ArticlePDF Available

THE MANAGEMENT IN “THE GOLDEN HOUR” AND THE SURVIVAL RATE OF THE POLYTRAUMATIZED PATIENT

Authors:

Abstract and Figures

Introduction – because of their characteristics, the polytraumatisms represent one of the most important aspects in the emergency medical activity, and the multiple injuries associations can raise a chain of problems initiating a big score of complex interactions, especially in the situations where the management isn’t fulfilled by an advanced trauma team.Paper purpose –is to identify the elements having the most impact in the polytraumatized patient survival rate. Resources and methods - 947 patients with multiple trauma received by UPU Craiova between 06.1997 –10.2004 These patients were divided in three groups: - ·Patients brought by mobile resuscitation units; - Patients brought by ordinary ambulances; - Patients brought by secular means. Conclusions:1.The survival rate is much more reliant on the „platinum minutes” than the overall intervention time, if it is maintained under 60 minutes; 2. Prolonged extrication because of the less specialized teams leads to a bad forecast factor; 3.A bigger downfall of the survival rate is the result of the lower TS and less specialized teams.
Content may be subject to copyright.
THE MANAGEMENT IN “THE GOLDEN HOUR” AND THE
SURVIVAL RATE OF THE POLYTRAUMATIZED PATIENT
INTRODUCTION
Emergency management of the polytraumatized
patient represents a complex action, which is being
much more unfolded than in other emergency cases,
calling the “golden hour” and the “platinum minutes”,
under more levels and successive stages (7), (24), (38),
claiming an medical deployment, specialized equipment,
experience and competence.
36
Journal of Experimental Medical & Surgical Research
Cercetãri Experimentale & Medico-Chirurgicale
Year XVII · Nr.1/2010 · Pag.36 - 43
Experimental
Medical Surgical
RESEARCH
JOURNAL of
Correspondence to:Luciana Rotaru, e-mail: lucianarotaru@yahoo.com
SUMMARY:
Introduction – because of their characteristics, the polytraumatisms represent one of the
most important aspects in the emergency medical activity, and the multiple injuries
associations can raise a chain of problems initiating a big score of complex interactions,
especially in the situations where the management isn’t fulfilled by an advanced trauma
team.Paper purpose –is to identify the elements having the most impact in the
polytraumatized patient survival rate. Resources and methods - 947 patients with multiple
trauma received by UPU Craiova between 06.1997 –10.2004
These patients were divided in three groups:
- ·Patients brought by mobile resuscitation units;
- Patients brought by ordinary ambulances;
- Patients brought by secular means.
Conclusions:1.The survival rate is much more reliant on the „platinum minutes” than the
overall intervention time, if it is maintained under 60 minutes;
2. Prolonged extrication because of the less specialized teams leads to a bad forecast
factor;
3.A bigger downfall of the survival rate is the result of the lower TS and less specialized
teams.
Key Words: golden hour’’, survival chance, multiple trauma
MANAGEMENTUL ÎN "ORA DE AUR" ªI RATA SUPRAVIEÞUIRII PECIENTULUI
POLITRAUMATIZAT
Rezumat: Datoritã caracteristicilor sale politraumatismul reprezintã un important aspect în
medicina de urgernþã, asocierea multiplelor leziuni putând genera complicaþii multiple, mai
ales dacã managementul accidentatului nu este fãcut de o echipã specializatã în
managementul avansat al traumatismelor. Scopul articolului este de a identifica elementele
care au impact major în suprevieþuirea pacientului politraumatizat. Material ºi metodã. 947
pacienþi primiþi în serviciul de urgenþã Craiova pentru politraumatism în perioada iunie 1997
- octombrie 2004. Pacienþii au fost împarþiþi în 3 grupuri: pacenþi aduºi de ambulanþa de
resuscitare; pacenþi aduºi cu ambulanþa obiºnuitã, pacenþi transportaþi cu mijloace
nemedicale. Concluzii. 1. Rata supravieþuirii este corelatã mai mult cu "minutele de platinã"
decât cu timpul total de intervenþie, dacã acesta este menþinut sub 60 minute.
2. Durata prelungitã a descarcerãri din cauza unei echipe mai puþin specializate constituie
un factor predictiv defavorabil.
3.Rata supravieþuirii scade semnificativ ca rezultat al uni scor traumatic scãzut ºi
intervenþiei unei echipe nespecializate.
