The influence of prehospital trauma care on motor vehicle crash mortality

BACKGROUND: This study evaluated the impact of the prehospital trauma care system on the mortality from motor vehicle crashes and on the temporal distribution between the crash and related death. METHODS: Autopsies performed by the Forensic Medical Institute on all deaths caused by motor vehicle crashes 1 year before and 1 year after the beginning of the prehospital trauma care system were evaluated. RESULTS: In the first period, 128 deaths occurred, 53.9% of them in the first hour after the crash, 36.7% between the first hour and the seventh day, and 9.4% after 1 week. In the second period, 115 deaths occurred, 40.8% of them in the first hour, 52.2% between the first hour and the seventh day, and 7% after 1 week. Central nervous system injury was the most frequent cause of death in both periods. Mortality was greatest among young people as well as male victims in both periods. CONCLUSION: After starting the prehospital trauma care system in our city, there was a decrease in the deaths occurring before hospital admission, a change in temporal distribution of deaths, and a reduction in the motor vehicle crash mortality rate.     

Update on prehospital emergency care of severe trauma patients

The prognosis of severe trauma patients is determined by the ability of a healthcare system to provide high intensity therapeutic treatment on the field and to transport patients as quickly as possible to the structure best suited to their condition. Direct admission to a specialized center (“trauma center”) reduces the mortality of the most severe trauma at 30 days and one year. Triage in a non-specialized hospital is a major risk of loss of chance and should be avoided whenever possible. Medical dispatching plays a major role in determining patient care. The establishment of a hospital care network is an important issue that is not formalized enough in France. The initial triage of severe trauma patients must be improved to avoid taking patients to hospitals that are not equipped to take care of them. For this purpose, the MGAP score can predict severity and help decide where to transport the patient. However, it does not help predict the need for urgent resuscitation procedures. Hemodynamic management is central to the care of hemorrhagic shock and severe head trauma. Transport helicopter with a physician on board has an important role to allow direct admission to a specialized center in geographical areas that are difficult to access.     

The effect of prehospital fluids on survival in trauma patients

The effect of prehospital intravenous fluids upon survival was studied in 6,855 trauma patients. Mean prehospital time was 36 minutes in both the group of patients who received fluids and the group that did not. The volume of fluid administered was not significantly different in the group who survived compared to those who died. Eighty-five per cent of the patients had an Injury Severity Score (ISS) less than 25 and the mortality rate in the 56% of patients in this group who received fluids was similar to that of the patients who did not receive fluids (0.7% vs. 0.5%). Twelve per cent of the patients had an ISS between 25 and 50. Sixty per cent of these patients received fluids and the mortality rates were similar to the patients who received fluids compared to those who did not (23% vs. 22%). Three per cent of patients had an ISS of greater than 50 and the mortality rate was highest in this group but was not influenced by the administration of fluids (90% vs. 86%). Comparison of groups with similar probability of survival according to the TRISS methodology also failed to show an influence of fluid administration on survival. The mortality rate in patients with an initial systolic blood pressure (BP) of 90 torr or greater was compared to the rate in patients with an admission BP less than 90 torr. Although hypotension was associated with a significantly higher mortality rate, the administration of fluids had no influence on this rate.(ABSTRACT TRUNCATED AT 250 WORDS)     

Problems of prehospital care for a severe combined trauma

The authors have analyzed the strategy and results of treatment of 455 casualties at the prehospital stage. Main defects of giving help at the prehospital stage and ways to improve it are described.     

Incidence of systemic fungal infection and related mortality following severe burns

Advancements in burn care therapy have extended survival of seriously burned patients, exposing burn patients to increased risk of infectious complications, notably fungal infections. We performed a 12-year review of autopsied patients with severe burns for the presence of fungal infection at the US Army Institute of Surgical Research Burn Center between February 1991 and November 2003. The primary goal was to identify the relationship between fungal element noted in autopsy and mortality, and to determine contributing factors that increase a patient's susceptibility to fungal infection. A total of 228 deaths (6.1%) resulted from the 3751 admissions of which 97 underwent autopsy. Fungal elements were identified on histopathology in 44% (43 of 97) of autopsied patients with an attributable mortality of 33% (14 of 43). Aspergillus and Candida were the most frequently recovered fungi, but Aspergillus was recovered in 13 of the 14 cases with fungus identified as an attributable cause of death. The most common sites of infections with attributable mortality were wounds (86%) and the pulmonary system (14%). Total body surface area (TBSA) burn and length of stay (survival after burn) were identified as contributing factors for the incidence of fungal element in autopsy on ROC curve analysis. More severely injured patients with greater %TBSA burn injury and full-thickness burns require a longer recovery period resulting in a longer hospital stay. The propensity for fungal infection increases the longer the wound is present. Therefore, the development of products to close the wound more rapidly, improvement in topical antifungal therapy with mold activity for treating wounds, and implementation of appropriate systemic antifungal therapy may improve outcome for severely injured burn victims susceptible to fungal infections.     

