current trauma manag, trauma system

Current Trauma Management Where Are We?

Trauma SystemBy

Mr. Mahmoud AbdulkareemM.S {Cairo} , FRCS {Glasgow}

Consultant Surgeon,King Fahad Specialist Hospital

Wednesday, May 3, 2023 3

Damage Control ResuscitationBy

DR. Mahmoud AbdulkareemM.S {Cairo} , FRCS {Glasgow}

Consultant Surgeon,King Fahad Specialist Hospital

Trauma is the most common cause of death in patients aged less than 40 years

Injuries Injuries result from acute exposure to

physical agents such as mechanical energy, heat, electricity, chemicals, and ionizing radiation in amounts or at rates above or below the threshold of human tolerance. R T As account for most injuries Followed by assaults, drownings, falls, burns.

TraumaTrauma is the study of medical problems associated with physical injury.

The trauma patient The trauma patient has been defined as “an

injured person who requires timely diagnosis and treatment of actual or potential injuries by a multidisciplinary team of health care professionals, supported by the appropriate resources, to diminish or eliminate the risk of death or permanent disability.”

Mortality is not the only side of this issue; for every trauma victim who dies, at least six are seriously injured

The scope of trauma as a problem

Editors: Feliciano, David V.; Mattox, Kenneth L.; Moore, Ernest E.Title: Trauma, 6th EditionCopyright ©2008 McGraw-Hill

THE NEED FOR TRAUMA SYSTEMS—HISTORY …. cont.

However, trauma is not yet recognized as a disease process. Many people still think of trauma as an accident.

“the neglected disease of modern society.”

THE NEED FOR TRAUMA SYSTEMS—HISTORY …. cont.

National Research Council: Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: U.S. Government Printing Office, 1966.

MODERN TRAUMA SYSTEMDEVELOPMENT …. cont.

MODERN TRAUMA SYSTEMDEVELOPMENT …. cont.

By 1975, Germany had established a nationwide trauma system, so that no patient was more than 15–20 minutes from one of these regional canters.

ATLS was developed as a protocol for the management of Trauma victims

MODERN TRAUMA SYSTEMDEVELOPMENT …. cont.

The landmark report of the Royal College of Surgeons (1988) on the management of patients with major injuries highlighted serious deficiencies in trauma management in the United Kingdom. Led to the introduction of the ATLs in the UK.

The trimodal distribution of trauma deaths

The second peak of approximately 30% of all deaths occurs during the initial hours post injury and preventing these deaths were initially the goal of modern trauma care, such as is taught through the Advanced Trauma Life Support (ATLS) course.

The Goal

MODERN TRAUMA SYSTEMDEVELOPMENT …. cont.

Studies of trauma systems have shown that: Salvage of the critically injured patient is optimized by a

coordinated team effort in an organized trauma system.And that:when severely injured patients are treated in specialized

trauma centers, patients have greater chances of survival.

(Cales 1984; Cales and Trunkey 1985; Guss, Meyer, Neuman, et al. 1989; Shackford et al. 1986; Smith et al. 1990; West, Cales, and Gazzaniga 1983).

MODERN TRAUMA SYSTEM DEVELOPMENT

MODERN TRAUMA SYSTEM DEVELOPMENT

The trimodal distribution of trauma deaths

Injury prevention

has become an essential focus for all trauma systems

prevention

Fundamental phases 1. Injury prevention has become an essential focus for all trauma systems in

order to proactively reduce the impact of injury. Many systems have developed formal injury prevention programs and dedicated centers to better address this need.

2. Pre-hospital care includes community access and communication systems as well as EMS systems and triage protocols. Universal access to emergency care (i.e., 911) is essential to allow efficient activation of the system.

3. Acute care facilities provide a range of injury management from initial stabilization and transfer to all-inclusive definitive care. Based on available resources, facilities are characterized by injury management capabilities and many are designated as trauma centers using a scale of 1 to 4, with Level 1 centers providing the most comprehensive level of care. Successful trauma systems benefit from the contributions of all available facilities to become more inclusive and to provide consistent care to all people within the system.

4. Post-hospital care is an important part of reducing disability and improving an injured patient's long-term outcome. Efficient transfer from the acute care setting to rehabilitation is a necessary attribute of a well-developed trauma system.West JG, Williams MJ, Trunkey DD, et al.: Trauma systems: Current status future challenges.