L. Rotaru1,
F. Calotã2
Received for publication: 01.01.2010
Revised: 14.02.2010
1. - UMF Craiova, UPU Clinical Hospital of Emergency Craiova; 2 - UMF Craiova, Clinical Hospital of Emergency Craiova
2nd Surgical Clinic
PAPER PURPOSE
The work wants to identify the elements which
conditions in the highest grade the survival rate of the
polytraumatized patient and also the complications
emergence, encroaching over recovery and social
reinsertion, and the correlation of these elements with
the basic marks of the management during the “golden
hour” and “platinum minutes”, hence the medical
management. In this way the evaluation elements are
highlighted (7), (15), management (2), (4), (5), (6), (18),
time (18), directions (24), (25), (38), from which, the
complex up mixing gives birth to the survival chance and
whose bettering can improve the instant vital and
functional prognostic of the polytraumatized patient.
Finally, we have aimed that the identified elements as
being relevant, so that they could be used in making
trauma simulations for the trauma team education and
the clinical management, and, in prospect, at the
dynamic management performance evaluation.
RESOURCES AND METHODS
The study was implemented on group of 947 gravelly
polytraumatized or mono traumatized patients, registered
at the emergency care unit (UPU) at Craiova Clinical
Hospital of Emergency, during 10 June 1997 – 1 October
2004.
They were divided in 3 major groups, as follows:
1. Orange group – extracted patients from the
accident scene and brought by secular means;
2. Blue group - extracted patients from the
accident scene with improvised means and transported
to UPU with different kinds of ambulances, accompanied
by unspecialized trauma teams and partial management;
3. Red group - extracted patients from the
accident scene by mixed resuscitation and extrication
specialized teams. In this group there was also included
and differentiated a patients subgroup that were
extracted from the accident scene with improvised
means until the arrival of the specialized teams and
assumed after the extrication by the intensive care units
(green group)(fig. 1) .
For every patient group, we studied lesion trauma
severity and complexity of the assessment score trauma
and abbreviated score trauma (29), (40), (41), the
dynamic complexity of management developed during
the “golden hour” (7), (24), satisfaction level of
therapeutic imperatives imposed by the “platinum
minutes” (2), the period of time until the polytraumatized
patient is delivered to the surgical trauma team (36),
severe injuries most frequently omitted from preliminary
clinical balance (17), (24), (37). We assessed the
patients’ survival rate at 4 hours.
After classification by groups of these patients have
achieved statistical study of data obtained and turned
them later in models (29), for each group of cases
detected through clinical evaluation of the situation and
to medical conduct.
We composed a score for each stage of intervention in
the context of the patient’s clinical situation, which was
introduced in a scale of comparative values that can be
appreciated correlated with the degree to which these
gestures and therapeutic decisions have implications for
influencing patient survival. As a result we have covered
that for each type of accident and profile of lesion, age
and trauma score can be the maximum rank and share
37
46
32
00
41
25
15
11
31
36
29
9
29
51
38
7
24
50
29
6
23
47
34
619
64
54
510
69
103
4
0
20
40
60
80
100
120
1997 1998 1999 2000 2001 2002 2003 2004
DISTRIBUTION CASES
secular means unspecialized ambulance
resusctitation resusctit atiion/meeting
Fig. 1. Distribution of cases per year and working groups.
the best time in the patient’s general treatment of each
gesture, so that they can be introduced as standard
practice and evaluation of all the teams involved in
trauma patient management (36).
RESULTS AND DISCUSSIONS
As the dispatchers got more active towards
polytraumas crews of resuscitation, the percentage of
polytraumatized patients arriving at hospital brought by
secular means has decreased. It can also be observed
that the incidence in the system has decreased “in the
meeting”, by recovery crews and ambulances from
ordinary laymen and the number of polytraumatized
patients or severe mono traumatized patients arriving at
the UPU with unspecialized ambulances, since the upper
classes have been targeted to be first dispatched to
traumatic critical emergency.
