichos pacientes en dos periodos suficientemente separados en el tiempo como para que aspectos demográficos, programas de salud o de otro tipo y aspectos puramente organizativos del sistema de emergencias hayan podido influir en los resultados en términos de mortalidad del PPT. Los datos pertenecientes al primer periodo de estudio fueron recogidos y tratados como parte de un programa de investigación que tenía como finalidad la creación y validación de un sistema de registro de traumatismo grave 4 . Para el segundo periodo de estudio se puso en marcha en el mes de enero de 2010 la base de datos web "Major Trauma de Navarra" con el objetivo de recoger datos de los PPT ocurridos en Navarra y monitorizar las variables epidemiológicas y de calidad asistencial, con el objetivo de mejorar la supervivencia de dichos pacientes. ...
... En cuanto al espectacular descenso del 20% en los PPT por accidentes de tráfico, puede deberse a que en la década 1990-2000 se detectó una situación muy preocupante en Navarra, producida por accidentes de tráfico que afectaba a personas jóvenes y generaba una importante mortalidad 4,18,19 . Otros estudios en España también demostraron un cambio en el patrón epidemiológico en los PPT similar al encontrado en nuestro estudio 7,20-23 . ...
Objectives:
To compare morbidity and mortality rates, the epidemiologic profile, and survival of patients with multiple injuries attended by the emergency services in the Navarre autonomous community in Spain in the periods of 2002-2003 and 2010-2012.
Material and methods:
Observational analysis of 2 cohorts of accident patients with Injury Severity Scores of 15 points or more. Logistic regression was used to identify variables related to mortality.
Results:
A total of 651 patients were attended in the first period; 626 were attended in the second. The annual multiple-injury incidence rate decreased from 58.1 per 100 000 population in the first period to 33.5 per 100 000 population in the second; mortality decreased from 30.3 to 15.3 per 100 000 population. The mean (SD) age was 45 (22) years in the first cohort and 52 (23) years in the second. The gender distribution (75% male) did not change. The percentage injured in traffic accidents decreased from 44% to 24%; the percentage of elderly patients hurt in falls increased from 9% to 26%.
Conclusion:
The problem of the number of young people injured in accidents in our community has been brought under control, but the proportion of older patients injured in falls has risen. This change may slow the effort to improve mortality rates in patients with multiple injuries and it obliges us to introduce measures to prevent falls in the elderly.
... En nuestra comunidad contamos con datos de dichos pacientes en dos periodos suficientemente separados en el tiempo como para que aspectos demográficos, programas de salud o de otro tipo y aspectos puramente organizativos del sistema de emergencias hayan podido influir en los resultados en términos de mortalidad del PPT. Los datos pertenecientes al primer periodo de estudio fueron recogidos y tratados como parte de un programa de investigación que tenía como finalidad la creación y validación de un sistema de registro de traumatismo grave 4 . Para el segundo periodo de estudio se puso en marcha en el mes de enero de 2010 la base de datos web "Major Trauma de Navarra" con el objetivo de recoger datos de los PPT ocurridos en Navarra y monitorizar las variables epidemiológicas y de calidad asistencial, con el objetivo de mejorar la supervivencia de dichos pacientes. ...
... En cuanto al espectacular descenso del 20% en los PPT por accidentes de tráfico, puede deberse a que en la década 1990-2000 se detectó una situación muy preocupante en Navarra, producida por accidentes de tráfico que afectaba a personas jóvenes y generaba una importante mortalidad 4,18,19 . Otros estudios en España también demostraron un cambio en el patrón epidemiológico en los PPT similar al encontrado en nuestro estudio 7,20-23 . ...
El objetivo del estudio es comparar las tasas de morbimortalidad, el perfil epidemiológico y la supervivencia de los pacientes politraumatizados atendidos en Navarra por el Sistema de Emergencias en los períodos:2002-2003 y 2010-2012.
Pacientes y Método: Estudio observacional, analítico, de dos cohortes de pacientes accidentados con un Injury Severity Score superior a 15 puntos. Se utiliza la Regresión Logística para identificar las variables involucradas en la mortalidad.
Resultados: Se comparan las variables de los 651 pacientes atendidos en el primer periodo con los 626 del segundo. La tasa de incidencia descendió de 58,1/100.000 habitantes año a 33,5 así como la de mortalidad, de 30,3 a 15,3. La edad media de los accidentados pasó de 45 (22) a 52 (23) años y se mantuvo su distribución por sexos (75 % varones). Disminuyeron los accidentados de tráfico del 44 al 24 % y se incrementaron las caídas en ancianos del 9 al 26 %.
Discusión: Vamos hacia un nuevo escenario en el que los politraumatizados por accidente de tráfico jóvenes han sido sustituidos por ancianos que se caen accidentalmente y en los cuales las acciones sanitarias son menos efectivas.
Conclusión: En los últimos años se ha controlado en nuestra comunidad el problema de los jóvenes accidentados de tráfico y ha surgido el grupo de ancianos que se cae accidentalmente. Esto puede ralentizar la mejora en las tasas de mortalidad de los politraumatizados y nos obliga a poner en marcha medidas preventivas en relación con este mecanismo en este colectivo.
... We identified 18 studies, described in 17 reports[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28], which presented data on the parameters of interest and were included in the systematic review. Studies were conducted in 13 countries; USA, Canada, UK, Australia, Brazil, Denmark, Norway, Mozambique, South Africa, Italy, France, Spain and India. ...
... In addition, we obtained data collected as part of the CRASH-2 trial, which recruited patients from hospitals in 40 countries throughout the world. The study selection process is summarised inFigure 2. Data extracted from the studies are summarised in Additional File 1. Fourteen studies[13][14][15]17,[19][20][21][22][23][24][25][26][27]involving 24,831 trauma deaths provided data on the proportion of deaths occurring in-hospital; the pooled proportion was 44% (95% CI 33 to 56%). Five studies[3,12,16,18,28]involving 9684 deaths presented data on the proportion of blunt trauma deaths due to haemorrhage; the pooled proportion was 18% (95% CI 13 to 23%). ...
The CRASH-2 trial showed that early administration of tranexamic acid (TXA) safely reduces mortality in bleeding in trauma patients. Based on data from the CRASH-2 trial, global mortality data and a systematic literature review, we estimated the number of premature deaths that might be averted every year worldwide through the use of TXA.
We used CRASH-2 trial data to examine the effect of TXA on death due to bleeding by geographical region. We used WHO mortality data (2008) and data from a systematic review of the literature to estimate the annual number of in-hospital trauma deaths due to bleeding. We then used the relative risk estimates from the CRASH-2 trial to estimate the number of premature deaths that could be averted if all hospitalised bleeding trauma patients received TXA within one hour of injury, and within three hours of injury. Sensitivity analyses were used to explore the effect of uncertainty in the parameter estimates and the assumptions made in the model.
There is no evidence that the effect of TXA on death due to bleeding varies by geographical region (heterogeneity p = 0.70). Based on WHO data and our systematic literature review, we estimate that each year worldwide there are approximately 400,000 in-hospital trauma deaths due to bleeding. If patients received TXA within one hour of injury then approximately 128,000 (uncertainty range [UR] ≈ 72,000 to 172,000) deaths might be averted. If patients received TXA within three hours of injury then approximately 112,000 (UR ≈ 68,000 to 148,000) deaths might be averted. Country specific estimates show that the largest numbers of deaths averted would be in India and China.
The use of TXA in the treatment of traumatic bleeding has the potential to prevent many premature deaths every year. A large proportion of the potential health gains are in low and middle income countries.
... Yeguiayan et al, in their study on the first assessment of the "French Intensive care Recorded in Severe Trauma" study noted that approximately 7% of severe trauma patients were not prehospitalized in France [29]. Gomez de Sergura Nieva et al, for their part, found a frequency of 75.5% and 90.4% of medical transport respectively in Spain and France [39]. ...
