Update on trauma care in Canada. 2. Update on pediatric trauma

Selective conservatism is the key to the rational management of pediatric trauma, realizing that children may harbour severe occult injuries. The modern treatment of childhood abdominal trauma best exemplifies this approach: nonoperative management of splenic trauma is now standard for children, and a selective conservative approach is advised in the handling of childhood liver and pancreatic injuries. Prevention of childhood injuries should be the goal. The development of a national database of childhood trauma should provide the basis for action to educate and legislate for prevention. When prevention fails, however, up-to-date quality pediatric trauma care is the key.     

Update on trauma care in Canada. 6. Update on trauma registries and trauma scoring

Developments in microcomputer technology and user friendly software have resulted in rapidly expanding interest in trauma registries and injury scoring. The trauma registry, particularly when it is population based, is an empowering tool for epidemiologic research, planning of trauma systems, development of prevention programs, outcome evaluation and research. Injury coding performed in conjunction with trauma registry can also provide the basis for institutional quality assurance. The Major Trauma Outcome Study has played a major role in this, through the development of normative standards, permitting inter-institutional comparisons. These issues as well as some of the present Canadian and American initiatives in the trauma registry field are reviewed in this paper. Advances in injury scaling are addressed as are some of the limitations in existing coding methodologies.     

Update on trauma care in Canada. 3. Pelvic ring fractures

Correct assessment and treatment of pelvic ring fractures in the multiply injured patient is important because it can result in fewer deaths and less long-term disability. There is ample evidence to show that surgical stabilization of unstable pelvic ring fractures is a life-saving intervention that should be done on the day of injury. Anterior frame external fixation is the standard form of treatment and is life-saving. However, it is not ideal biomechanically, and over the next decade open reduction and internal fixation of pelvic ring fractures will likely become the treatment of choice.     

Update on trauma care in Canada. 1. Recent advances in thermal injuries

Thermal injury frequently occurs in traumatized patients in North America and causes serious morbidity and mortality, predominantly to children and young adults. Over the past decade, considerable technologic advances have improved survival after burn injury. Ongoing research coupled with current surgical advances in equipment, technique, early wound closure and alternative forms of wound coverage offer the potential for greater survival with enhanced quality of life for traumatized patients with burn injuries. However, sepsis and inhalation injury remain important ongoing causes of death, for which the understanding and solutions appear to be unfolding as research into the multisystem effects of the inflammatory process continues.     

Update on trauma care in Canada. 4. Resuscitation through the three phases of hemorrhagic shock after trauma

There are three phases of acute hemorrhagic shock after trauma. In phase I (from injury to operation for control of bleeding) the patient suffers from low cardiac output, tachycardia, reduced organ perfusion, oliguria and decreased capillary hydrostatic pressure, which in turn reduces extravascular fluid loss. Contraction of the interstitial space matrix replenishes plasma volume. Optimal therapy includes blood and crystalloid replacement to restore plasma volume, red cell mass and interstitial fluid. Three litres of crystalloid are usually required for each litre of blood lost. After operation, a period of obligatory extravascular fluid sequestration occurs as the intracellular and interstitial spaces expand (phase II). Optimal replacement therapy during this phase maintains plasma volume. Replacement is provided according to the patient's vital signs, because extravascular fluid expansion cannot be influenced by therapeutic manipulation. Phase III is a mobilization and diuretic phase. During this phase systolic hypertension may occur, and the patient must be treated with restriction of fluid, diuresis and careful monitoring of the heart and lungs. Attempts to alter these physiologic responses with supplemental albumin have proved detrimental. The albumin causes salt and water retention in the nephron, leading to weight gain, higher central filing pressures and worsening pulmonary function, and a greater need for diuretic and inotropic therapy. Albumin therapy also induces relocation of non-albumin proteins into the interstitial space, leading to impaired immunocompetence and coagulation. Successful resuscitation is facilitated by adaptation to these physiologic responses of hemorrhagic shock rather than manipulation of them.     

Coalition on trauma--trauma prevention and trauma care: presidential address, Trauma Association of Canada

Injury is the leading cause of death in persons under 40 years of age. The cost to society financially and in nonmonetary terms is enormous. For a successful assault on this major health epidemic, a cooperative effort between those involved in the development of prevention strategies and those involved in the care of the injured patient must develop. For our society to accept some of these prevention strategies, the rights of the community as a whole will have to be allowed to prevail over the rights of the individual. To facilitate this process, a National Advisory Committee on Injury in Canada needs to be formed. Its mandate will be to develop a set of national objectives on injury morbidity and mortality, to establish a national trauma registry, and to implement specific programs--a strategic plan. Only through a coalition of efforts between all groups involved with injury can we hope to lower the prevalence of injury in Canada.     