Analyzing the average time of arriving to the injured,
average time of the accident to the resuscitation process,
stabilizing or prosthesing the vital functions and the total
38
URBAN DYNAM IC INT ERVENTION TIM E
4
37
25
11
43
38
5.4
10 .5
33
5.4
12 .7
29
0
5
10
15
20
25
30
35
40
45
50
averr age t ime unt i l t he
pati ent
resuscit ati on mean vi t al
func t ions
tot al aver age
int erv ent ion t ime
secular
unsp eci al i zed ambu lan ces
SMURD
smur d
Fig. 2 a
RURAL DYNA M IC INTERV ENTION T I M E
8
55
38
24
68
55
13 . 7 19 . 2
49
13 . 7
22.3
43
0
10
20
30
40
50
60
70
80
aver rage t ime unt i l t he
patient
resuscit at ion mean vi t al
funct ions
t otal aver age
int erv ent ion t ime
Fig. 2 b
ASOCIERI
LEZIONALE
TRAUMA RATES
3 4 5 6 78910 11 12 13 14 15 16
CcFTAM 21 17 34 57 33 18 20 31 10 12 15 622
CcFTA 4 7 9 13 57811 689785
CcFTM 5 9 11 17 84910 457867
CcFAM 1 2 3 6 3 6 8 2 3 5 7 9 4 7
TAM 11452487124354
CcFT 1 2 1 1 1 0 0 2 4 3 3 7 4 1
CcFA 3 0 0 1 0 1 1 1 3 4 4 3 3 8
CcFM 0 0 1 2 1 1 1 2 1 2 2 2 6 10
TA 11120102124738
TM 01111211112124
ararsid100995
89 AM 00020111113289
Cc(F) 514 10 16 7957235957
T111310121021211
A000100010121113
M010200120000018
TABLE 1 - Initial scores on the association of trauma lesion
C – skull, c – cervical spine, F – facial, T – thorax, A – abdomen, M – pelvis and/ or limbs, Ia – absolute incarceration, Ir –
relative incarceration, E – out of the vehicle ejected patient.
average intervention premedical stage (until the entry in
UPU we acknowledged – see figure 2a, b) (table 1 )
The next thing we followed the developments of
trauma scores for each working group and the original
score of trauma throughout the golden hour and
introduced these values in a statistical formula. The
momentwe recalculated the trauma score were
established at the end of the „platinum minutes”(10
minutes after the accident) and then every 10 minutes.
This means that we have pursued the ideal range to
restore vital functions or to make a prothesis for the vital
functions (24), respectivelly, the first 10 minutes of the
accident and then monitoring the manner on how the
medical team, optimizes and leverages the benefits
obtained in the „platinum minutes”.
Finally a comparison through superpositioning the
curves for every trauma score cathegory and for each
work group was made (figures 3,4,5,6) and the score
trauma of the patients with cardiopulmonary arrest, ST
patients 4 – 6, 7 – 10, 11 – 14, 15 – 16, laymen assisted,
medium or specialized teams (we proceeded to this
group because of their similarity, we observed significant
39
THE EVOLUTION OF THE
TRAUMATIZED PATIENTS BROUGHT
BY LAYM EN
3
5
7
9
11
13
15
010 20 30 40 50 60
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Fig. 3
THE EVOLUTION OF THE
TRAUMATIZED PATIENTS
BROUGHT BY UNSPECIALIZED
AMBULANCES
3
5
7
9
11
13
15
010 20 30 40 50 60
3
3
5
6
7
8
9
10
11
12
13
14
15
15
Fig. 4
THE EVOLUTION OF THE
TRAUMATIZED PATIENTS BROUGHT
BY SM URD
3
8
13
010 20 30 40 50 60
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Fig. 5
EVOLUTION OF THE ST AND THE
INCARCERATED ASSISTED
PATIENTS "AT THE MEETING " BY
SM URD
3
8
13
010 20 30 40 50 60
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Fig. 6
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
010 20 30 40 50 60
TRAUM A SCORE EVOLUTION OF
THE TRAUMATIZED PATIENTS WITH
CARDIOPULM ONARY ARREST
laymen
ordinary
ambulances
intensive care
ambulances
meeting
Fig. 7– ST patients evolution with
t
e
mporal evolution of patients with trauma scores
attached).
From studying the data presented in these graphs
outstanding issues arise:
1. The ST evolution dynamics for patients with fewer
than 10 ST was similar in patients assisted with the
assistance of secular and non-specialized
ambulances - standing curve downward, more
marked in patients transported by laymen.
2. The more ST value was weaker, the more the
degradation evolved in patients brought by lay
rescuers, uncompensated degradation by the
medical team, after entering UPU (the average ot the
last 20 minutes of the „golden hour”) so that the
trauma score continued to remain low throughout the
‘golden hour’.