Aim: To describe the profile of severe trauma adults who died in polyvalent intensive care unit at University Hospital of Brazzaville. Materials and methods: It was a retrospective, cross-sectional study carried out in polyvalent intensive care unit of University Hospital of Brazzaville, during 30 months period. We included all severe trauma who died, aged 18 years or over patients regardless of age or sex and treated for at least one hour in intensive care. Epidemiological, clinical and therapeutic parameters were recorded and analyzed with Excel 2016 for Windows. Results: During the study period, 35 deaths out of 90 severe trauma patients were recorded, i.e. a lethality rate of 38.8%. The mean age was 42.4±18.6 years (sex ratio=7.5). Admissions were primary in 58.8%. Road traffic collisions (RTC, 73.5%) were the most common mechanism of injury involved. In intensive care, 82.4% of patients presented with severe trauma brain injury (TBI), of which 50.0% was isolated. Respiratory (47.1%) and hemodynamic (17.6%) distress were observed. Pickup and transport of trauma victims were not medical. Oxygen therapy (91.2%), blood transfusion (23.5%), use of vasopressor amines (47.1%) and osmotherapy (23.5%) were necessary. The patients were intubated and ventilated then sedated in 64.7%. Surgical management concerned 20.6% and was dominated by neurosurgical indications. Neurological distress (61.8%) was the main cause of death. Conclusion: The lethality rate of severe trauma patients was high, affecting young males, victims of both RTC and severe TBI. This confirms the need to promote collaboration and communication between hospital structures, to set up pre-hospital care structures, to improve the technical platform and to train staff involved in their care.
... Our study showed that in patients with multiple traumas, TASH scoring system (prognostic system) had significant relationships with hospital mortality while this relationship was not significant with RDW. The prognostic role of the anatomical ISS system and physiological RTS system has been well established; these systems are helpful in determining the prognosis of trauma patients [31,32]. In a study by Kuhls et al., [33] the predictive value of physiological systems was found to be equivalent to anatomical systems in determining the mortality of trauma patients. ...
Objective
To investigate the role of red cell distribution width (RDW) in comparison with Trauma-Associated Severe Hemorrhage (TASH) system in predicting the mortality of multiple trauma patients, referred to the hospital emergency department.
Methods
This follow-up study was conducted on multiple trauma patients (age ≥ 18 years) with Injury Severity Scores (ISS) of ≥ 16, who were referred to the emergency department from March 1, 2017, to December 1, 2017. First, all patients were evaluated based on the Advanced Trauma Life Support (ATLS) guidelines, and then, their blood samples were sent for RDW measurements at baseline and 24 hours after admission. The ISS, Revised Trauma Score (RTS), and TASH were measured in the follow-ups and recorded by third-year emergency medicine residents. Hospital mortality was considered as the outcome of the study.
Results
In this study, 200 out of 535 multiple trauma patients were recruited. The frequency of hospital mortality was 19 (9.5%). In the univariate analysis, there was no significant relationship between hospital mortality and RDW at baseline, RDW on the first day, and ΔRDW (RDW at baseline - RDW on the first day), unlike ISS, RTS, TASH (p=0.97, P= 0.28, and p=0.24, respectively). On the other hand, in the multivariate analysis, ISS, RTS, and TASH showed a significant relationship with hospital mortality. The greatest area under the ROC curve (AUC) was attributed to TASH and RTS systems (0.94 and 0.93, respectively).
Conclusion
TASH scoring system, which was mainly designed to predict the need for massive transfusion, may be of prognostic value for hospital mortality in multiple trauma patients, similar to ISS and RTS scoring systems.
... Gomez de Segura et al. compared the Navarra Emergency System and Atlantic Pyrenees (France) using data from 2001 to 2002. The results showed that despite more aggressive approach and employment of great resources, the French comprehensive emergency system didn't show greater survival rates among injured patients compared to Navarra [5]. ...
Background
International benchmarking can help identify trauma system performance issues and determine the extent to which other countries also experience these. When problems are identified, countries can look to high performers for insight into possible responses. The objective of this study was to compare the treatment and outcome of severely injured patients in Germany and Navarra, Spain.
Methods
Data collected, from 2010 to 2013, in the Navarra Major Trauma Registry (NMTR) and the TraumaRegister DGU® (TR-DGU) were compared. Both registries followed the Utstein Trauma Template (European Core Dataset) for documentation of trauma patients. Adult patients (≥ 16 years) with New Injury Severity Score (NISS) being >15 points were included in this study. Patients who had been admitted to the hospital later than 24 h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded.
Demographic data, injury data, prehospital data, hospital treatment data, time intervals, and outcome were compared. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II).
Results
A total of 646 and 43,110 patients were included in the outcome analysis from NMTR and TR-DGU, respectively. The difference between observed and expected mortality was −0.4% (standardized mortality ratio [SMR] 0.97; 95% CI 0.93–1.04) in Germany and 1.6% (SMR 1.08; 95% CI: 1.02–1.14) in Navarra. Differences in the characteristics of trauma patients and trauma systems between the regions were noted.
Conclusion
The higher observed mortality in Navarra is consistent with the epidemiological characteristics of its population. However, to improve the quality of trauma care in the Navarra trauma system, certain improvements are necessary. There were less young adults with severe injuries in Navarra than in Germany. It is possible to compare data of severely injured patients from different countries if standardized registries are used.
... If this trend maintains itself, it may evidence an increasingly greater awareness of parents and caregivers in the area of protection of the health and life of their children, and effectiveness of prophylactic actions undertaken. Analysis of the relevant literature does not confirm any considerable decrease in the scope of engagement of children and adolescents in work on farms [13,18,21,22,23]. ...
Introduction and objective:
In Poland and worldwide, injury rates, as well as accident rates among children and adolescents still remain a social, health and economic problem, despite an attempt to inhibit the growing tendency of this phenomenon.
Objective:
An attempt to evaluate current trends in injury rates among children and adolescents based on the example of two provinces in the Lublin Region of Poland during the period 2006-2010.
Materials and method:
The retrospective study was conducted by the method of examination of documents, using the technique of content analysis. The research material was data from the Emergency Procedures Charts and Medical Emergency Team Response Charts, while the study group were children and adolescents aged from 6 weeks - 19 years, from the counties of Kraśnik and Świdnik in the Lublin Region.
Results:
Analysis of the research material showed that during the period examined the number of injuries and accidents in the study group remained on a constant level, with a slight decrease in the number of events at home, accompanied by an increase in the number of road accidents and events which occurred in the school environment and in a public place. It was also found that the spring-autumn season, and in particular the summer months, the age group 7-13 and male gender exerted an effect on the number of injuries and accidents. The analysis did not confirm that injuries related with employment of children and adolescents in agriculture and deaths due to external causes constituted a considerable percentage of the events registered.
Conclusion:
Analysis of trends should be a basis for the planning of prophylactic actions and the promotion of safety in all environments in which the study population functions.
... Patients with multiple trauma are often suffering from bleeding, shock, and severe physiological disorders, some life-threatening. 1 The injuries can be induced by intentional causes (domestic violence, suicides, homicides, and war) and non-intentional ones (sports-related injuries, falls, traffic crashes, near-drowning, burns, and accidental poisoning). 2 More than 5 million deaths per year resulted from injuries, 3 and about 50% of young children with non-intentional injuries are left with disabilities. 4 Thus, it is very urgent to study the molecular mechanisms of multiple trauma and develop therapeutic schedules. ...
Multiple trauma can induce sepsis and organ failure, even threaten people’s lives. To further study the mechanisms of multiple trauma, we analyzed microarray of GSE5760. GSE5760 was downloaded from the Gene Expression Omnibus including a total of 58 peripheral blood transcriptome from patients without (WT, n = 30) and carrying (MUT, n = 28) the tumor necrosis factor (TNF) rs1800629 A variant. The differentially expressed genes (DEGs) were screened using the limma package in R and the Benjamin and Hochberg method in a multi-test package. Then, functional enrichment analysis of DEGs was performed. Also, transcription factors significantly related to DEGs were searched using WebGestalt and interaction network of transcription factors and DEGs were constructed using STRING online software. Furthermore, pathway enrichment analysis for the DEGs in the interaction network was conducted using KO-Based Annotation System (KOBAS). We screened 39 DEGs including 27 upregulated and 12 downregulated genes. The enriched functions were associated with biological process (BP) (such as response to hypoxia, P value = 0.039803), cell components (CC) (such as mitochondrial part, P value = 0.043857), and molecular function (MF) (such as structural constituent of ribosome, P value = 0.008735). Besides, RPS7 and RPL17 were associated with ribosome and participated in ribosome pathway. PPP2R2B was related to mitochondrion. KCNMA1, ALAS2 and SOCS3 were associated with hypoxia. Moreover, transcription factors of LEF1, CHX10, ELK1, SP1, and MAZ were significantly related to DEGs. RPS7, RPL17, PPP2R2B, KCNMA1, ALAS2, and SOCS3 might relate to multiple trauma. And TNF-α mutation could cause sepsis in patients with multiple trauma by changing the expression of these genes.