Trauma and hypothermia

Hypothermia occurs commonly in patients sustaining injury and may result in morbidity and mortality due to impaired cardiorespiratory function, peripheral vasoconstriction, bleeding diathesis, metabolic acidosis, diminished hepatorenal function, and impaired immune response. Hypothermia decreases metabolic function of the body and is neuroprotective. However, injured patients in whom hypothermia develops have a higher mortality than do patients with a similar injury severity who remain normothermic. Also, post-injury life-threatening coagulopathy is predicted by persistent hypothermia in patients receiving massive transfusion. Treatment of hypothermia in the trauma patient should begin with the ABCs (airway with cervical spine protection, breathing, circulation and control of bleeding). Prevention of further heat loss is achieved by maintaining the patient in a thermoneutral environment at high ambient temperature and use of warmed intravenous (i.v.) fluids. The thermal stress from cold fluid resuscitation can substantially decrease core temperature mandating the use of effective fluid and blood warming devices in all severely injured patients. Several non-invasive and invasive rewarming methods are available. Of the various non-invasive treatment modalities, convective warming appears to be most effective for mild (32–35°C) and mild–moderate (30–32°C) hypothermia. Continuous arteriovenous rewarming may be used in the patient with moderate–severe (28–32°C) and severe (<30°C) hypothermia provided there is an adequate perfusing rhythm. Cardiopulmonary bypass or body cavity lavage may be indicated for severe hypothermia in the absence of a perfusing cardiac rhythm.     

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.     

Trauma care at rural level III trauma centers in a state trauma system

BACKGROUND: Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care. METHODS: During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail. RESULTS: A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5. CONCLUSIONS: Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.     

2010 Trauma Association of Canada presidential address: why the Trauma Association of Canada should care about space medicine

The Trauma Association of Canada is now 27 years old, having been officially founded in 1983, at the meetings of the Royal College as a maturation of the trauma committee of the Canadian Association of General Surgeons. The first page of the official minutes also stressed the need to welcome other disciplines into the fold. Personally, it has taken me years of involvement, as well as the Presidency, to truly appreciate the depth of our Founding Members commitment. These individuals set lofty mission goals for the organization, namely: to strive to improve the quality of care provided to the injured patient, including prehospital management and transport, acute care hospitalization, and reintegration into society; to support, conduct, and apply basic science and clinical and outcome research related to trauma; to encourage effective and efficient use of healthcare resources in the delivery of trauma care; and to foster professional and community education in the field of injury prevention and in the care of the injured patient. As daunting as these responsibilities are, I am suggesting one more: to overcome the great penalty of geography that challenges our nation and penalizes many of our citizens by aspiring to optimize these four goals, for all Canadians, irrespective of where they live--our potential fifth mission. Furthermore, I believe that lessons from space medicine may offer some strategies to accomplish this goal.     

Trauma care construction under the guidance of county-level trauma centers

Severe trauma has the characteristics of complicated condition, multiple organs involved, limited auxiliary examinations, and difficulty in treatment. Most of the trauma patients were sent to primary hospitals to receive treatments. But the traditional mode of separate discipline management can easily lead to delayed treatment, missed or wrong diagnosis and high disability, which causes a high mortality in severe trauma patients. Therefore, if the primary hospitals, especially county-level hospitals (usually the top general hospital within the administrative region of a county), can establish a scientific and comprehensive trauma care system, the success rate of trauma rescue in this region can be greatly improved. On March 1st, 2013, Tiantai People's Hospital of Zhejiang Province, China set up a trauma care center, which integrated the pre-hospital and in-hospital trauma treatment procedures, and has achieved good economic and social benefits. Till March 1st, 2017, 1265 severe trauma patients (injury severity score >16) have been treated in this trauma center. The rescue success rate reached 95% and the delayed and/or missed diagnosis rate was less than 5%. Totally 86 severe cases of pelvic fractures with unstable hemodynamics were treated, and the success rate was 92%. The in-hospital emergency rescue response time is less than 3 min, and the time from definite diagnosis to surgery is within 35 min.     

Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score

Evaluation of trauma care must be an integral part of any system designed for care of seriously injured patients. However, outcome review should offer comparability to national standards or norms. The TRISS method offers a standard approach for evaluating outcome of trauma care. Anatomic, physiologic, and age characteristics are used to quantify probability of survival as related to severity of injury. TRISS offers a means of case identification for quality assurance review on a local basis, as well as a means of comparison of outcome for different populations of trauma patients. Methods for calculating statistics associated with TRISS are presented. The Z and M statistics are explained with the nonstatistician in mind. We feel this article is a source for those interested in developing or upgrading trauma care evaluation.     

Trauma registry data validation: Essential for quality trauma care

BACKGROUND: The main function of a trauma registry is to assess quality assurance and performance improvement (QA/PI) in an individual institution. Nonvalidated registry data may produce unreliable reports and QA/PI information. This study examines the types of data entry errors in a trauma registry database; the effect of errors on time variable estimates, case ascertainment and statistical measurement; dynamics of error occurrence; and data validation (DV) scheme for a trauma registry. METHODS: Query and cross-tabulation techniques were used to expose a variety of data entry errors. Conceptual aspect for each type of error in DV, especially with respect to QA/PI, is given. RESULTS: Findings of different errors are provided: out-of-range time values; false positive and false negative errors; errors of commission and omission; duplication errors; errors in demographics; and errors because of inconsistent and incongruent coding. Error rates were less than 3% in commonly occurring data, such as scene time, demographics, hospital discharge and transportation, and greater in less commonly occurring but important data, such as thoracic aorta injury (9.5%) and audit filter for admit Glasgow Coma Scale in emergency department (55.6%). Dynamics of error occurrence that can prevent or minimize errors is described. The main features of a data validation scheme are displayed. CONCLUSIONS: Errors in a trauma registry database cause invalid frequencies, rates, time estimates and statistical measures and affect QA/PI in trauma care. Every functioning trauma registry should develop an on-going program for DV.