3. Patients assisted by teams of trauma resuscitation
the trauma score evolution registered earlier steep
rising of the trauma score to the patients that were in
40
0
5
10
15
010 20 30 40 50 60
ST P ATIENT EVOLUTION 7-10
laymen
ordinary
ambulances
intensive care
ambulances
meeting
Fig. 9 – ST PATIENT EVOLUTION 7-10
Cardio respiratory arrest
0
5
10
15
010 20 30 40 50 60
ST PATIENT EVOLUTION 11-14
laymen
ordinary
ambulances
intensive care
ambulances
meeting
Fig. 10 – ST PATIENT EVOLUTION 11-14
0
5
10
15
00.5 11.5 22.5 33.5 4
MORTALITY RATE AT THE
POLYTRAUMATIZED PATIENTS HAVING
THE ST 3 - 4
decreases over 3 decreases 1-3
constant increases 1- 3
increases over 3
Fig. 11 – ST 3-4 patients mortality rate
0
5
10
15
20
00.5 11.5 22.5 33.5 4
MORTALITY RATE AT THE
POLYTRAUMATIZED PATIENTS HAVING
THE ST 5-6
decreases over 3 decreases 1-3
constant increases 1- 3
increases over 3
Fig. 12 –ST 5 – 6 patients mortality rate
0
5
020 40 60
ST P ATIENTS EVOLUTION 4-6
laymen
ordinary
ambulances
intensive care
ambulances
meeting
Fig. 8– ST patients evolution 4-6
specialized care from the beginning, than those who
were taken late in pregnancy by a dedicated team.
The category of trauma patients with initial scores
between 11 and 14, particularly interesting, should be
considered carefully as part of the initial score because at
first glance it does not indicate an imminent major risk,
but by ordinary ambulances condition assisting or by
laymen assisting the rapid degradation of the trauma
score in the first 20-30 minutes, place them on patients
with high risk category patients. This is the „preventable
deaths in trauma” cathegory, (26), or the patients that
„talk and die”.
CONCLUSIONS
Clearly the survival curve is correlated with the
polytraumatized patient curve correlated with the trauma
score recorded during the „golden hour”, there is clearly a
big difference in development score according to the
applied trauma management, which can send the patient
in a different class of prognostic scores corresponding to
other initial trauma, with other words, benefits can be
compromised or „bought „ for the patient when
sometimes early gestures are made(22), sometimes by
simple therapeutic gestures(25), and quickly applied(34).
1. There are cases which have not received
management that respects the principle of „golden
hour’’ (11,96%), expressing a proportion of patients
at risk of not having access to definitive treatment.
2. Vital function resuscitation time. Only 22,86% of
patients received resuscitation maneuvers for vital
functions inside, ‘’platinum minutes” (1), (2),(6), (31),
(32), (39), and over 35% of stroke patients had more
than 30 minutes of resuscitation, which means that
they didn’t benefit from resuscitation during transfer
to hospital but only after reaching the UPU.
3. Average survival time of the patients who have been
taken ordinary crew is with 36,8% smaller than the
patients who have been taken by an advanced crew
and of patients who have taken laity is with 49.7 %
shorter than in patients assisted by advanced crews.
The presence of a secondary recovery crew at the
scene could only partially restore „survival chances”
average duration of survival in such cases being
higher with about 1,9 times than those obtained by
non-specialized or lay ambulances, but lower with
41
0
1
2
3
4
5
00.5 11.5 22.5 33.5 4
MORTALITY RATE AT THE
POLYTRAUMATIZED PATIENTS HAVING
THE ST15-16
decreases over 3 decr eases 1- 3
co nst ant increases 1 - 3
increases o ver 3
Fig. 15 –ST 15 – 16 patients mortality rate
0
5
10
15
20
25
30
35
0.5 11.5 22.5 33.5 4
GENERAL MORTALITY RATE IN THE
FIRST 4 HOURS
ST 3-4 ST 5 - 6 ST 7 - 1 0
S T 11- 14 S T 15 - 16
Fig. 16 – global mortality in the first 4 hours
0
5
10
15
00.5 11.5 22.5 33.5 4
MORTALITY RATE AT THE
POLYTRAUMATIZED PATIENTS HAVING
THE ST 7-10
decreases over 3 decreases 1-3
constant increases 1- 3
increases over 3
Fig. 13 –ST 7 – 10 patients mortality rate
0
2
4
6
00.5 11.5 22.5 33.5 4
MORTALITY RATE AT THE
POLYTRAUMATIZED PATIENTS HAVING
THE ST11-14
decreases over 3
decreases 1 -3
co nst ant
increases 1 - 3
increases o ver 3
Fig. 14–ST 11 – 14 patients mortality rate
1,3 times than those obtained by the resuscitation
team’s primary access stage.
4. At the same time of resuscitation and intervention for
all different average length of survival decreases
steadily with increasing time of intervention, even in
average times considered by laymen and ordinary
ambulances optimal for patients assisted.
5. Identical to the total time of intervention,
resuscitation times lengthening the duration of
survival decreases, especially for recovery crews.
For patients and other lay retrieve ambulances,
correlations are conclusive only for short TTI,
because survival after resuscitation is influenced
more by the UPU.
