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Dats A.V., Dats L.S., Khmelnitskiy, I.V.
Irkutsk State Medical Academy of Postgraduate Education – Branch of Russian Medical Academy of Continuous Professional Education, Irkutsk, Russia
THE STRUCTURE OF DEFECTS OF MEDICAL ASSISTANCE IN POLYTRAUMA
A
severe injury is one of the main problems of public healthcare. Annually, more than
5 million people die as result of polytrauma. The predicted value is about 8
million and more in 2020 [1-4].
Uncontrolled
posttraumatic hemorrhage, which is caused by vascular damage, loss
coagulopathy, hypothermia, consumption coagulopathy and rarefraction
coagulopathy in infusion therapy, is a leading cause of potentially preventable
deaths in patients with polytrauma [5].
According
to V.V. Agadzhanyan and coauthors [6], the diagnostic defects were identified
in 52.9 % of deceased patients with polytrauma, including 1.9 % with thanatological
significant patterns. Moreover, the highest amount of errors (80.2 %) was
related to the objective causes (extremely severe condition, need for
resuscitation and surgical measures, short stay in hospital) and insufficient
physicians’ experience.
According
to the study by Maksimov A.V., based on the analysis of forensic medicine
reports, the defects in rendering medical care for polytrauma did not prevent
the lethal outcome by means of hypodiagnostics of the dominating injury in 18.8
% and its complications in 12 %, underestimation of severity of a complication
in 10.7 % and inadequate treatment in 2.3 % [7]. The severity of the injuries
often conceals the defects in diagnostics and treatment, resulting in objective
estimation of realized medical care.
The
analysis of the case records of the victims of road traffic accidents showed
that 90.5 % of the defects in medical care for polytrauma were associated with
diagnostics and treatment and also were related to subjective nature [8].
During forensic expertise, the identification of defects in diagnostics and
treatment does not exclude them from the range of causal factors of unfavorable
result of medical care.
Insufficient
efficiency of results of medical and diagnostic process and, as result,
decreasing quality of medical care were caused by lacks in organization and material-technical
supply, absence of clear protocols for inhospital care for patients with shock-producing
injury, imperfect regulatory documents describing the order of arrangement and
realization of forensic expert activity [9].
The
defects in arrangement of medical care present the serious healthcare problem
and constitute a threat to safety of patients with polytrauma. Therefore, the
problem of defects in rendering medical care for polytrauma is one of the most
actual ones.
MATERIALS AND METHODS
The
study was retrospective and consisted in the examination of the case records of
64 deceased patients with polytrauma who were admitted to the ICUs of 24
regional and city hospitals (level 2 and 3 trauma centers) of Irkutsk region in
2010-2016. The age of the patients was from 17 to 84. The case records were
provided by the Territorial fund of obligatory medical insurance for residents
of Irkutsk region. The study included only the diseases, which expertise
results were approved by the representatives of the hospital administration.
At
the moment of admission, the severity of traumatic injuries was estimated with
Injury Severity Score (ISS). ISS was 25-40. The main injuries were identified:
traumatic brain injury in 24 %, concurrent injuries in 24 %, skeletal injury in
21 %, thoracic injury in 16 %, abdominal injury in 12 %, spinal cord injury in
3 %.
The
study protocol was approved by the ethical committee of Irkutsk State Medical
Academy of Postgraduate Education (the session #1, January 14, 2010).
The
medical care quality expertise was carried out according to the Order by
Russian Health Ministry, November 12, 2012, No.901n, “About confirmation of the
Order of arrangement of traumatological and orthopedic medical care for the
population” [10], the Order by Russian Health Ministry, November 15, 2012 No.
919n, “About confirmation of the Order of arrangement of anesthesiology and
critical care services for adult population” [11], the Order by Russian Health
Ministry, July 7, 2015, No.422an, “About confirmation of criteria for
estimating quality of medical care” [12], the project of clinical
recommendations (the treatment protocol) for arrangement of medical care for
multiple and associated injury (polytrauma) [13], the European guidance
“Management of bleeding and coagulopathy following major trauma” (4th edition,
2016) [5].
Non-compliance
of the above-mentioned national and international guidelines for examination,
diagnostics, prevention and treatment of patients with polytrauma, as well as non-compliance
of the instructions for prescription of medical drugs, were estimated by us as
a defect in medical care arrangement.