Acute lung failure following thoracic trauma

Pulmonary failure is almost always present in the early or late phase of multiple organ failure (MOF). Acute lung failure (ALF) is a uniquely constant response to direct or indirect insults to the lung. Increased pulmonary microvascular permeability (PMVP) is associated with the onset of lung permeability edema, the hallmark of ALF. The sequence of PMVP and the development of ALF caused by direct insults are studied. METHODS. A series of 255 trauma patients admitted to our intensive care unit (ICU) from 1987 to 1988 were enrolled in this prospective study. ALF was defined as stage III of the Posttraumatic Pulmonary Insufficiency Score; sepsis syndrome, according to Montgomery; organ failure, as stage II of the MOF score, and MOF was recorded when at least two organs had failed. Thoracic injury and aspiration were expected as direct, sepsis and shock alone as indirect insults to the lung. A computerized large field of view gamma camera was used to measure PMVP simultaneously over both lungs by means of 113mIn-transferrin and 99mTc-erythrocytes. The pulmonary microvascular permeability index (PMVPI; %/h) was used to quantify PMVP in the dynamic scintigraphic measurement. RESULTS. Of the 255 trauma patients (ISS = 33.9 +/- 18.7), 21% (52) patients (ISS = 41 +/- 17.8) developed ALF. 50 (or 96%) of the ALF patients developed MOF in addition, and 27 (72%) of the patients with directly induced ALF developed sepsis syndrome later. Direct lung injury was present in 77% (37) of the patients with posttraumatic ALF. Thoracic injury was the main cause of ALF: 58% (30) of 52 patients with ALF had a thoracic injury, which was true of only 30% of the non-ALF group (P less than 0.05). 33 (or 89%) of the ALF patients with direct injury developed ALF less than 72 h after injury (early ALF), and only 11% (4) later than 72 h after injury (late ALF). Indirect injury of the lung was present in 22% (12) of the patients with posttraumatic ALF. Indirectly induced ALF occurred in less than 72 h in 36% (4) and more than 72 h after injury in 64% (7) trauma patients. PMVP was determined in 21 of the 30 patients with thoracic injury. Initial evaluation of these patients with direct induced ALF showed significantly elevated (P less than 0.01) PMVP for the traumatized (PMVPI = 10.8 +/- 5.1%/h) but normal values for the nontraumatized lung (PMVPI = 3.9 +/- 3.4%/h), whereas 4 days later the PMVP increased significantly (P less than 0.05) on the primarily healthy side (PMVPI = 8.0 +/- 5.0%/h) while remaining elevated for the traumatized lung (PMVPI = 10.9 +/- 6.0%/h). In the control group the PMVPI was 2.6 +/- 2.8%/h for the right and 2.0 +/- 2.8%/h for the left lung. Similar values were found in mechanically ventilated ICU patients without ALF. DISCUSSION. Direct injury seems to be the dominant mechanism for early manifestation (less than 72 h) of posttraumatic ALF. The thoracic trauma seems to damage the pulmonary endothelium directly, thus increasing PMVP in a circumscribed region. An overwhelming inflammatory response may cause the later increase in PMVP in the primarily healthy lung areas.     

The management of subclavian artery injuries following blunt thoracic trauma

The records of 15 patients who sustained blunt rupture of the subclavian artery were reviewed. The findings on physical examination included arterial hypotension, unilateral absence of the radial pulse, brachial plexus palsy, and supraclavicular hematoma. The chest roentgenographic findings included wide mediastinums, apical pleural hematomas, and first rib fractures. Fourteen patients survived to undergo angiography and operation. Arterial continuity was restored by primary anastomosis, synthetic grafts, and venous interposition grafts. Ligation of a pseudoaneurysm was carried out in 1 patient with a complete brachial plexus palsy. Amputation of an upper extremity was required in 1 patient. Two patients died postoperatively. We conclude that blunt subclavian artery injuries may be suspected clinically. Absent upper extremity pulses, a wide mediastinum, unrelenting thoracic hemorrhage, and persistent hypotension dictate the necessity for aortography. Relative indications for angiography include brachial plexus palsy, apical pleural hematoma, and a fractured first rib.     

Patterns of infection and mortality in thoracic trauma.

Tissue infection and systemic sepsis are common causes of morbidity and late mortality after major thoracic trauma. To seek causative mechanisms, prognostic indicators, and areas of possible improvement in therapy, we reviewed 310 consecutive adults admitted with major thoracic trauma. Of these, 56 (18%) died of massive injuries in the first 5 days; the remaining 254 were considered at risk for infectious complications. There were 21 late deaths in this group, and 15 (71%) were caused by systemic sepsis. Eighty-four patients (33%) developed thoracic infections, and 15 (6%) had significant nonthoracic infections. Markers of increased risk of infection included blunt injury, shock and unconsciousness on arrival, and splenectomy. Pulmonary infection was increased significantly following prolonged endotracheal intubation, but was virtually absent following tracheostomy. The risk of infection was increased significantly if prophylactic antibiotics were not used, but no definite correlation could be made to advanced age, pre-existent disease, nor post-traumatic malnutrition. Attention to some of these factors may decrease the risk of infection in thoracic trauma.     