6. At the same time the total time of intervention and
stabilization of the vital functions, the difference in
survival time for advanced management
physiopathological visa (8), (11), (20), (23), including
general anesthesia and preoperative preparation
(10), (13), (21), (28), (30), and co-management and
non-lethal injuries that impact in context (14), (17),
(27), - the survival time is 2.48 times higher in
patients assisted by crews from the assisted
recovery and of other types of ambulances and 3.73
times higher than those assisted by laymen. The
survival time of patients assisted by ambulances is
1.5 times higher than that recorded in the same TTI
and TR patients laymen retrieve.
7. Incarcerated patients survival - incarceration,
even for a short while, is a major factor affecting the
prognosis significantly, (7), (14), average length of
survival decreasing with the prolongation of
extrication. For ST 4, common in patients assisted by
ambulances to extend the extrication process 5 ‘ the
survival rate is reduced with an average of 15,8%. In
patients with TD assisted ambulances from 30 to 45
minutes. average survival time is 1.86 times lower
than the average duration of survival for patients of
this group and 2.53 times lower than the survival
time of patients assisted by resuscitation –
extrication complex teams that don’t have
significantly alter the average length of patient
survival, compared with the unincarcerated patient
to incarcerated of up to 45 minutes.
8. Chance of survival during resuscitation of vital
functions. TS 7-10 group has has won the most
chance of survival if resuscitation is early (33), (34),
and energical (10), (25),. For the inferior TS’s of TS6
the rule is maintained, but the benefits are harder to
isolate revealed only to this parameter, patients
belonging to these unavoidable posttraumatic
deaths. For the superior TS over 12, survival
difference is not so obviously correlated with survival
of patients in these categories tolerating latency
longer in the rehabilitation of vital functions without
significant deterioration of the prognosis. Class TS 11
proves risky in terms of degradation rate of survival in
the timing of gestures for the provided y vital
functions recovery (23), (30), (33), (difference in
survival time 25% to 10 minutes resuscitation time
delay). These patients appear in the category of the
preventable trauma deaths.
9. Rate of degradation of the duration of survival is even
faster as the TS are lower and survival is dependent
on TS and not on the trauma mechanism (3,9,16,19).
10. Complications occurred can aggravate both secured
vital prognosis (5), (12) and the opportunity for
rehabilitation.
42
REFERENCES
1. American College of Emergency Physicians. Advanced Emergency Airway Management; Charlotte; North Carolina;tab 1 –
13: 15: 16,1997
2. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support for Doctors. Student Course Manual
sixth ed.edn. ACS, Chicago; 127:134 – 53:215 – 30, 1997
3. Argyros GJ. Management of primary blast injury. Tox i col ogy; 121: 105-115, 1997
4. Baerga-Varela Y, Zietlow S, Bannon MP, Harmsen WS, Ilstrup DM. Trauma in pregnancy. Mayo Clin Proc;75:1243-8,
2000
5. Bãdeþi R, Babeu A, et.al.: Urgenþe pediatrice. Algoritme diagnostice ºi terapeutice; ed. Brumar Timiºoara; 321 – 341, 2005
6. Bickell W., Wall M., Pepe P., et. al. Immediat versus delayed fluid resuscitation for hypotensive patients with penetrating