RESULTS
The table 1 shows the analysis of the causes of lethal outcomes depending on the period of polytrauma.
Table 1. The causes of lethal outcomes in various periods of polytrauma
|
Causes of lethal outcomes |
Period of appearance of lethal outcomes |
|||
|
Before 2 days |
3-7 days |
More than 7 days |
Total |
|
|
Hemorrhagic shock |
20 |
- |
- |
20 |
|
Brain edema and disclocation in TBI |
2 |
8 |
6 |
16 |
|
Ascendant spinal cord edema |
1 |
1 |
- |
2 |
|
Nosocomial pneumonia |
- |
- |
5 |
5 |
|
Sepsis, septic shock |
- |
- |
8 |
8 |
|
Fat embolia of pulmonary and cerebral vessels |
2 |
- |
- |
2 |
|
Pulmonary embolia |
- |
- |
3 |
3 |
|
Cardiac tamponade |
1 |
1 |
||
|
Meningitis |
- |
- |
1 |
1 |
|
Acute renal failure |
- |
- |
4 |
4 |
|
CHF decompensation |
- |
- |
2 |
2 |
|
ARDS |
- |
2 |
2 |
|
|
Total |
26 |
11 |
29 |
66 |
26
(39.4 %) patients died within 2 days. Most deaths were caused by hemorrhagic
shock (20 patients, 30.3 %). In the late period of polytrauma (more than 7
days), most cases of lethal outcomes (14, 21 %) were associated with infectious
complications (sepsis, nosocomial pneumonia and meningitis).
The
structure of the laboratory examination defects in the patients with polytrauma
in the ICU is presented in the table 2.
Table 2. The structure of defects in laboratory examination of patients with polytrauma in the intensive care unit
|
Defects in examination |
Rate of defects (%)* |
|
Not examined: |
|
|
Biochemical blood analysis |
5 (7.6) |
|
Coagulogram |
10 (15.1) |
|
Serum lactate |
53 (80) |
|
Plasma electrolytes |
25 (37.9) |
|
Arterial blood gases and base deficiency |
65 (98.5 %) |
|
Bloog group and Rh factor |
12 (18.1 %) |
|
Not examined over time: |
|
|
General blood analysis |
6 (9 %) |
|
Coagulogram |
5 (7.6 %) |
|
Biochemical blood analysis |
7 (10.6 %) |
Note: * percentage is indicated in relation to the total amount of the patients with polytrauma (n = 66).
It
was found that the most common defects in the examination were the absence of
arterial blood gases examination (98.5 %), and serum lactate (80 %).
53
% of the cases were associated with the absence of primary clinical estimation
of blood loss according to the changes in the main physiological values and
response to initial intensive care for identification of coagulopathy risk and
determination of the mode of infusion-transfusion therapy at the moment of
admission to the ICU.
There
was not any additional examination of the chest, the abdominal cavity and the
pelvis, which present the main blood loss sources in trauma. The source of
internal bleeding was not identified in 5 of 20 (25 %) patients with
hemorrhagic shock.
The
table 3 shows the structure of the defects and complications in the patients
with polytrauma in the ICU.
Table 3. The structure of defects in diagnostics of injuries and complications in patients with polytrauma in the intensive care unit
|
Diagnostics defects |
% (number of defects/total amount of patients for each nosological form) |
|
Non-diagnosed complicatons: |
|
|
Acute respiratory insufficiency |
44 (20/45) |
|
Hemorrhagic shock |
20 (4/20) |
|
DIC syndrome |
57 (4/7) |
|
Sepsis |
75 (6/8) |
|
Acute renal insufficiency |
50 (2/4) |
|
Nosocomial pneumonia |
40 (2/5) |
|
Pulmonary embolism |
67 (2/3) |
|
Acute respiratory distress syndrome |
75 (3/4) |
|
Fat embolia |
50 (1/2) |
|
Non-diagnosed injuries: |
|
|
Liver rupture |
40 (2/5) |
|
Pelvic injury |
20 (2/10) |
|
TBI |
6 (1/16) |
|
Lung contusion |
63 (5/8) |
|
Massive hemothorax |
50 (1/2) |
|
Cardiac tamponade |
50 (1/2) |
Sepsis
was not diagnosed in 6 of 8 patients (75 %), ARDS – in 3 of 4 patients (75 %),
lung contusion – in 5 of 8 (62.5 %), ARF – in 20 of 45 (44 %).