JAMA 259:3597, 1988.

conditioning

Prehospital Care cont.

Critically injured patients must receive high-quality care from the earliest postinjury moment to have the best chance of survival.

Triage: the aim is to provide optimum care to maximum No of pt. by ensuring that they are treated in order of need so that pt. with severe injury that is potentially survivable are given priority of care. The most experienced person present should carry out triage.

Prehospital Care ….cont.

Advanced life support is provided [by an organized trauma team]

Early hospital phase:

Phases of management of the injured patient

Principles of Initial Trauma Management• Organized team approach1. Complexity of multiple trauma patients2. Trauma victims are best managed by a team approach• Assumption of most serious injury1. assume that the worst possible injury has occurred and act accordingly until

the diagnosis is confirmed• Treatment before diagnosis1. urgency of situation often demands treatment based on an initial brief

assessment• Thorough examination1. initial survey of vital organ systems, followed by resuscitative interventions2. Most missed injuries occur in unconscious patients• Frequent assessment1. helps detecting early changes in physical findings and thus lead to prompt

corrective actions• Prioritisation, optimisation, anticipation and planning are keys to success

Trauma TeamDefinitionThe trauma team is an organized group of professionals who perform initial assessment and

resuscitation of critically injured patients. Team composition, level of response, and responsibilities of each member are institution-specific. Personnel are outlined as follows:

1. Trauma surgeon—a general surgeon with demonstrated training and interest in trauma care. In designated trauma centers, the trauma surgeon typically functions as the trauma team leader.

2. Emergency medicine physician—in many hospitals, the emergency medicine physician functions as the trauma team leader depending on the perceived severity of injuries. Ideally, these physicians have Advanced Trauma Life Support (ATLS) certification.

3. Anesthesiologist—a physician with special skills in airway management, sedation, and analgesia. In many trauma centers, this role may be fulfilled by a certified registered nurse anesthetist

4. Trauma nurses—emergency department nurses with specialized training and demonstrated interest in trauma care.

5. Resident physicians—residents in emergency medicine or surgery and trauma fellows may assume active roles in the trauma team. In Level I and II trauma centers, senior surgical residents and trauma fellows may function as trauma team leaders.

6. Respiratory therapist—therapist available to assist in the evaluation and management of the patient's respiratory status.

7. Radiology technicians—technicians available to obtain x-rays as indicated by the initial assessment and secondary survey.

8. Surgical subspecialists—although not typically involved in the initial assessment, surgical consultants (e.g., orthopedic surgeons, neurosurgeons) are vital members of the trauma team.

9. Other personnel—the trauma team may also include OR nurses, laboratory technicians, ECG technicians, chaplains, social workers, transport personnel, and case managers.

Hospital trauma teamtransferring a new patient.

The rapid sequence intubation team

Original articleImpact of a multifunctional image-guided therapy suite

on emergency multiple trauma careT. Gross1, P. Messmer1,7, F. Amsler5, I. Fu¨ glistaler-Montali1, M. Zu¨ rcher2, R. W. Hu¨ gli1,6,

P. Regazzoni1,3 and A. L. Jacob1,4British Journal of Surgery 2010; 97: 118–127

Conclusion: Implementation of a MIGTS in the emergency treatment of multiple trauma significantlyaccelerated the procedure and reduced the number of in-hospital transports.

ATLS overview

• Preparation• Triage• Primary Survey

(ABCDE’s)• Resuscitation• Adjuncts to primary

survey and Resus.

• Secondary Survey• Adjuncts to Secondary

survey• Continued post-resus

monitoring• Definitive Care

Care in a trauma system consists of many phases: surgical phase Damage

Control

Damage Control Surgery

1. Control hemorrhage2. Stop further

contamination3. Rapid closure or open

packing 4. Resuscitation in SICU5. Return to OR in 24-48

hours for definitive repair.

IN A TRAUMA PATIENT who is hemorrhaging, increased risk of death arises from a vicious cycle of hypothermia, coagulopathy, and metabolic acidosis known as the triad of death.

Trauma Handbook of the Massachusetts General Hospital, The, 1st Edition

Care in a trauma system consists of many phases: I C U phase

Unique Critical Care Issues Related to Trauma