... The United States has been successful in reducing traffic fatalities by both improving trauma care and enacting injury prevention strategies (Guan 2006; MacKenzie et al. 2006; Nathens et al. 2000a; Nathens et al. 2000b). Comparing in-hospital mortality after injury between these two countries may help quantify the extent to which the excess traffic mortality in Saudi Arabia is due to differences in hospital care, and point to opportunities for quality improvement (Boulanger et al. 1993; Gómez de Segura Nieva et al. 2009; Hildebrand et al. 2005; Jenkinson 1999; Roudsari et al. 2007; Tan et al. 2012). Previous studies of cardiac and high-risk surgery outcomes have suggested that providing healthcare settings with information on their risk-adjusted outcomes is associated with subsequent reductions in mortality and morbidity (Hannan 1994; Khuri 2002; O'Connor and The Northern New England Cardiovascular Disease Study Group 1996). ...
Traffic-related fatalities are a leading cause of premature death worldwide. According to the 2012 report the Global Burden of Disease 2010, traffic injuries ranked 8th as a cause of death in 2010, compared to 10th in 1990. Saudi Arabia is estimated to have an overall traffic fatality rate more than double that of the U.S., but it is unknown whether mortality differences also exist for injured patients seeking medical care. We aim to compare in-hospital mortality between Saudi Arabia and the United States, adjusting for severity and demographic variables.
The analysis included 485,611 patients from the U.S. National Trauma Data Bank (NTDB) and 5,290 patients from a trauma registry at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. For comparability, we restricted our sample to NTDB data from level-I public trauma centers (≥400 beds) in the U.S. Multiple logistic regression analyses were performed to evaluate the effect of setting (KAMC vs. NTDB) on in-hospital mortality after adjusting for age, sex, Triage-Revised Scale (T-RTS), Injury Severity Score (ISS), mechanism of injury, hypotension, surgery and head injuries. Interactions between setting and ISS, and predictors were also evaluated.
Injured patients in the Saudi registry were more likely to be males, and younger than those from the NTDB. Patients at the Saudi hospital were at higher risk of in-hospital death than their U.S. counterparts. In the highest severity group (ISSs, 25–75), the odds ratio of in-hospital death in KAMC versus NTDB was 5.0 (95% CI 4.3-5.8). There were no differences in mortality between KAMC and NTDB among patients from lower ISS groups (ISSs, 1–8, 9–15, and 16–24).
Patients who are severely injured following traffic crash injuries in Saudi Arabia are significantly more likely to die in the hospital than comparable patients admitted to large U.S. trauma centers. Further research is needed to identify reasons for this disparity and strategies for improving the care of patients severely injured in traffic crashes in Saudi Arabia.
... Elle retrouvait une atteinte abdominale dans 13 % des traumatismes balistiques et dans 34 % des traumatismes par AB (Fig. 1) [6]. En 2009, une é tude ré alisé e dans les Pyré né es-Atlantiques estimait que les traumatismes pé né trants ne repré sentaient que 13 % des traumatismes sé vè res (Revised Trauma Score (RTS) > 12) [7]. Plus gé né ralement, les plaies par armes repré sentent en France 5 à 13 % des traumatismes et 1 % de la totalité des victimes prises en charge par les Smur [8,9]. ...
Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.
... However, the same was not true in the analysis by type of vehicles; patients being treated by the USA vehicles showing the worst prognosis, according to the data found. A study conducted in Spain by Nieva et al [32] compared two models of emergency trauma care in two different towns: Pyrénées-Atlantiques (France) and Navarra (Spain). The authors found significant statistical differences in rescue times in APH, but comparable in-hospital mortality rates (p = 0.138). ...
Pre-hospital care (PH) in Brazil is currently in the phase of implementation and expansion, and there are few studies on the impacts of this public health service. The purpose of this study is to assess the quality of care and severity of trauma among the population served, using trauma scores, attendance response times, and mortality rates. This work compares two pre-hospital systems: the Mobile Emergency Care Service, or SAMU 192, and the Fire Brigade Group, or CB.
Descriptive study evaluating all patients transported by both systems in Catanduva, SP, admitted to a single hospital.
850 patients were included, most of whom were men (67.5%); the mean age was 38.5 ± 18.5 years. Regarding the use of PH systems, most patients were transported by SAMU (62.1%). The trauma mechanisms involved motorcycle accidents in 32.7% of cases, transferred predominantly by SAMU, followed by falls (25.8%). Regarding the response time, CB showed the lowest rates. In relation to patient outcome, only 15.5% required hospitalization. The average score on the Glasgow Coma Scale was 14.7 ± 1.3; average RTS was 7.7 ± 0.7; ISS 3.8 ± 5.9; and average TRISS 97.6 ± 9.3. The data analysis showed no statistical differences in mortality between the groups studied (SAMU - 1.5%; CB - 2.5%). The trauma scores showed a higher severity of trauma among the fatal victims.
Trauma victims are predominantly young and male; the trauma mechanism that accounted for the majority of PH cases was motorcycle accidents; CB responded more quickly than SAMU; and there was no statistical difference between the services of SAMU and CB in terms of severity of the trauma and mortality rates.
... Elle retrouvait une atteinte abdominale dans 13 % des traumatismes balistiques et dans 34 % des traumatismes par AB (Fig. 1) [6]. En 2009, une é tude ré alisé e dans les Pyré né es-Atlantiques estimait que les traumatismes pé né trants ne repré sentaient que 13 % des traumatismes sé vè res (Revised Trauma Score (RTS) > 12) [7]. Plus gé né ralement, les plaies par armes repré sentent en France 5 à 13 % des traumatismes et 1 % de la totalité des victimes prises en charge par les Smur [8,9]. ...
Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.
... 20 Com-parisons of EMS systems around the world show great differences with regard to qualification of staff, management, logistics and infrastructure. 8,13,18,22 Roudsari et al. 19 provided insights into the international variability in patient mix, processes of care, and performance of different pre-hospital trauma care systems worldwide; however, the analysis was not TBI-specific. Germany's EMS is an example of a system where physician-operated advanced life support (DOC-ALS) EMS run the majority of pre-hospital acute trauma care and are utilised more frequently as compared to other developed countries. ...
In Germany, physician-operated emergency medical services (EMS) manage most pre-hospital trauma care. Australia uses a different EMS system, deploying highly trained paramedics for road and air transport of trauma patients. The effect of these different systems on secondary insults to traumatic brain injury (TBI) patients is unclear. There is conflicting evidence regarding which system is preferable. To add to the body of evidence, we compared the profile of injury, pre-hospital management and outcomes of TBI patients from both populations.
Cases aged > or = 16 years, with AIS head > or = 3, AIS other body parts < or = 3, recorded in the Victorian State Trauma Registry (VSTR) and Trauma Registry of the German Society of Trauma Surgery (TR-DGU) from 2002 to 2007 were compared.
10,183 cases (5665 German, 4518 Australian) were included. No difference in sex or median age was observed. There were major between-registry differences in type of injury, trauma circumstance, intent and severity of injury. German cases sustained more serious injury and received more pre-hospital interventions. Mortality was significantly higher amongst German patients even when adjusted for demographics, injury severity and in- and pre-hospital parameters. German patients had a longer hospital and ICU stay.
