PROBLEMS OF STAGED TREATMENT OF PATIENTS WITH SEVERE CONCOMITANT INJURIES IN A REGIONAL TRAUMA SYSTEM
Goncharov A.V., Samokhvalov I.M., Suvorov V.V., Markevich V.Yu., Pichugin A.A., Petrov A.N.
Chair
(clinic) of military field surgery,
Kirov Military Medical Academy,
Saint
Petersburg, Russia
Currently, most developed countries have the regional trauma systems, the functioning of which involves the transportation of victims from the scene of injury to specialized trauma centers of various levels. The type of sanitary transport and the level of a trauma center are determined by injury severity and the severity of the patient’s condition.
Objective – to conduct the analysis of the structure of injuries and the features of surgical treatment of patients in conditions of the regional trauma system.
Materials and methods. The research is based on the medical records of 336 patients transferred to the clinic of military field surgery of Kirov Military Medical Academy in 2010-2015 from hospitals included in the regional trauma system as trauma centers of levels 2-3.
Results. When analyzing the terms of the transfer of the victims, it was found that the majority of patients had been transferred to the clinic within the first 3 days after injury. The majority of victims had the severe and very severe damages. The most frequent leading localizations were the injuries to the extremities, the spine and the head, while the victims with polytrauma had the injuries to the head, the pelvis and the abdomen.
Conclusion. The research showed that the optimal level of specialized medical care for polytrauma was completely realized only in conditions of the level 1 trauma center. At the moment of admission of patients with polytrauma, the task of 2-3 level trauma centers is the life salvage with implementation of multistaged surgical treatment (both for vital indications and medico-tactical ones), stabilizing condition and rapid transfer to the specialized hospital (level 1 trauma centers). Any delay in the evacuation of such patients is accompanied by a risk of adverse consequences of delayed or inadequate resuscitation and surgical treatment, and the increase in the rate of fatal outcomes.
Key words: polytrauma; regional trauma system; trauma center; transportation; specialized care; multistaged surgical treatment
The issues of treatment of severeconcomitant injuries are important for development of modern health care. The
common feature of the last decades is the changes in structure of injuries by
means of increasing severity of trauma and higher proportion of concomitant and
multiple injuries (their rate is 55-80 %) that determine the high mortality and
disability in young persons of working age [1-3].
Most developed countries have the
regional trauma systems. Such systems imply the transfer from the accident site
to the specialized trauma centers (TC) of different levels. The type of a
sanitary vehicle and the level of TC are conditioned by severity of an injury
and the patient’s condition. Rapid transportation of patients with polytrauma
to level 1 TC can be achieved with available number, appropriate territorial
coverage and transport accessibility of TC. So, Germany had 108 level 1 TCs,
209 level 2 TCs and 431 level 3-4 TCs in 2006 [4].
The regional trauma centers appear in
the Russian federation from beginning of 2000s. There were more than 1,500 TCs in
2015 [1]. However their availability (that also depends on the geographic
features) does not provide the rapid transfer of all patients with polytrauma
to the level 1 TC from the accident site. Most patients are initially
transferred to level 2-3 TCs, where they receive the emergent surgical
interventions. After stabilizing their condition, the patients who require for
the specialized (including high-tech) medical care, which cannot be conducted
in such trauma centers, are transferred to level 1 TC [5, 6].
The objective of the study – to conduct the
analysis of the structure of injuries and the features of surgical treatment of
patients in conditions of the regional trauma system.
MATERIALS AND METHODS
The retrospective analysis included
336 patients who were transferred to the military field surgery clinic of Kirov
Military Medical Academy in 2010-2015 from the hospitals, which were included
into the regional trauma systems as level 2-3 TCs.
The severity of the injuries was
assessed with Military Field Surgery-Injury score [7].
The statistical analysis was
conducted with the applied software Statistica-6 (StatSoft, 2010) and Microsoft
Office Excel 2010 with obligatory estimation of statistical significance of the
identified relationship (p < 0.05).
RESULTS AND DISCUSSION
The figure 1 shows the time course of admission of the patients according to the years. It notes the gradual decrease in the amount of transferred patients: from 72 patients in 2010 to 36 ones in 2015. It reflects the improving activity of the regional trauma center. However the number of patients with polytrauma changes in a less degree and varies from 10 to 19 patients per year. The proportion of the patients with polytrauma varied from 16.9 % in 2013 to 33.3 % in 2015.