Heart rate variability and its association with mortality in prehospital trauma patients

BACKGROUND: Accurate prehospital triage of trauma patients is difficult, especially in mass casualty situations. Accordingly, the U.S. Military has initiated a program directed toward improving noninvasive prehospital triage algorithms based on available physiologic data. The purpose of this study was to assess heart rate variability and its association with mortality in prehospital trauma patients. METHODS: Trauma patients without significant head injury requiring helicopter transport were identified from a retrospective research database. An equal number, unmatched sample of patients who lived were compared with those who died (n = 15 per group). All patients were transported to a single Level I urban trauma center. The primary independent variable was mortality. Patients with Abbreviated Injury Scale head scores >2 were excluded from the analysis, so that the effects seen were based on hemorrhagic shock. Age, sex, Glasgow Coma Scale score (GCS), blood pressure, pulse pressure, pulse, intubation rate, SpO2, mechanism of injury, transport time, and time of death after admission were recorded. R-waves from the first available 120 seconds of usable data were detected from normal electrocardiograms and heart rate variability was assessed. RESULTS: Patients who died demonstrated a lower GCS (7.9 +/- 1.4 versus 14.4 +/- 0.2; p = 0.0001) and higher intubation rate (53% of patients who died versus 0% patients who lived). Pulse rate, arterial pressure, and SpO2 were not distinguishable statistically between groups (p = 0.08), but pulse pressure was lower in patients who died (39 +/- 3 versus 50 +/- 2 mm Hg; p = 0.01). Compared with patients who lived, those who died had lower normalized low-frequency (LF) power (42 +/- 6 versus 62 +/- 4 LFnu; p = 0.009), higher high-frequency (HF) power (42 +/- 3 versus 32 +/- 3 HFnu; p = 0.04) and higher HF-to-LF ratio (144 +/- 30 versus 62 +/- 11nu; p = 0.01). With absolute HF/LF adjusted for GCS, the intergroup variance accounted for by HF/LF was reduced to 6% (p = 0.16). CONCLUSIONS: Analysis of heart rate variability provides insight into adequacy of autonomic compensation to severe trauma. In our cohort of trauma patients, low pulse pressures coupled with relatively higher parasympathetic than sympathetic modulation characterized and separated patients who died versus patients who survived traumatic injuries when standard physiologic measurements are not different. These data do not suggest advantages of heart rate variability analysis over GCS scores, but suggest future possibilities for remote noninvasive triage of casualties when GCS scores are unattainable.     

Non-invasive positive pressure ventilation for severe thoracic trauma

A 35-year-old man was admitted to the intensive care unit (ICU)following a road traffic accident. He had sustained severe traumato the left side of his chest, as well as other musculoskeletalinjuries. After a short initial period of ventilation of thelungs via a tracheal tube, he was managed using a combinationof continuous positive airway pressure and non-invasive positivepressure ventilation. He avoided ventilator-associated pneumonia,and spent a large part of his time on the ICU without any invasivemonitoring lines, another potential focus of infection. He wasdischarged from the ICU after 25 days without having sufferedany septic complications. The role of non-invasive positivepressure ventilation in severe thoracic trauma is discussed. Br J Anaesth 2000; 85: 788–90 ^* Corresponding author     

Use of bronchofiberscopy in management of severe thoracic trauma

Objective： To investigate the diagnos- tic and therapeutic effect ofbronchofiberscopy in the manage- ment of severe thoracic trauma. Methods： A retrospective study was conducted on 207 consecutive patients with severe thoracic trauma enrolled in our hospital between January 2008 and June 2012. During the period, 488 bronchofiberscopies and lavages were done. The bronchofiberscope was inserted through tracheal inci- sion （282）, nasal cavity （149） and oral cavity （57）. Intensive SaO2 monitoring as well as blood gas analysis were per- formed pre-, intra- and postoperatively. Simultaneously oxy- gen therapy or ventilatory support was given. Sputum cul- ture was done intraoperatively. Results： Diagnosis in 207 cases was confirmed by bronchofiberscopy. The result of sputum culture was posi- tive in 78 cases. Lavage was performed on 156 cases. SaO2 significantly increased after bronchofiberscopies as well as lavages and PaO2 obviously improved 2 h after surgery （both P〈0.05）. Heart rate and respiratory rate decreased. There was no bronchofiberscopy-related death. Conclusion： Bronchofiberscopy plays an important role in the diagnosis and treatment of severe thoracic trauma, which can not only timely diagnose bronchial injury and collect deep tracheal sputum for bacterial culture but also effectively remove foreign body, secretion, blood and spu- tum crust in the airway, manage obstructive atelectasis and pneumonia, and signifcantly improve respiratory fimction and treatment outcome.     

Postoperative results following severe craniocerebral trauma

918 patients were operated because a severe head injury in our Neurotraumatological Clinic during a period of 12 years. 733 patients (80 per cent) could been evaluated as well with regard to the Glasgow Coma Scale and the Glasgow Outcome Scale as analysed in four diagnose groups corresponding to the period of live. Patients with epidural haematoma and open head injuries showed a better forecast than patients with acute subdural haematoma. Those with contusion of the brain and less than 8 points in the Glasgow Coma Scale or those in a higher age had a bad prognosis.