There were clear differences in injury characteristics and outcomes in TBI patients between Germany and Australia. As differences in coding, data collection and patient selection are evident, firm conclusions regarding the contribution of variations in pre-hospital care are not possible. The differences in outcome deserve further exploration in prospective studies.
Background:
Trauma is a global health problem. The causes of trauma-led deaths may also be diverse depending on socioeconomic and geographical factors, outlining various regional patterns. There are few local studies about trauma in consideration of socio-demographical and geographical factors. The aim of the study is to provide policy insights for reduction of trauma death or disorder rates by investigating the relationships between trauma and geographical factors.
Method:
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a literature search of international and Korean databases from 2000 to 2020.
Results:
Thirty-two studies showed a positive relationship between the outcomes of major trauma and geographical factors. The study investigated regional factors including economic factors such as urban size, GDP, and poverty rate, as well as hospital factors such as presence of trauma centers, and number of hospital beds. There was a tendency for higher mortality rates in rural and low-income areas, and most literature reported that the presence of trauma centers had an impact on reducing mortality rates.
Conclusion:
Our study showed that geographic factors have impacts on trauma outcomes. This suggests that appropriate care plans should be considered and developed by taking a geographical approach to reduce the rates of death and disability caused by trauma.
Background:
In October 2021, French acute care societies jointly published cognitive aids to standardise practices and limit cognitive biases to ensure greater safety in management of severe trauma patients. The aim of the study was to evaluate the impact of a checklist on emergency physicians' adherence to the recommendations.
Methods:
This prospective before-and-after study study took place in a French mobile emergency and resuscitation service. All adults trauma patients referred to hospital were included. A checklist on trauma management inspired by the MARCHE acronym was produced. During phase I, the checklist was performed within 24 h after the end of the intervention. During phase II, the checklist was performed during the patient's transport to hospital, thus allowing potentially omitted procedures to be performed initially. The use of the checklist was systematically evaluated using an anonymous questionnaire among doctors and nurses. In phase II, doctors and nurses who did not perform checklist were systematically asked to answer a specific online questionnaire. The primary outcome was the overall omission rate of checklist items during each phase of the study.
Results:
One hundred and sixteen patients were included, 53 in phase I and 63 in phase II. Eleven patients did not have a checklist in phase II. The overall omission rate of checklist items was significantly lower with checklist (17%) than without (25%) (p = 0.02). This trend increased in proportion to severity with an omission rate of 30% without checklist versus 15% with checklist (p = 0.03) for patients with an ISS ≥ 25. A majority of doctors and nurses who used the checklist considered that it should be made compulsory (82% and 67% respectively). Paradoxically, only 55% of doctors who did not perform the checklist thought it was useful, while the omission rate was significantly higher (17% with checklist compared with 59% without checklist, p < 0.01).
Conclusion:
This work shows a significant reduction in the number of omissions on the actions carried out during the management of a trauma patient in prehospital settings, allowing better adherence to the recommendations. Its benefit is increased in severely traumatised patients.
Background
Trauma registries are a crucial component of trauma systems, as they could be utilized to perform a benchmarking of quality of care and enable research in a critical but important area of health care. The aim of this study is to compare the performance of two national trauma systems: Germany (TraumaRegister DGU®, TR-DGU) and Israel (Israeli National Trauma Registry, INTR).
Methods
The present study was a retrospective analysis of data from the described above trauma registries in Israel and Germany. Adult patients from both registries treated during 2015–2019 with an Injury Severity Score (ISS) ≥ 16 points were included. Patient demographics, type, distribution, mechanism, and severity of injury, treatment delivered and length of stay (LOS) in the ICU and in the hospital were included in the analysis.
Results
Data were available from 12,585 Israeli patients and 55,660 German patients. Age and sex distribution were comparable, and road traffic collisions were the most prevalent cause of injuries. The ISS of German patients was higher (ISS 24 vs. 20), more patients were treated on an intensive care unit (92 vs. 32%), and mortality was higher (19.4 vs. 9.5%) as well.
Conclusion
Despite similar inclusion criteria (ISS ≥ 16), remarkable differences between the two national datasets were observed. Most probably, this was caused by different recruitment strategies of both registries, like trauma team activation and need for intensive care in TR-DGU. More detailed analyses are needed to uncover similarities and differences of both trauma systems.
Résumé
Objectif
Décrire la prise en charge (PEC) des traumatisés graves (TG) de l’adulte admis en réanimation polyvalente du centre hospitalier universitaire de Brazzaville (CHU-B).
Matériels et méthodes
L’étude était transversale et rétrospective sur 30 mois en réanimation du CHU-B. Étaient inclus tout TG d’au moins 18 ans, pris en charge pendant au moins 6 heures. Les variables sociodémographiques, cliniques, thérapeutiques et évolutives étaient analysées sur Excel 2016 et Epi-info 7.
Résultats
Au total, 70 patients étaient retenus (âge moyen : 39 ± 15 ans ; sex ratio : 4,8). Cinquante pour cent des patients provenaient des urgences. Les accidents de la voie publique (84,3 %) étaient la principale circonstance traumatique. Les patients présentaient un traumatisme crânien grave (47,2 %) parmi lesquels 27,1 % étaient isolés des détresses respiratoires (38,6 %) et hémodynamiques (14,6 %). Le ramassage et le transport des patients n’étaient pas médicalisés. La PEC avait consisté en un remplissage vasculaire avec des cristalloïdes et des colloïdes, une oxygénothérapie (84,3 %), une transfusion sanguine (30 %), un recours aux amines vasopressives (34,3 %), et une osmothérapie (10 %). Le drainage thoracique était réalisé chez 9,9 % des patients. Les patients étaient intubés et sédatés dans 40 % des cas. La PEC chirurgicale concernait 21,4 % des TG. L’antibiothérapie était administrée chez 74,7 % des patients. La mortalité globale était de 41,4 %.
Conclusion
Les TG sont un motif fréquent en réanimation. Ils touchent surtout la population juvénile masculine et sont consécutifs aux accidents de la voie publique. Leur PEC codifiée demeure insuffisante du fait de la mortalité élevée qui leur est imputable.
Introduction
The maintenance of military surgeons’ operative skills is challenging. Different and specific training strategies have been implemented in this context; however, little has been evaluated with regard to their effectiveness. Cancer surgery is a part of military surgeons’ activities in their home hospitals. This study aimed to assess the role of oncological surgery in the improvement of military surgeons’ operative skills.
Methods
Between January and June 2019, the surgical activities of the departments of visceral, ear, nose, and throat, urological, and thoracic surgery were retrospectively reviewed and assessed in terms of the operative time (OT). All surgeons working at the Sainte Anne Military Teaching Hospital were sent a survey to rate on a 5-point scale the current surgical practices on their usefulness in improving surgical skills required for treating war injuries during deployment (primary endpoint) and to compare on a 10-point visual analog scale the influence of cancer surgery and specific training on surgical fluency (secondary endpoint).
Results
Over the study period, 2,571 hours of OT was analyzed. Oncological surgery represented 52.5% of the surgical activity and almost 1,350 hours of cumulative OT. Considering the primary endpoint, the mean rating allocated to cancer surgery was 4.53 ± 0.84, which was not statistically different than that allocated to trauma surgery (4.42 ± 1.02, P = 0.98) but higher than other surgery (2.47 ± 1.00, P < 0.001). Considering the secondary endpoint, cancer surgery was rated higher than specific training by all surgeons, without statistically significant difference (positive mean score of + 2.00; 95% IC: 0.85–3.14).
Conclusion
This study demonstrates the usefulness of cancer surgery in improving the operative skills of military surgeons.
Introduction
Pre-hospital emergency systems provide service by Franco-German and Anglo American models. This study was carried out to compare the Iranian emergency medical service (EMS) with the two models regarding timing and equipment.
Methods
In this cross sectional study, response time, scene time, and transport time to hospital as well as ambulance equipment of five hundred thousand Tehran EMS recorded missions, during one year, were compared with Franco-German and Anglo American models, trying to determine the pattern of EMS delivery in Iran.