Figure 1. The characteristics of patients transferred to
the military field surgery clinic in 2010-2015 (absolute number), n = 336
The analysis of time of transfer ofthe patients (Fig. 2) shows that 140 patients (41.6 %) were transported to the clinic within 3 days after trauma, 116 patients (34.5 %) – from 4th to 10th day, and only 80 patients (23.8 %) – after 10 days.
Figure 2. The terms of transferring the patients to the
military field surgery clinic (n = 336)
The general severity of the injuries
was 5.9 ± 1.3, the severity of the injuries in the patients with polytrauma –
14.6 ± 3.4 according to Military Field Surgery-Injury (MFS-I) score. The severe
and extremely severe injuries were in 81.4 % of the patients.
The most common locations of the
injuries in the transferred patients were the injuries to the extremities (34.8
%), the spine (17.0 %) and the head (16.7 %), whereas the patients with
polytrauma had the injuries to the head (30.7 %), the pelvis (22.7 %) and the
abdomen (18.2 %) (the table 1).
Table 1. Main location of injuries in the patients (n = 336) / among them, patients with polytrauma (n = 88)
Year of admission |
Head |
Chest |
Abdomen |
Pelvis |
Spine |
Extremities |
2010 |
11/5 |
7/2 |
8/4 |
9/6 |
17/3 |
22/1 |
2011 |
13/6 |
4/0 |
5/2 |
6/2 |
13/3 |
16/0 |
2012 |
7/4 |
6/3 |
6/3 |
8/5 |
12/0 |
21/3 |
2013 |
6/3 |
5/2 |
4/3 |
4/3 |
8/0 |
19/1 |
2014 |
9/5 |
4/0 |
5/2 |
8/2 |
4/1 |
23/2 |
2015 |
10/4 |
7/2 |
4/2 |
4/2 |
3/0 |
16/2 |
TOTAL |
56/27 |
33/9 |
32/16 |
39/20 |
57/7 |
117/9 |
For estimating the characteristics of
the injuries, the efficiency of the treatment in the trauma centers of
different levels, and for identification of the most important problems in
carrying out the surgical care, the general groups were divided into the
subgroups according to locations of the injuries.
The head injuries were in 197 transferred patients
(58.8 %), including 56 patients (16.6 %) with the head injuries as the main
location of the concomitant injury. According to MFS-I, the general severity of
the injuries was 2.4 ± 0.8, whereas in the patients with the head injury as the
main trauma – 11.9 ± 1.4.
The patients received 231 surgical
interventions. Most interventions were the head wound suturing in different
locations. Among 9 patients who required for decompressive interventions for
the cranium and the brain in level 2-3 TCs, 4 (44.4 %) patients needed for
urgent retrepanation in the day of admission according to the results of the
examinations. It was determined by either insufficient volume of a primary
intervention (the untreated compression fracture of the left temporal and
parietal bones (Fig. 3) or recurrent intracranial hematoma (3 patients).
Figure 3. The untreated depressed fracture of the left
temporal and parietal bones
Patients with injuries to the middle and lower regions of the face presented the special problem for the surgeons in level 2-3TCs. During treating such patients, the surgical activity was low and was presented by anterior and posterior nasal tamponage and fixation of mandibular fractures with the wire splints. Surgical interventions were not conducted for most patients with the verified fractures of facial bones. It is conditioned by complexity of this pathology, uncertainty of the applied approaches and the lack of specialists and appropriate equipment. It was especially evident during primary surgical preparation of the gunshot wounds of the maxillo-facial area. The common errors are insufficient volume of removed necrotic tissues, inadequate draining of the intermuscular regions of the face and the neck, underestimation of injuries severity, the drive to suture the facial gunshot wound at all costs (Fig. 4a), unstable fixation of fractures with internal metal constructs, refusal from external fixing devices (Fig. 4b) or their absence in a trauma center.
Figure 4. A patient with the gunshot wound of the head: a)
appearance after transfer; b) resection of necrotic tissues, fixation with the
external device
Spinal injuries took the place in 91 patients
(27 %), including 57 patients (16.9 %) with such injuries as the main ones. The
general severity of the injuries was 2.3 ± 0.6, in the group with the spinal
injury as the main damage – 3.1 ± 1.4.