The
analysis of the ICU treatment of the patients with polytrauma identified the
main groups of the defects: in correction of hypoxemia (the table 4), in
intensive care of hemorrhagic shock (the table 5) and in non-compliance of the
contraindications for prescription of medical drugs (the table 6).
Table 4. The structure of defects which appeared during correction of hypoxemia in patients with polytrauma in ICU
|
Treatment defects |
Rate of defects, total (%)* |
|
No tracheal intubation in airways obstructions: coma, injury to lower jaw bone and neck |
2 (4.4) |
|
No prescription of oxygen in hypoxemia |
3 (6.7) |
|
No ALV in persistent hypoxemia at the background of maximal delivery of oxygen |
4 (8,8) |
|
Late initiation of ALV (at stage of hypoxic heart arrest) |
2 (4.4) |
|
Incompliance of ALV parameters with low respiratory volume (6 ml/kg) in patients with ARDS or risk of its development |
3 (6.7) |
Note: * – percentage is indicated in relation to total amount of patients with hypoxemia (n = 45).
Table 5. Структура дефектов интенсивной терапии геморрагического шока у пациентов с политравмой
|
Intensive care defects |
Rate of defects, total (%)* |
|
Insufficient volume of introduced packed red blood cells 250-500.0 in hemorrhagic shock (targeted level of hemoglobin = 70-90 g/l is not achieved) |
4 (20) |
|
No transfusion of packed red blood cells in hemorrhagic shock |
2 (10) |
|
No transfusion of plasma in bleeding and more than 1.5-fold increasing prothrombin time and APTT |
2 (10) |
|
No introduction of cryoprecipitate and/or plasma at plasma level of fibrinogen < 1.5-2 g/l |
2 (10) |
|
No introduction of platelets in thrombocytopenia lower than 50×109/l |
3 (15) |
|
No introduction of platelets in thrombocytopenia lower than 100×109/l |
2 (10) |
|
Prescription of vasopressors without designation of dose in µg |
3 (15) |
|
Introduction of vasopressors for patients without TBI at the background of continuous bleeding in systolic arterial pressure > 90mm Hg |
3 (15) |
Note: * – percentage is indicated in relation to total amount of patients with hemorrhagic shock (n = 20).
In 18% of the cases, the defects in the treatment were determined by inadequate
intensive care of hypoxemia relating to airway management, oxygen prescription
and ALV.
In
30 % of the cases, the defects in the treatment were determined by inadequate
intensive care of hemorrhagic shock as result of insufficient volume or non-use
of packed red blood cells.
Prescription
of non-prescribed medical agents was identified in 30 % of the cases.
Table 6. The structure of defects as result of incompliance of contraindications in drugs prescription
|
Treatment defects |
Amount of defects |
|
Introduction of potassium in oligo-, anuria |
3 |
|
Introduction of b-adrenoblockers at background of arterial hypotony |
2 |
|
Introduction of NSAIDs in non-corrected hypovolemia and/or ongoing bleeding |
6 |
|
Introduction of curantyl in ongoing bleeding |
2 |
|
Introduction of trental in ongoing bleeding |
1 |
|
Introduction of aspirine in ongoing bleeding |
2 |
|
Introduction of heparine in ongoing bleeding |
1 |
|
Planned introduction of lasix in TBI |
5 |
|
Planned introduction of mannitol in TBI |
4 |
|
Introducton of 5% glucose in acute period of TBI |
6 |
|
Introduction of tranexam in subarachnoidal bleeding |
1 |
|
Introduction of prednisolone in TBI |
3 |
DISCUSSION
Our study includes the analysis of the defect in
arrangement of medical care for the patients with traumatic injuries admitted
to the ICU of the regional and city hospitals of Irkutsk region.
We have found that the most common defects in the
examination are absent study of arterial blood gases and deficiency of the
bases, which control the oxygenation, ventilation and perfusion of tissues, as
well as absence of primary clinical estimation of blood loss volume according
to the changes in the main physiological values, and according to response to
primary intensive care that are necessary for identification of coagulopathy
risk and hemorrhage control.
Considering the danger of hypoxemia or hyperoxia, hypercapnia
or hypocapnia during ALV, it is necessary to control the breathing in
compliance with the patient’s requirements, with dynamic control for most
important parameters including arterial blood gases and airway pressure.