Results
The mean response time, scene time, and transport time to hospital were 15.00 ±10.88, 18 ±11.48, and 15.00 ±11.20 minutes, respectively. The mean response time (p<0.035), scene time (p<0.033), and transport time to hospital (p<0.015) were more than the standard time. Percentage of ambulances quipped with automated external defibrillator (45%, p<0.001), ventilator (2%, p<0.001), disposable splint (0%, p<0.001), and wheelchair (0%, p<0.001) were very far from standards.
Conclusion
The pattern of EMS delivery in Iran was a combination of Anglo American and Franco-German system.
Objective: To explore the value of peripheral blood serum levels of PCT, CRP, TNF-α and free DNA of cells in predicting the development of MODS in patients with multiple trauma. Methods: Complete detail clinical data of 54 casualties with multiple trauma admitted within 24 hours after accident from January 2011 through January 2012 were collected for retrospective study. The patients were divided into MODS group and non-MODS group according the criteria set forth by the Chinese Society of Critical Care and Emergency Medicine in 1995 national conference. The data of two groups are comparable, and data of another 20 healthy subjects undertaking routine annual physical examination were taken as control. The peripheral blood levels of PCT, CRP, TNF-α and free DNA of patients of two groups were determined 1 d, 2 d, 3 d, and 5 days after admission. Then the results were analyzed and compared between groups. Results: Compared with non MODS group, the levels of PCT, CRP, free DNA of cells in MODS group were significantly higher (P <0. 05), but there was no deference in TNF-a between MODS group and non-MODS group (P> 0.05). When the relative risks of increased PCT (PCT≥s6 mg/L), increased CRP (CRP≥ 130 mg/L), and increased free DNA of cells (free DNA ≥ 10 0005/L) were analyzed, the presence of these 3 biomarkers with high levels occurred at the same time was the most accurate way to predicts MODS in 6.00 relative risk (RR), and the positive predictive value was 100%. Conclusions PCT, CRP, free DNA of cells could be the predictors of MODS in patients with severe multiple trauma, and the presence of high levels of these three biomarkers appearing together had high sensitivity and specificity for prediction.
To describe the technical features of the first population-based register for multiple-injury cases to be developed in Spain. Description of the system architecture and technical features of this population-based register, including the variables in the database, the case-finding strategy used, data inputting and maintenance, and quality control. Between January 1, 2010 and December 31, 2011, we found 243 cases. The system was supervised by a database administrator and allowed 97 users in 7 different departments to enter data. The level of reporting of 63 variables was 90%. Mortality was 27%. Response times (emergency call to hospital arrival and hospital arrival to first computed tomography scan or first key intervention) were similar to those recorded in other European registers. The first Utstein-style register for multipleinjuries in Spain is now being used in Navarre. The system architecture allows us to collect information prospectively and retrospectively from all who treat multiple-injury patients no matter their position on the staff of various hospital departments. This register has helped us determine the characteristics of multiple-injury patients and the quality of care they receive. We have been able to compare our setting with others' and have provided a source of data for researchers in the Navarre health service.
The relation between response times and mortality of polytrauma patients in the so-called “golden hour” continues to be a subject of debate.
The purpose of this study is to determine the variables related to mortality in these patients and the influence of response times of the Emergency Medical Services in this mortality.
To this end, the data in the “Major Trauma of Navarre” Register (retrospective cohort of polytrauma patients attended to by the Navarre Health Service) were analyzed for the four year period between 2010 and 2013.
Of the 217 trauma cases available for the analysis, 42 (19%) died. No significant association was found in the multivariate analysis between the different response times and mortality: arrival at the scene (odds ratio (OR) 1.0; 95% confidence interval (CI) from 0.99 to 1.01), in the scenario (OR 1.00; 95% CI from 0.98 to 1.02) and total time (OR 1.00; 95% CI from 0.99 to 1.01). The variables that influenced mortality are patient age and severity of injuries measured by the prehospital Triage-Revised Trauma Score (T-RTS) and the New Injury Severity Score (NISS).
The mortality of polytrauma patients attended to by the emergency system in our region is influenced by age and by the intensity of the aggression suffered, determined by the prehospital T-RTS and by the NISS. The response times of the hospital do not have a significant influence
La relación entre los tiempos de respuesta y la mortalidad de los pacientes politraumatizados en la denominada hora de oro sigue siendo tema de debate.
El objetivo del presente estudio es determinar las variables relacionadas con la mortalidad en dichos pacientes y la influencia de los tiempos de respuesta de los Servicios Médicos de Emergencia en dicha mortalidad.
Para ello se analizaron los datos del Registro “Major Trauma de Navarra” (cohorte prospectiva de pacientes politraumatizados atendidos por el sistema sanitario de Navarra) durante los cuatro años comprendidos entre 2010 y 2013.
Resultados: De los 217 casos de trauma disponibles para el análisis, fallecieron 42 (19 %). En el análisis multivariante no se encontró asociación significativa entre los diferentes tiempos de respuesta y la mortalidad: llegada a la escena (odds ratio (OR) 1,0; intervalo de confianza al 95 %(IC) de 0,99 a 1,01), en el escenario (OR 1,00; IC 95% de 0,98 a 1,02) y tiempo total (OR 1,00; IC 95 % de 0,99 a 1,01). Las variables que influyen en la mortalidad son la edad del paciente y la gravedad de las lesiones medidas por el Triage- Revised Trauma Score (T-RTS) prehospitalario y el New Injury Severity Score (NISS).
Conclusiones: La mortalidad de los pacientes politraumatizados atendidos por el sistema de emergencias en nuestra región está influida por la edad, y por la intensidad de la agresión sufrida determinada por el T-RTS prehospitalario y por el NISS. Los tiempos de respuesta prehospitalarios no influyen significativamente.
Trauma is a pandemic disease in the current society. In an attempt to minimize its impact, trauma care systems have been developed, the basic component being the Trauma Centers (TC). Management of the patient with severe trauma in the TC is supported by moderate scientific evidence, with many studies, but of weak quality. It is described how the volume, experience, availability of resources and other aspects are able to decrease mortality and achieve functional improvement in the TC in severe trauma patients.
Copyright 2009 Elsevier España, S.L. y SEMICYUC. All rights reserved.
We to study the epidemiologic characteristics of patients with multiple injuries alter attempted suicide who were treated by the emergency health system of Navarre between 2004 and 2005. The patients that had 1 or more severe injuries from mechanical force after a suicide attempt were included. The injuries were life-threatening or could be the cause of severe complications or sequelae. An inclusion criterion was a New Injury Severity Score (NISS) of more than 15, or death. The annual incidence of such injuries was 5.7 per 100 000 population. The ratio of men to women was 3:1. In order of frequency, the most common methods were jumping from a high place, jumping in front of an oncoming train, and gunshot. Eighty percent of the patients died.
The mean age was 50 years. Jumping from heights was chosen most often by both men and women, but men also chose the other methods (train and gunshot) more often than women. The mean NISS was 37 points. We conclude that the incidence of violent suicide is low in Navarre. Mortality is high because of the severity of injuries caused by the methods chosen mainly by men. Women mainly choose jumping from heights whereas men use additional methods. [Emergencias 2012;24:208-210]
To describe the technical features of the first population-based register for multiple-injury cases to be developed in Spain. Description of the system architecture and technical features of this population-based register, including the variables in the database, the case-finding strategy used, data inputting and maintenance, and quality control. Between January 1, 2010 and December 31, 2011, we found 243 cases. The system was supervised by a database administrator and allowed 97 users in 7 different departments to enter data. The level of reporting of 63 variables was 90%. Mortality was 27%.
Response times (emergency call to hospital arrival and hospital arrival to first computed tomography scan or first key intervention) were similar to those recorded in other European registers. The first Utstein-style register for multipleinjuries in Spain is now being used in Navarre. The system architecture allows us to collect information prospectively and retrospectively from all who treat multiple-injury patients no matter their position on the staff of various hospital departments. This register has helped us determine the characteristics of multiple-injury patients and the quality of care they receive. We have been able to compare our setting with others’ and have provided a source of data for researchers in the Navarre health service.
[Emergencias 2013;25:196-200]
Keywords: Registries, population-based. Wounds and injuries. Health care quality. Computer architecture. Epidemiology Spain.