The analysis of the conducted
surgical interventions identified two problems (the table 2). Firstly, the
urgent surgical interventions (laminectomy) for spinal injuries were carried
out only for 43.8 % of the patients. In some cases, the spinal injuries could
be identified only in the examination in the clinic. It was determined by the
severity of the concomitant injuries in the patients with polytrauma, when the
urgent interventions for other regions of the body were carried out in level
2-3 TCs. Such patients received the surgical interventions within 24 hours
after admission to the clinic (Fig. 5).
Table 2. The characteristics of main surgical interventions in spine injury with vertebral fractures
Trauma center |
Urgent surgery |
Osteosynthesis |
||
Indicated |
Performed |
|
|
|
level 2-3 |
16 |
7 |
0 |
|
level 1 |
10 |
10 |
36 |
|
Figure 5. C6 vertebra dislocation fracture and the surgery
outcome in the clinic
Secondly, the absence of conditionsand equipment in level 2-3 TCs did not allow the spinal fixation, although surgical interventions were performed by the qualified neurosurgeons. One patient had the migration of the autograft that resulted in urgent recurrent surgery in the clinic (Fig. 6).
Figure 6. Migration of the bone autograft of C7 vertebra
and the outcome of repeated operation in the clinic
Thoracic injury was in 123 patients
(36.5 %). Such damage was the main injury in 33 patients (9.8 %). The general
severity of the injury was 2.3 ± 0.6, in the group with the thoracic injury as
the main trauma – 3.1 ± 1.0.
The table 3 shows that the most
common surgical interventions in all trauma centers were thoracocentesis and
pleural cavity draining. Single mistakes were usually associated with choice of
the diameter of the draining tube or the place of thoracocentesis. Inadequate
pleural cavity draining caused the necessity for recurrent thoracocentesis or
development of clotted hemothorax. Only
a single urgent thoracotomy for a penetrating chest injury with heart damage was
conducted in level 2 TC. In the clinic, 5 patients received the diagnostic and
curative thoracoscopy for big hemothorax (1 patient), 3 cases – for recurrent
tension hemothorax, 1 patient – for clotted hemothorax.
Table 3. The characteristics of surgical interventions for chest injury
Trauma center |
Total amount of operations |
Thoracotomy |
Thoracoscopy |
level 2-3 |
28 |
1 |
0 |
level 1 |
23 |
0 |
5 |
An unexpected problem was preparation
and realization of medical evacuation to the clinic. Some patients were
admitted with the pleural drains, which were ligated or connected with the
drain camera (Redon system). The keys
for successful treatment of patients with chest trauma in level 1 TC are:
1) obligatory chest computer
tomography after transfer of patients with chest injury and polytrauma;
2) use of low invasive methods for
diagnostics and treatment;
3) appropriate intensive therapy for
lung and heart contusion in the specialized ICU.
Abdominal injuries were diagnosed in 70 patients
(20.8 %). 32 patients had the abdominal injury as the main location of
injuries. The injury severity was 4.2 ± 0.4 according to MFS-I. The general
injury severity was 2.3 ± 0.4, in the group with abdomen as the main region of
trauma – 3.1 ± 1.1.
The analysis of surgical activity
(the table 4) showed that only 11 patients were operated in the clinic, but
they received 33 surgical interventions. In most cases, the multi-staged
surgical treatment was conducted.
Only one patient with the gunshot
abdominal wound with the injuries to the duodenum, caput pancreatic, ductus
choledochus and the inferior vena cava received the relaparotomy as the third
stage of damage control in the day of admission. The timely breakaway of the
duodenum, jejunostomy, sanitation and draining of the abdominal cavity were
carried out. The subsequent posttraumatic pancreatitis with purulent-fibrous
peritonitis required for another three programmed relaparotomy procedures.
Table 4. The characteristics of complex surgical interventions for abdominal injury
Trauma center |
Amount of laparotomy procedures |
Amount of patients with performed laparotomy |
level 2-3 |
38 |
38 |
level 1 |
33 |
11 |
For other 10 patients, laparotomy was
conducted for programmed treatment of peritonitis. The causes were the
injuries, which were not diagnosed or were missed during urgent laparotomy, for
example, a full rupture of the small intestine identified in the clinic on 9th
day after the road traffic injury (Fig. 7).
Figure 7. Full rupture of the small intestine and its
mesentery
The multi-staged treatment included
the systems with controlled negative pressure.
75 patients (22.3 %) had the pelvic
injuries. The general severity of the injury was 4.4 ± 2.2, in the group with
the pelvis as the main injured region – 3.1 ± 1.6. The pelvic injury as the
main trauma was in 39 (11.6 %) patients.