torso injuries. NEJM;.331;1105 – 9,1994
7. Cameron P, Yates D. Trauma. In Jelinek G, Kelly A.M, Murray L, Heyworth J. Textbook of adult emergency medicine;
Harcourt Publishers Limited; 39 – 102, 2000
8. Cantrill SV. Facial trauma. In Rosen P, Barkin RM (eds) Emergency medicine – concepts and clinical practice, 3rd edn.
Mosby Year Book, St. Louis; 355 – 70, 1992
9. Chandler CF, Lane JS, Waxman KS: Seatbelt sign following blunt trauma is associated with increased incidence of
abdominal injury. Am Surg; 63(10): 885-8, 1997 (Oct)
43
REFERENCED (CONTINUED)
10. Chiorean M, Cardan E, Cristea I: Medicinã intensivã vol. 3; ed. Prisma, TîrguMureº; 11- 44, 601 – 07, 1999
11. Cooper A, Barlow B, DiScala C, et al: Efficacy of MAST use in children who present in hypotensive shock. J
Trauma;33:151,1992
12. Cotulbea R M, Ghelase F: Chirurgie toracicã; Ed Didacticã ºi Pedagogicã R.A, Bucureºti; 302 – 27, 1999
13. Cristea I, Ciobanu M: Ghid de anestezie terapie intensivã; ed. Medicalã; Bucureºti; 411 – 54: 842 – 92: 939 – 41, 2003
14. Danzl D.F ; Accidental hypothermia; In Auerbach PS editor: Wilderness medicine; 4th edition, By Mosby 2001
15. Davis MA, Votey SR., Greenough GP. Signs & Symptoms In Emergency Medicine; Mosby; 458 - 77, 1999
16. DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med; 352: 1335-1342, 2005
17. Enderson BL, Reath DB, Meadors J: The tertiary trauma survey: a prospective study of missed injury. J Trauma ; 30(6):
666-9; discussion 669-70, 1990 (Jun)
18. European Resuscitation Council (ERC). Guidelines for Resuscitation 2005. Elsevier Science Resuscitation 67: 71 – 5: 144 –
5:156 – 62, 2005
19. Feliciano DV, Rozicky GS. The management of penetrating abdominal trauma. Advances in surgery. 28:1 – 39, 1995
20. Fortune JB, Fenstel PJ, Graca L, Husselbarth J, Kuchler DH. Effect of hyperventilation, Mannitol and ventriculostomy
drainage on cerebral blood flow after head injury. Journal of Trauma, Injury, Infection and Critical Care 39 (6): 1091 –
1099,1995
21. Gaines BA, Ford HR. Abdominal and pelvic trauma in children.crit care med; 30 (11): S416- S423, 2002
22. Grossman N.B Blunt Trauma in Pregnancy. Am Fam Physician;70:1303-10,1313, 2004
23. HachimiIdrissi S, Corne L, Ebinger G, Michotte Y, Huyghens L. Mild hypothermia inducet by a helmet device: a clinical
feasibility study. Elsevier Science Resuscitation; 51: 275 – 81, 2001
24. Hodgetts T, Deane S, Gunning K; Trauma rules. BMJ Publishing Group; London;3 – 10: 13 – 30: 32 – 5:39 – 42: 45 – 51: 55:
59 – 62: 67 – 95, 1997
25. Holliman J, Arafat R, Boeriu C: Asistenþa de urgenþã a pacientului traumatizat; Casa de Editurã Mureº, TîrguMureº, 5 –
153. 169 – 212: 265 – 96, 2004
26. Hussain L, Redmond A. Are the pre – hospital deaths from accidental injury preventable? – BMJ; 308: 1077 – 80, 1994
27. Knudson MM, McAninch JW, Gomez R, et al: Hematuria as a predictor of abdominal injury after blunt trauma. Am J Surg;
164(5): 482-5; discussion 485-6, 1992 (Nov)
28. Lockey D.J.Prehospital trauma management. Oficial J. Of European resuscitation Council: 5 – 17, 2001 (Jan)
29. Marcin JP, Pollack MM. Triage scoring systems, severity of illness measures, and mortality prediction models in pediatric
trauma. Crit Care Med;30 (11 suppl):S457-67, 2002
30. Piek J. – Guidelines for the Pre-Hospital Care of Patients with Severe Head Injuries; - European Society of Intensive Care
Medicine, Brussels, 1996
31. Pryor JP, Pryor RJ, Stafford PW:Initial phase of trauma management and fluid resuscitation.Trauma Reports;3(3):1-12,
2002
32. Roberts JR, Hedges JR, Dronen SC: Pharmacologic Adjuncts to Intubation. In: Clinical Procedures in Emergency Medicine.
3rd ed. Philadelphia, Pa: WB Saunders Co;: 45-57, 1998
33. Rosen P, Barkin RM, eds: Emergency Medicine: Concepts and Clinical Practice. Vol 1. 4th ed. St. Louis, Mo: Mosby-Year
Book;:555-61, 1998
34. Schalamon J, v Bismarck S, Schober PH, Hallwarth ME. Multiple trauma in pediatric patients. Pediatric Surgery
International; 19(6): 417-423, 2003
35. Schneider C, Gomez M, Lee R: Evaluation of ground ambulance, rotor-wing, and fixed-wing aircraft services. Crit Care Clin;
8:533, 1992
36. Smith J, Caldwell E, Sugrue M. Difference in trauma team activation criteria between hospitals within the same region.