Background:
Trauma injuries are the main cause of death in the world. The aim of this study is to determine how trauma patients are treated in Spain at an organizational level.
Material and methods:
A questionnaire was prepared consisting of 14 questions regarding aspects of the trauma care organization and trauma education. It was posted on the web site of the Spanish College of Surgeons and all members were encouraged to participate.
Results:
One hundred and ninety questionnaires from 110 different hospitals were received. More than two-thirds (67.3%) of the centers had protocols for treating trauma patients, with 81% of them based on ATLS guidelines. Almost three-quarters (72.6%) of the doctors had completed the ATLS course, and 38.9% the DSTC course. There was a specific education program in trauma in 24.5% of the centers, and 35.5% had a Trauma Committee. There was a rehabilitation program in 24.5% of the centers.
Conclusion:
Very few of the participating centers would fulfill the requirements of the American College of Surgeons accreditation for trauma centers. Trauma care in Spain has improved a lot in the recent years, but there is still a lot to do to reach the level of that in the United States of America.
We to study the epidemiologic characteristics of patients with multiple injuries after attempted suicide who were treated by the emergency health system of Navarre between 2004 and 2005. The patients that had 1 or more severe injuries from mechanical force after a suicide attempt were included. The injuries were life-threatening or could be the cause of severe complications or sequelae. An inclusion criterion was a New Injury Severity Score (NISS) of more than 15, or
death. The annual incidence of such injuries was 5.7 per 100 000 population. The ratio of men to women was 3:1. In order of frequency, the most common methods were jumping from a high place, jumping in front of an oncoming train, and gunshot. Eighty percent of the patients died. The mean age was 50 years. Jumping from heights was chosen most often by both men and women, but men also chose the other methods (train and gunshot) more often than women.
The mean NISS was 37 points. We conclude that the incidence of violent suicide is low in Navarre. Mortality is high because of the severity of injuries caused by the methods chosen mainly by men. Women mainly choose jumping from heights whereas men use additional methods. [Emergencias 2012;24:208-210]
Key words: Population study. Mortality. Suicide. Wounds and injuries, severe. Incidence.
Information obtained from vehicle crash scenes, called kinematics, may prove useful in the management of victims and may complement anatomical and physiological findings.
In addition to analyzing the significance of age, gender, position occupied in the vehicle, the use of restraint systems, and ejection from the vehicle, the objective was to carry out a preliminary study of what we have defined as the Structural Deformity Index (SDI) to verify its usefulness in predicting injury severity at the scene of a motor vehicle crash. The index consists of various parameters that can be easily identified at the crash scene.
An historical cohort of vehicle occupants involved in crashes in the Navarra province of Spain from January 1, 2001 to December 31, 2002 was studied. Information was collected from the database of the Navarra Severe Trauma Victim group study. Bivariate statistical analysis and multivariate logistic regression models were employed for statistical management.
There were 212 vehicle occupants identified. Significant differences in severity of injury, and of mortality, were observed based on age, ejection from the vehicle, and a high SDI. Logistic regression showed significant differences in injury severity by age (odds ratio [OR] 6.55, 95% confidence interval [CI] 1.6-26.7) and high SDI (OR 1.84, 95% CI 1-3.3), as well as differences in the patient death rate by age (OR 6.92, 95% CI 1.2-38.9) and high SDI (OR 3.28, 95% CI 1.5-6.8).
The SDI is useful to the first responders, enabling them to alert and transmit objective, reliable information to the emergency coordination center, thus efficiently activating health care resources. In addition, use of the SDI may assist prehospital and hospital health care providers to suspect the presence of particular serious injuries when anatomical and physiological criteria are not definitive.
Trauma is a pandemic disease in the current society. In an attempt to minimize its impact, trauma care systems have been developed, the basic component being the Trauma Centers (TC). Management of the patient with severe trauma in the TC is supported by moderate scientific evidence, with many studies, but of weak quality. It is described how the volume, experience, availability of resources and other aspects are able to decrease mortality and achieve functional improvement in the TC in severe trauma patients.
RESUMEN La atención global al politraumatizado grave no está habitualmente unificada en nuestro medio. Diferentes organizaciones y liderazgos actúan en cada fase del proceso, con una gran estanqueidad, opacidad y descoordinaci ón entre ellos, lo que hace dificultoso realizar una evaluación global del funcionamiento de un Sistema de Cuidado Traumatológico (SCT). El propósito de esta revisión es describir los aspectos característicos de un SCT y revisar los diferentes métodos utilizados en la actualidad para auditar la calidad asistencial del mismo. Actualmente se acepta que los métodos utilizados para dicha evaluaci ón traumatológica son los constituídos por la auditoría clínico y autópsica apoyadas por la metodología TRISS. El proceso de auditación consiste en realizar una contrastación entre las variables de actividad del propio SCT y sus resultados, con referencia a estándares de calidad aceptados internacionalmente y a los índices de gravedad predictivos de uso más frecuente. Un elemento clave es el análisis necrópsico de todos los éxitus traumáticos que clasifica a los fallecimientos como "evitables", "inevitables" y "potencialmente evitables". El resultado final trata de valorar la magnitud del problema, detectar en qué fases de la cadena de cuidados se ubican los fallos, emitir propuestas de mejora, y aportar además una herramienta que permita verificar los efectos reales que producen las propuestas recomendadas. INTRODUCCIÓN Los traumatismos en general y especialmente los ocasionados por accidentes de tráfico, constituyen uno de los primeros problemas de salud pública en las sociedades occidentales 1 . Representan la cuarta causa de muerte para todas las edades, son responsables del 80% de los fallecimientos entre los adolescentes y los adultos jóvenes y constituyen la primera causa de discapacidad. Implican además unos costos socioeconómicos ingentes en sufrimiento, secuelas, gastos de tratamiento, pensiones de invalidez y en pérdidas de años de trabajo 2,3 . Los traumatismos deben considerarse como un proceso de enfermedad, que obliga a generar una disciplina de tratamiento que considere el trauma como un proceso "predecible", "prevenible" y "tratable" 4 . Cabe recordar que más del 50% de las muertes se producen instantáneamente en el lugar de los hechos, antes de que puedan recibir una atención sanitaria, por lo que su posible tratamiento radicaría en la prevención 5 -7 .
Introducción: la enfermedad traumática es la principal causa de muerte en menores de 40 años y la tercera causa de muerte en la población general, tanto en Uruguay como en países industrializados. A pesar de ello, desconocemos en gran medida las características epidemiológicas de la enfermedad para los traumatizados que llegan a las puertas de emergencia de nuestros hospitales.
Objetivo: conocer las características epidemiológicas de la enfermedad traumática grave en el departamento de emergencia de un hospital de agudos de Montevideo.
Material y método: se registraron 101 traumatizados graves que ingresaron a la emergencia en forma sucesiva en un período de 21 meses. Fueron incluidos en el estudio los pacientes que se catalogaron como traumatizados graves en base a criterios clínicos. Los enfermos fueron además categorizados en base a la escala fisiológica RTS (Revised Trauma Scale) y mediante el ISS (Injury Severity Score).
Resultados: la edad media fue de 34,6 años. Predominó el sexo masculino (80%). El tipo más frecuente de traumatismo fue la colisión vehicular: 46,5%. Llegaron a la emergencia dentro de los primeros 60 minutos 67,5% de ellos, y 91% fueron trasladados por unidades de emergencia móvil. La mortalidad global de la serie fue de 20%. De los traumatizados con GCS menor a 9 por trauma encefalocraneano, 31% llegaron a la puerta de emergencia sin estabilización cervical. A ninguno de los traumatizados operados en shock se le aplicó cirugía de control de daños.
Conclusiones: las características epidemiológicas de esta población son comparables a otras series en cuanto a edad, sexo y tipo de trauma. El ISS promedio para los pacientes vivos demostró un "sobretriage" para la selección clínica. La falta de una normativa en la asistencia a traumatizados se hizo evidente, con fallas tanto a nivel de la asistencia prehospitalaria como hospitalaria.