The table 5 shows a fairly high proportion
of the patients with extrafocal fixation of unstable pelvic fractures in level
2-3 TCs. It was associated with improvement in the system of medical care for
injuries, development of well-equipped traumatology units. However 10 patients
were admitted to the clinic with non-fixed fractures. Moreover, some patients received
the interventions, but the goal was not achieved. The figure 8 shows the CT
images of the patient with the applied rod device, but the vertical
displacement of the right half of the pelvis and the dislocation of the left
hip were not corrected.
Table 5. The characteristics of complex surgical interventions for pelvic injury
Trauma center |
Extrafocal fixation |
Pelvic organs injuries |
Osteosynthesis |
level 2-3 |
25 |
5 |
4 |
level 1 |
10 |
4 |
49 |
Figure 8. Untreated vertical displacement of the right
half of the pelvis and dislocation of the left hip
The separate problem was therecurrent interventions for the patients with injuries to the pelvic organs. Among 5 patients, 4 ones needed for recurrent surgery due to disadvantages in primary surgical interventions and inadequate draining of paravesical fat (Fig. 9), resulting in inconsistency of urinary bladder sutures and formation of pelvic urohematoma.
Figure 9. Infected urohematoma of paravesical cellular
tissue
The injuries to the extremities
were identified in 212 patients (63.1 %). The general severity of trauma was
2.1 ± 0.5, in the group with the extremities as the main injured regions – 3.1
± 1.2. Such injuries were main ones in 177 (34.8 %) patients.
The treatment of this category of the
patients was associated with three main problems. The first problem was the
disadvantages in transport immobilization of extremities fractures during
transfer to the clinic. As the table 6 shows, 25 patients received the
extrafocal osteosynthesis in level 2-3 TCs, whereas other 40 patients also
needed for this procedure. The attempts to perform immobilization with the
plaster bars or dressings were usually non-efficient. The result of inadequate
immobilization of a leg fracture in one patient was popliteal artery thrombosis
with development of non-compensated ischemia in the leg and the foot, with
requirement for urgent vascular reconstruction.
Table 6. The characteristics of complex surgical interventions for injuries to extremities
Trauma center |
Extrafocal fixation |
External osteosynthesis |
|
Patients |
Surgery for extremities segments |
Patients |
|
level 2-3 |
25 |
30 |
11 |
level 1 |
40 |
57 |
126 |
The second problem was inadequate awareness
among the physicians of level 2-3 TCs in relation to the treatment techniques
for extensive circular detachments of the skin. The attempts to suture the
detached skin flaps caused their necrosis (Fig. 10), and the absence of
immobilization of an injured extremity was the cause of inappropriate survival
of the autograft.
Figure 10. Necrosis of circularly detached skin flaps
The surgical treatment of extensive injuries to the soft tissues of the extremities was the third problem in this group of the patients (Fig. 11). The attempt to complete the surgery with application of the primary suture by any costs was the frequent error on primary surgical preparation. The edema of the injured tissues caused their secondary necrosis (Fig. 12), development of purulent-septic complications and recurrent surgical interventions.
Figure 11. Extensive damage of soft tissues of the right
forearm
Figure 12. Consequences of application of primary suture in
extensive injuries to soft tissues of the extremities
The analysis of the treatment outcomes of all patients showed the mortality of 9.8 % among the transferred patients (22.7 % in the patients with polytrauma) (the table 7). There were not any reliable differences in the general mortality in the patients who were initially admitted to the clinic. However the calculation of these values in the patients who survived within the first 24 hours after primary admission to the clinic identified the lower values of the general mortality in polytrauma.
Table 7. Mortality in military field surgery clinic
Injury type |
Mortality in patients transferred to clinic, % |
Mortality on primary admission to clinic |
|
General, % |
After 1st day, % |
||
All injuries |
9.8 |
10.2 |
6.6* |
Polytrauma |
22.7 |
24.8 |
17.3* |
Note: * – differences are reliable as compared to the group of the transferred patients (p < 0.05).
CONCLUSION
1. The variant of the course of
traumatic disease is determined by both the severity of trauma and the volume
and adequacy of the treatment.
2. The optimal level of surgical and
intensive care for polytrauma is fully realized only in conditions of the
specialized hospital (level 1 trauma center).