Emergency Medicine Australasia 17:5-6: 480-487, 2005
37. Sung C, Kim KH. Missed injuries in abdominal trauma. Journal of Trauma; 41: 276 – 78, 1996
38. Tintinalli J.E (Editor), Gabor D., Kelen Md. (Editor), Stapczynski J. S. (Editor) Emergency Medicine: A Comprehensive
Study Guide 6th edition By McGraw-Hill Professional; (9):65 – 107: (192). 6178 – 82: (246) 6808 – 16: (251) 6900 – 13 :
(252) 6929 – 42: (255) 6960 – 81, 2003
39. Wang HE, Yealy DM: Out-of-hospital rapid sequence intubation: is this really the “success” we envisioned?. Ann Emerg
Med; 40(2): 168-71, 2002 (Aug)
40. Wetzel RC, Burns RC. Multiple trauma in children: Critical care overview. Crit Care Med; 30(11): S468-477, 2002
41. Yates DW. Scoring systems. In: Skinner d. Driscoll P, Earlam R. ABCof Major Trauma, 2nd edn. London: BMJ Publishing
Group, 1996
... The first hour after a crash has occurred is commonly referred to as "golden hour" [97,98], during which if the victim receives proper first aid, the chances of survival and reduction in severities of other injuries are high. Unfortunately, current system for emergency medical care of crash victims in KSA is lagging international standards. ...
Article
Full-text available
Road traffic crashes (RTCs) are one of the most critical public health problems worldwide. The WHO Global Status Report on Road Safety suggests that the annual fatality rate (per 100,000 people) due to RTCs in the Kingdom of Saudi Arabia (KSA) has increased from 17.4 to 27.4 over the last decade, which is an alarming situation. This paper presents an overview of RTCs in the Eastern Province, KSA, from 2009 to 2016. Key descriptive statistics for spatial and temporal distribution of crashes are presented. Statistics from the present study suggest that the year 2012 witnessed the highest number of crashes, and that the region Al-Ahsa had a significantly higher proportion of total crashes. It was concluded that the fatality rate for the province was 25.6, and the mean accident to injury ratio was 8:4. These numbers are substantially higher compared to developed countries and the neighboring Gulf states. Spatial distribution of crashes indicated that a large proportion of severe crashes occurred outside the city centers along urban highways. Logistic regression models were developed to predict crash severity. Model estimation analysis revealed that crash severity can be attributed to several significant factors including driver attributes (such as sleep, distraction, overspeeding), crash characteristics (such as sudden deviation from the lane, or collisions with other moving vehicles, road fences, pedestrians, or motorcyclists), and rainy weather conditions. After critical analysis of existing safety and infrastructure situations, various suitable crash prevention and mitigation strategies, for example, traffic enforcement, traffic calming measures, safety education programs, and coordination of key stakeholders, have been proposed.
... It is noteworthy that a number of these causes of death can be missed on a superficial evaluation due to the incomplete clinical picture, nonspecific or inconsistent due to the traumatic associations described with high visibility in the immediate perspective on the evolution of the patient (such as the shock not high lightened and treated in its "compensated" early stages, can have a dramatic evolution, sometimes irrecoverable). Others can cause chain pathophysiological alterations that can impede the development at distance of the patient, and thus may alter his chance of survival, such as hypothermia or crush syndrome that can have misleading appearances of gravity which make them invisible to an unsuspecting and untrained eyes [28] . ...
Article
Full-text available
Background Brain injury provide a significant percentage of,, preventable deaths '' in trauma, makes the threaten in the highest degree the survival chance leads to definitive impairment of the brain functions, generates traumatic disability and concomitant lesion associations. Purpose of the paper is to highlight specific diagnosis but also management and evolution medical issues that each of the two lesion types generate and which can lead to misdiagnosis symptoms and signs. We focused on the specific ways trough abdominal and brain injury interacts each other to produce a traumatic complex evolving and adding secondary traumatic effects In the same time we aimed to distinguish very particular emergency approach standards to minimize the risks of worsening evolution The method of study We analyzed 398 patients assisted by the prehospital teams related to ED County Hospital Craiova (2009 – 2012) with different association of multiple trauma lesions but significant abdominal and brain trauma association Conclusions 1. clinical examination data are difficult to analyze in the presence of altered mental status and paraclinically resources must be widespread or systematic used 2. cervical spine lesions or spinal shock hide most significantly clinical abdominal signs 3. neurogenic shock can create confusion in the hemorrhagic shock interpretation 4. secondary brain injury is maintained or worsening by the presence of shock, but overcorrection of those to 5.general anesthesia should be early considered in tactics, techniques and means custom, which has undeniable benefits in combating shock and brain protection 6. temperature control should be considered
Conference Paper