To determine what proportion of pre-hospital deaths from accidental injury--deaths at the scene of the accident and those that occur before the person has reached hospital--are preventable.
Retrospective study of all deaths from accidental injury that occurred between 1 January 1987 and 31 December 1990 and were reported to the coroner.
North Staffordshire.
Injury severity score, probability of survival (probit analysis), and airway obstruction.
There were 152 pre-hospital deaths from accidental injury (110 males and 42 females). In the same period there were 257 deaths in hospital from accidental injury (136 males and 121 females). The average age at death was 41.9 years for those who died before reaching hospital, and their average injury severity score was 29.3. In contrast, those who died in hospital were older and equally likely to be males or females. Important neurological injury occurred in 113 pre-hospital deaths, and evidence of airway obstruction in 59. Eighty six pre-hospital deaths were due to road traffic accidents, and 37 of these were occupants in cars. On the basis of the injury severity score and age, death was found to have been inevitable or highly likely in 92 cases. In the remaining 60 cases death had not been inevitable and airway obstruction was present in up to 51 patients with injuries that they might have survived.
Death was potentially preventable in at least 39% of those who died from accidental injury before they reached hospital. Training in first aid should be available more widely, and particularly to motorists as many pre-hospital deaths that could be prevented are due to road accidents.
The purpose of this study was to test the existence of the plateau effect at the social level. The authors tried to confirm the preliminary conclusion that people may not be willing to trade off any longevity to improve the health state of a large number of people if the health states are mild enough. They tested this assumption using the person-tradeoff technique. They also used a parametric approach and a nonparametric approach to study the relationship between individual and social values. Results show the existence of the plateau effect in the context of resource allocation. Furthermore, with the nonparametric approach, a plateau effect in the middle part of the scale was also observed, suggesting that social preference may not be directly predicted from individual utilities. The authors caution against the possible framing effects that may be present in these kinds of questions.
Trauma is the most frequent cause of mortality in childhood and adolescence and causes almost 25% of admissions in Pediatric Intensive Care Units (PICU). We have evaluated the initial assesment of the severely injured children admitted in our PICU (pre-hospital care).
We reviewed the children younger than 16 years admitted in our PICU between January 1996 and December 2002. Prehospital caretakers, transportation after initial evaluation and therapeutic management were analized, using Pediatric Trauma Score (PTS) and Pediatric Risk of Mortality Score (PRISM) as predictors of injury severity and mortality, respectively.
We treated 152 traumatized children in this period, 106 males and 46 females, with a mean age of 7.5 +/- 4.3 years. 116 patients received inmediate medical care with a mean PTS significatively greater than non-medical group (12 children). Non-medical caretakers treated 8.1% of severe trauma (PTS<8). Specialized transporter was inadequated in 7.1% of severe traumatized children. Gastric and vesical tube and spinal inmobilization were accomplished in 50%, specially in children with low PTS and high PRISM. We found a great variability in fluid and drugs administration.
Although there has been a good evolution in treatment of pediatric trauma, in order to diminish morbidity and mortality it is necessary to identify and correct deficiencies in management, specially during the "golden hour", and train pre-hospital caretakers in pediatric trauma management.
Hospitals have difficulty justifying the expense of maintaining trauma centers without strong evidence of their effectiveness. To address this gap, we examined differences in mortality between level 1 trauma centers and hospitals without a trauma center (non-trauma centers).
Mortality outcomes were compared among patients treated in 18 hospitals with a level 1 trauma center and 51 hospitals non-trauma centers located in 14 states. Patients 18 to 84 years old with a moderate-to-severe injury were eligible. Complete data were obtained for 1104 patients who died in the hospital and 4087 patients who were discharged alive. We used propensity-score weighting to adjust for observable differences between patients treated at trauma centers and those treated at non-trauma centers.
After adjustment for differences in the case mix, the in-hospital mortality rate was significantly lower at trauma centers than at non-trauma centers (7.6 percent vs. 9.5 percent; relative risk, 0.80; 95 percent confidence interval, 0.66 to 0.98), as was the one-year mortality rate (10.4 percent vs. 13.8 percent; relative risk, 0.75; 95 percent confidence interval, 0.60 to 0.95). The effects of treatment at a trauma center varied according to the severity of injury, with evidence to suggest that differences in mortality rates were primarily confined to patients with more severe injuries.
Our findings show that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization.
Standardized methodologies for assessing economic burden of injury at the national or international level do not exist.
To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses.
The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000.
Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism.
More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of 406 billion dollars; 80 billion dollars for medical treatment and 326 billion dollars for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0-44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase.
These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.
The overall medical attention to the severely multiple traumatized patients is not usually unified in our setting. Different organizations and leadership act in each process phase, with marked standstill, opacity, and lack of coordination between them, which makes functioning the overall difficult to evaluate of a Traumatology Care System (TCS). The objective of this review is to describe the characteristic aspects of a TCS and to review the different methods currently used to audit its care quality. It is currently accepted that methods used for such a traumatology evaluation are made up by the clinical and necropsic audit supported with the TRISS methodology. The audit consists of contrasting the variables of activity of the TCS and the results, with reference to internationally accepted quality standards and predictive severity indices most commonly used. A key element is the necropsic analysis of all traumatic deaths classified as 'avoidable', 'non-avoidable', and 'potentially avoidable'. The final result tries to evaluate the magnitude of the problem, to detect the failing links in the chain, to issue proposals for improvement, and to provide tools for checking the true effects generated by the recommended proposals.
This paper focuses on the appropriateness of outcome measures to evaluate trauma care. The preventable death rate (PDR), based on the study of deceased patients only, has been the traditional measure of the impact of trauma care on improving the survival of patients with severe trauma. Another measure frequently used in other ares of evaluation research is the effectiveness rate--i.e. the survival rate in the total population of severe trauma patients. Because both the PDR and the effectiveness rate vary with the proportion of patients who would die even under conditions of optimal care, these two measures can be misleading. We illustrate their inadequacy by using published data on the impact of regionalization of trauma care. We propose the use of a third outcome measure of the impact of trauma care on survival, the efficacy rate--i.e. the survival rate among severe trauma patients with a potential for survival. Evaluation of trauma care should also measure outcomes other than survival and need not be restricted to patients with the most severe trauma. Evaluation of trauma care therefore requires outcome measures, such as the efficacy rate, which are based on the population at risk of manifesting the outcome of interest.
The Trauma Score (TS) has been revised. The revision includes Glasgow Coma Scale (GCS), systolic blood pressure (SBP), and respiratory rate (RR) and excludes capillary refill and respiratory expansion, which were difficult to assess in the field. Two versions of the revised score have been developed, one for triage (T-RTS) and another for use in outcome evaluations and to control for injury severity (RTS). T-RTS, the sum of coded values of GCS, SBP, and RR, demonstrated increased sensitivity and some loss in specificity when compared with a triage criterion based on TS and GCS values. T-RTS correctly identified more than 97% of nonsurvivors as requiring trauma center care. The T-RTS triage criterion does not require summing of the coded values and is more easily implemented than the TS criterion. RTS is a weighted sum of coded variable values. The RTS demonstrated substantially improved reliability in outcome predictions compared to the TS. The RTS also yielded more accurate outcome predictions for patients with serious head injuries than the TS.
To determine the effect of implementation of a regional trauma system on utilization of medical care we studied ambulance transports, emergency department (ED) visits, and hospital days for trauma and nontrauma patients before and after system implementation. Serious injury affects approximately one of every 1,000 persons each year and accounts for approximately one of every 250 ED visits, one of every 100 hospital days, and one of every 20 ambulance transports. Following system implementation the trauma hospitals experienced insignificant changes in annual percentage of market share of ED visits and hospital days and in annual rate of growth of ED visits and hospital days. We conclude that implementation of a medically directed regional trauma system has resulted in a predictable redistribution of a small number of seriously injured patients, and has not been associated with significant changes in utilization of EDs or hospitals.