3. The task of level 2-3 trauma
centers at the moment of admission of patients with polytrauma is life-saving
with use of multi-staged treatment, the patient’s condition stabilization and
fast transfer to the specialized centers (level 1 trauma centers). Any delay in
evacuation of such patients is accompanied by risk of development of unfavorable
consequences of untimely or inadequate surgical and intensive care, and
increasing mortality.
4. The multi-staged surgical
treatment for life salvage in level 2-3 trauma centers can be realized
according to the vital (refusal from full volume of a surgical intervention
owing to severity of condition) and tactical (absence of a technical
possibility for realization of full volume of surgical intervention)
indications.
5. For full realization of the
required level and volume of medical care in the trauma centers of the level
2-3, it is necessary to give the special attention to material and technical
resources and to staff education concerning the actual problems of polytrauma.
6. The system of medical care
realization for patients with polytrauma should consist in maximal reduction of
the stages and time of all types of surgical care.
Information about conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.
REFERENCES:
1. Agadzhanyan
VV, Kravtsov SA, Shatalin AV, Levchenko TV. Hospital mortality in polytrauma
and main directions for its decrease. Polytrauma. 2015; 1: 6-15. Russian (Агаджанян В.В., Кравцов С.А., Шаталин А.В.,
Левченко Т.В. Госпитальная летальность при политравме и основные
направления ее снижения //Политравма. 2015. № 1. С. 6-15)
2. About results of work of the Ministry of
health of the Russian Federation in 2015 and tasks for 2016 [Electronic
resource]: The report by Skvortsova V.I., the Minister of Health of the Russian
Federation, at the meeting of the final Board of Ministry of Health of Russia.
Mode of access: https://www.rosminzdrav.ru/ministry/61/22/stranitsa-979/doklad-ob-itogah-raboty-ministerstva-zdravoohraneniya-rossiyskoy-federatsii-v-2015-godu-i-zadachah-na-2016-god. Russian (Об итогах работы Министерства здравоохранения Российской Федерации в 2015
году и задачах на 2016 год: доклад Министра здравоохранения Российской
Федерации Скворцовой В.И. на заседании итоговой Коллегии Минздрава России «»
[Электронный ресурс]. Режим доступа: https://www.rosminzdrav.ru/ministry/61/22/stranitsa-979/doklad-ob-itogah-raboty-ministerstva-zdravoohraneniya-rossiyskoy-federatsii-v-2015-godu-i-zadachah-na-2016-god)
3. On organization of medical
aid in road traffic accidents. [Electronic resource]: the order of the Health
Ministry of the Krasnodar territory No.5844 from 14.10.2015. Mode of access: http://www.kubved.ru/upload/iblock/01f/skhema-organizatsii-pomoshchi-pri-dtp-v-krasnodarskom-krae.pdf. Russian (Об
организации медицинской помощи пострадавшим при дорожно-транспортных
происшествиях» [Электронный ресурс]: приказ
МЗ Краснодарского края № 5844 от 14.10.2015г. Режим доступа: http://www.kubved.ru/upload/iblock/01f/skhema-organizatsii-pomoshchi-pri-dtp-v-krasnodarskom-krae.pdf)
4. Kühne C.A., Ruchholtz S., Buschmann C., Sturm J., Lackner C.K., Wentzensen A., Bouillon B., Waydhas C., Weber C. Trauma centers in Germany. Status report. Unfallchirurg. 2006; 109(10): 913
5. Polytrauma: traumatic illness, immune
system dysfunction, modern treatment strategy. Eds. Gumanenko EK., Kozlov VK. Moscow: GEOTAR-Media, 2008. 608 p. Russian (Политравма:
травматическая болезнь, дисфункция иммунной системы, современная стратегия
лечения /под ред. Е.К. Гуманенко и В.К. Козлова. М.: ГЭОТАР-Медиа, 2008. 608 с.)
6. Sokolov VA. Multiple and
concomitant injuries. Moscow: GEOTAR-Media, 2006. 512 p. Russian
(Соколов В.А. Множественные и сочетанные травмы. М.: ГЭОТАР-Медиа, 2006. 512 с.)
7. Gumanenko EK, Boyarintsev VV, Suprun TYu, Ljashed'ko
PP. Objective assessment of the severity of the injury. Saint Petersburg, 1999.
53 p. Russian (Гуманенко Е.К., Бояринцев В.В., Супрун Т.Ю., Ляшедько П.П. Объективная оценка тяжести травм. СПб.: ВМедА,
1999. 53 с.)
Статистика просмотров
Ссылки
- На текущий момент ссылки отсутствуют.