Therapies to lower intracranial pressure (ICP) after traumatic brain injury (TBI) include hyperventilation (HV), intravenous mannitol (IM), and cerebrospinal fluid drainage from a ventriculostomy (DV). To determine the effects of these therapies on cerebral blood flow (CBF), fiberoptic oximetry was used to measure jugular venous O2 saturation (SjvO2) as an index of the CBF to cerebral metabolic rate for O2 (CMRO2) ratio after IM (25 g IV for more than 5 min), DV (3 min), or HV (increase respiratory rate by 4) therapy for elevated ICP. Assuming CMRO2 is constant, changes in SjvO2 reflect changes in CBF. Continuous measurements of SjvO2, ICP, blood pressure, arterial O2 saturation, and end-tidal CO2 were obtained in 22 patients with a Glasgow Coma Scale score of 5.3 +/- 0.4 (mean +/- SD) in the first 5 days after TBI. Therapy was initiated a total of 196 times when ICP was > 15 mm Hg for > 5 minutes, and measurements made at 20 minutes after treatment were compared with those made just before. After DV, ICP fell in 90% of the observations by 8.6 +/- 0.7 mm Hg (mean +/- SEM, n = 119); after IM, ICP fell in 90% of the observations by 7.4 +/- 0.7 mm Hg (n = 43); and after HV, ICP fell in 88% of the observations by 6.3 +/- 1.2 mm Hg (n = 14). In patients where ICP fell, SjvO2 increased by 2.49 +/- 0.7% saturation (from 68.0 +/- 1.3%) with IM, but only by 0.39 +/- 0.4% saturation (from 67.2 +/- 0.9%) with DV.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Among the 1,484 patients included in the Renal Trauma Project with evidence of blunt trauma and hematuria, 160 patients were found to have both hematuria and a significant intra-abdominal injury not related to the genitourinary system. The incidence of abdominal injury generally increased with the degree of hematuria, approaching 24% in patients with gross hematuria. For each category of degree of hematuria, patients with shock had a significantly higher incidence of abdominal injury (p < 0.05) than patients without shock. The incidence of abdominal injury in patients with microscopic hematuria and shock was 29%, and it was 65% for patients with both gross hematuria and shock. All patients with gross hematuria after blunt abdominal trauma and all patients with microscopic hematuria and a history of shock should be evaluated for both urologic and extra-renal abdominal injuries.
Article
It is hoped that this article has offered insightful suggestions and criteria in choosing the most appropriate method to transport patients. Ground ambulances, rotor-wing, and fixed-wing aircraft each have advantages and disadvantages in particular circumstances. The advantages and disadvantages of any mode of transport must be considered to best meet the needs of the patient. In the twentieth century alone, great strides have been made in the field of emergency stabilization and transport. An efficient, well-trained ground ambulance program remains the backbone of prehospital and interhospital transport systems. Helicopters and fixed-wing transports must be integrated into the EMS system. One advantage of the helicopter and fixed-wing aircraft is rapid travel times when time is critical. As Hicks et al said, "early resuscitation and timely transfer of selected patients are critical factors in reducing morbidity and mortality." The future holds many possibilities for enhanced patient transport. Hospitals may be able to use tilt-rotor, vertical landing, fixed-wing aircraft to combine the advantages of helicopter and fixed-wing aircraft. After all, our primary goal is to get the right patient, with the right personnel, to the right place in the right amount of time.
Article
The Advanced Trauma Life Support Course defines a primary and a secondary survey to rapidly identify life-threatening and associated injuries, respectively, in multiple trauma patients. However, circumstances during resuscitation, including multiple casualties, emergent operation, unconsciousness, etc., may interfere with this process. An initial review of our trauma registry data yielded a modest 2% incidence of missed injuries in a 90% blunt trauma population. In order to determine the true incidence of missed injuries, a tertiary survey was performed prospectively on all injured patients (N = 399) admitted during a recent 3-month period. After completion of the primary and secondary surveys (including appropriate roentgenographs), all injuries were listed in the trauma admission record. Patients were later reexamined immediately before ambulation or, in head-injured patients, upon regaining consciousness. All missed injuries were documented, including site and type of injury, reason missed, how identified, and attendant morbidity. Forty-one missed injuries were found in 36 patients (9%). These included: 21 extremity fractures, five spinal fractures, two facial fractures, five thoracic injuries, six abdominal injuries (including five splenic lacerations), and two vascular injuries. The most common reason for injuries to be missed was altered level of consciousness due to head injury or alcohol. Other reasons included severity of injury and instability requiring immediate operation, lack of symptoms at admission, technical problems, and low index of suspicion by the examiner. None of the missed injuries resulted in death. However, one missed injury caused serious disability and seven required operative correction.(ABSTRACT TRUNCATED AT 250 WORDS)