A clinical scale has been evolved for assessing the depth and duration of impaired consciousness and coma. Three aspects of behaviour are independently measured—motor responsiveness, verbal performance, and eye opening. These can be evaluated consistently by doctors and nurses and recorded on a simple chart which has proved practical both in a neurosurgical unit and in a general hospital. The scale facilitates consultations between general and special units in cases of recent brain damage, and is useful also in defining the duration of prolonged coma.
A method for comparing death rates of groups of injured persons was developed, using hospital and medical examiner data for more than 2,000 persons. The first step was determination of the extent to which injury severity as rated by the Abbreviated Injury Scale correlates with patient survival. Substantial correlation was demonstrated. Controlling for severity of the primary injury made it possible to measure the effect on mortality of additional injuries. Injuries that in themselves would not normally be life threatening were shown to have a marked effect on mortality when they occurred in combination with other injuries. An Injury Severity Score was developed that correlates well with survival and provides a numerical description of the overall severity of injury for patients with multiple trauma. Results of this investigation indicate that the Injury Severity Score represents an important step in solving the problem of summarizing injury severity, especially in patients with multiple trauma. The score is easily derived, and is based on a widely used injury classification system, the Abbreviated Injury Scale. Use of the Injury Severity Score facilitates comparison of the mortality experience of varied groups of trauma patients, thereby improving ability to evaluate care of the injured.
To evaluate the effectiveness of the trauma care system in the Hudson Valley Emergency Medical Services (EMS) Region, (with no designated regional trauma care center) 421 consecutive trauma autopsy reports for 1979-80 were analyzed. Of the 421 trauma patients, 194 died at the scene (DAS), most from vehicular accidents. The remaining 227 patients were triaged into the EMS system. Ninety-five were dead on arrival (DOA) at medical facilities; of 132 (31 per cent) who arrived alive at hospitals, 35 died in emergency rooms and 97 died later as inpatients. Nearly 60 per cent of the deaths involved brain injuries. A panel of five physician-evaluators examined the pathologist's analysis of those deaths considered to have been possibly preventable and concluded that 10 deaths (7.6 per cent) of in-hospital cases were preventable. The study showed the need for primary prevention of accidents to decrease the number of victims (46 per cent) who died at the scene and those (23 per cent) who were dead on arrival at hospitals.
The above discussion brings together a vast body of data that together proclaim with fervent clarity: Traumatic injuries are expensive. The expense is paid in productive lives lost, in permanent disability, in pain and suffering, and in health care resources consumed. As local and regional trauma systems struggle for development and survival, competition for the health care dollar casts in the additional necessity of providing the service of trauma care with maximum efficiency. Despite the variety of cost-efficiency measures described above, a majority of trauma centers continue to operate "in the red." Such cannot continue indefinitely. Fiscal responsibility dictates that health care institutions must balance budgets in order to maintain operations. Four primary strategies for cost containment appear from the above discussion: 1. Improve reimbursement rates from trauma patients. 2. Increase outside funding from government sources. 3. Improve cost efficiency of diagnostic and therapeutic procedures used in trauma patient management. 4. Increase efforts aimed at primary prevention of intentional and unintentional injuries. In the final analysis, most authors agree that the last strategy offers the best hope. As stated in their article, "The Economic Impact of Injuries," Harlan and colleagues conclude that "the most effective medical and cost reduction strategy would be prevention." The same article goes on to detail how greater funding for research into optimal prevention modalities could reap societal and economic benefits far beyond the value of the initial outlay. Yet such research funding continues to be inadequate. For every dollar spent on medical care of cancer patients, nine cents is directed to research. For every dollar spent on trauma care, less than a penny is spent on research. Until the public recognizes the terrible toll trauma extracts in lives, livelihood, and money wasted and until it realizes the pre-eminent importance of prevention, care of the trauma patient cannot truly achieve cost efficiency.
Trauma registries offer distinct advantages and disadvantages when assessing the effectiveness of trauma systems. Detailed injury data and statistical comparisons that use TRISS methodology and the Major Trauma Outcome Study norms provide advantages over population-based or preventable death studies. However, miscodings and registry differences in injury severity coding limit the validity and generalizability of findings. The purpose of this study was to identify these strengths and weaknesses and to determine whether registry studies provide evidence of trauma system efficacy.
A systematic review of published literature assessing trauma systems effectiveness by using registry-based data.
Eight of 11 articles reviewed provided comparable data and consistently demonstrated a 15 to 20% reduction in the risk of death comparing trauma system outcomes to Major Trauma Outcome Study norms.
These studies provide evidence of the effectiveness of trauma systems. However, future studies that use trauma registries would be strengthened by including both prehospital and postdischarge trauma deaths, standardizing trauma registry inclusion criteria and developing a contemporary national reference norm for trauma outcome.
The term "golden hour" is commonly used to characterize the urgent need for the care of trauma patients. This term implies that morbidity and mortality are affected if care is not instituted within the first hour after injury. This concept justifies much of our current trauma system. However, definitive references are generally not provided when this concept is discussed. It remains unclear whether objective data exist. This article discusses a detailed literature and historical record search for support of the "golden hour" concept. None is identified.
To provide reliable and comparable information on major injury (MIJ) (Injury Severity Score (ISS) > 15) by establishing a comprehensive and Utstein-style compliant registry of all occurrences in a defined geographical area.
Prospective, population-based, 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia (FVG). Deliberate self-harm was excluded.
The total number of MIJ cases was 627, the resulting incidence 522 per million per year. Trauma was mostly blunt (98.4%). Young (15-44 years) adults (54.8%) and males (78.6%) were most affected. Leading mechanisms of injury were traffic accidents (81%) and falls (9.1%). Most events occurred in rural (80.9%) areas despite one third of the regional population living in major urban centres. Summer and weekends carried the highest frequency. The mean ISS ( n = 455 ) was 30.0, median 25. On-scene vital parameters were often subnormal, e.g. 53.9%, GCS < 14. The Emergency Medical System was nearly always activated (98.4%). The time intervals were within standards although in part susceptible of improvement. The percentage of direct triage to the definitive hospital was 79.8%. Overall mortality was 45.6% or 238 per million per year. Most fatalities were found already dead (171/300) and no trimodal distribution was verified. Only 1.5% of the patients found alive died outside hospital. Mean GOS was 4.4 +/- 1 (S.D.), median 5.
A considerable amount of information on MIJ in FVG has been gathered, of both local and general interest because it can help to assess the local trauma system and also, given the relative scarcity of prospective, population-based information on MIJ, contribute to scientific research.
Response time is a very important factor in determining the quality of prehospital EMS. Our objective was to model the response by Israeli ambulances and to offer model-derived strategies for improved deployment of ambulances to reduce response time. Using a geographic information system (GIS), a retrospective review of computerized ambulance call and dispatch logs was performed in two different regional districts, one large and urban and the other rural. All calls that were pinpointed geographically by the GIS were included, and their data were stratified by weekday and by daily shifts. Geographic areas (polygons) of, at most, 8 minutes response time were simulated for each of these subgroups to maximize the timely response of calls. Before using the GIS model, mean response times in the Carmel and Lachish districts were 12.3 and 9.2 minutes, respectively, with 34% and 62% of calls responded within 8 minutes. When ambulances were positioned within the modeled polygons, more than 94% of calls met the 8-minute criterion. The GIS simulation model presented in this study suggests that EMS could be more effective if a dynamic load-responsive ambulance deployment is adopted, potentially resulting in increased survival and cost-effectiveness.
The establishment of trauma systems was anticipated to improve overall survival for the severely injured patient. We systematically reviewed the published literature to assess if outcome from severe traumatic injury is improved for patients following the establishment of a trauma system.
A systematic literature review of all population-based studies that evaluated trauma system performance was conducted. A qualitative analysis of each study's design and methodology and a meta-analysis was performed to evaluate the evidence to date of trauma system effectiveness.
A search of the literature yielded 14 published articles. Trauma systems demonstrated improved odds of survival in 8 of the 14 reports. The overall quality-weighted odds ratio was 0.85 lower mortality following trauma system implementation.
The results of the meta-analysis showed a 15% reduction in mortality in favor of the presence of a trauma system. Evaluation of trauma system effectiveness must remain an uncompromising commitment to optimal outcome for the injured patient.
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