We have found that pulse oximetry was a single tool for
controlling the breathing in all patients with polytrauma. One should remember
about the technical limitations for pulse oximetry that influence on the
accuracy of saturation assessment such as signal receipt disruption during
transportation, external lighting from fluorescent sources, an inappropriately
selected transducer, presence of anemia and abnormal forms of hemoglobin,
vasoconstriction and poor tissue perfusion.
One should remember that pulse oximetry cannot
estimate hyperoxia and the values of ventilation. According to a recent study,
hyperoxia is associated with increasing mortality owing to increasing
production of free radicals and intensifying hyperoxic vasoconstriction [14]. PaO2
> 200-300 is considered as the level of hyperoxia that causes some
complications [15]. Long term hyperoxia can cause the atelectasis and lung
injury in polytrauma [5]. For minimizing the complications of hyperoxia during
ALV it is necessary to control the oxygenation with consideration of arterial
blood gases.
It is necessary to consider that pulse oximetry
measures the oxygenation, but not ventilation. According to the data by E.
Damiani et al. (2014), hyperventilation in ALV causes the increase in mortality
after polytrauma [14]. The target carbon dioxide partial pressure (PaCO2)
should be 35-40 mm Hg.
Hyperventilation-associated hypocapnia leads to
increasing vasoconstriction, decreasing cerebral perfusion and disordered
perfusion in cerebral tissue. Cerebral lactic acidosis appears immediately
after induction of hypocapnia in children and adults with TBI and hemorrhagic
shock [15]. Even the moderate level of hypocapnia (PaCO2 < 27 mm
Hg) can worsen a primary cerebral injury by means of apoptosis. If hypovolemia
is absolute or relative, then hypoventilation with positive pressure can
decrease the venous return and cause the hypotonia and cardiovascular
insufficiency [8].
The problem of measurement of arterial
blood gases is associated with presence of appropriate equipment in ICU and
professional level of a physician. According to the international and national
clinical guidelines for assessment of hypoxemia, hypercapnia, acid-base balance
in determination of indications and carrying out ALV for patients in ICU, it is
necessary to examine the parameters of arterial blood gases [5, 11, 12, 15];
gas analyzers are included into the list of necessary equipment in ICU [15].
Posttraumatic bleeding is the main cause
of death in patients with polytrauma. It can arise after vascular injury and
dilution coagulopathy during infusion therapy. Therefore, to minimize the blood
loss it is necessary to identify the bleeding source and make the surgical and
coagulation control over it.
We have found that the bleeding source
was not identified in 25 % of the patients with hemorrhagic shock because of
absence of an additional examination of the chest, the abdomen and the pelvis,
which present the main sources of posttraumatic blood loss. According to the
European and Russian recommendations, the diagnostics of unidentified source of
bleeding in hemorrhagic shock should include ultrasonography, CT and diagnostic
peritoneal lavage for abdominal bleeding, radiography, ultrasonography, CT,
pleural puncture for pleural bleeding, and radiography and CT for pelvic injury
[5, 13].
We have found that 20 % of the patients
with hemorrhagic shock did not receive any plasma transfusion, cryoprecipitate
or platelets. In case of bleeding, plasma transfusion should be performed for more
than 1.5-fold increasing prothrombin time and APTT. Cryoprecipitate is used if
plasma fibrinogen is lower than 1.5-2 g/l. Platelets are transfused for
thrombocytopenia < 50 in patients without TBI and < 100 in patients with
TBI [5].
Further examinations are required for
more detailed analysis of defects in medical care for polytrauma with division
into the separate topics (for example, acute respiratory and renal failure,
coagulopathy, sepsis and others) with development of recommendations for
treatment.
CONCLUSION
The
most common defects in examination of polytrauma are absence of examination of
arterial blood gases, deficiency of bases and lactate, and absent initial
clinical estimation of blood loss according to a response to initial intensive
care.
The
source of internal bleeding was not identified in 5 of 20 (25 %) patients with
hemorrhagic shock owing to absent additional examination of the chest, the
abdomen and the pelvis.
The
treatment defects in 31 % of the cases were determined by inadequate removal of
hypoxemia after airway management, prescription of oxygen and ALV, and in 55 % – with non-adequate intensive care of hemorrhagic
shock owing to insufficient volume and absent introduction of packed red blood
cells.
Information of financing
and conflict of interests:
The study was conducted without sponsorship.
The authors declare the absence of
any clear or potential conflicts of interests relating to publication of this
article.
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