Poly Trauma Management
Knowledge, Training and Preparation can Save Lives
Dr Prashant Agrawal
Injury has become a major cause of death and disability worldwide. Organised approaches to its prevention and treatment are needed. In terms of treatment, there are many low-cost improvements that could be made to enhance the care of injured persons. Population-based studies and trauma registry studies show a fairly consistent 1520% or greater reduction in mortality for better organised systems, compared with either the same systems prior to improvements in organisation or to other less organised systems.
Standard trauma treatment should realistically be made available to almost every injured person in the world. The resources that would be necessary to assure such care include human resources (staffing and training) and physical resources (infrastructure, equipment and supplies). Strengthening and improvements in trauma treatment worldwide needs organisation and planning which will improve outcome of injured persons, with minimal increases in expenditures.
Methods to promote such standards include training, performance improvement, trauma team organization in primary hospital set-up. In working towards decreasing the burden of death and disability from injury, a spectrum of activities needs to be considered, ranging from surveillance and basic research to prevention programmes, to trauma management. Large gains are to be made in prevention, and hence a major emphasis should be placed on this approach. There are also major gains to be made by addressing treatment. That is to say, low-cost initiatives can help to reinforce current trauma treatment.
There are notable disparities in mortality rates for injured patients around the world. Considering only patients who survive to reach the hospital, has high mortality, such mortality increased from 6% in a hospital in a high-income country to 36% in a rural area of a low-income country.
In addition to an excess mortality, there is a tremendous burden of disability from extremity injuries in many developing countries. By comparison, head and spinal cord injuries contribute a greater percentage of disability in high income countries. Much of the disability from extremity injuries in developing countries should be eminently preventable through inexpensive improvements in orthopedic care and rehabilitation. Improvement in the organisation of trauma services should be achievable in almost every setting and may represent a cost effective way of improving patient outcomes.
In most developing countries, little consideration has been given to optimise the training of medical and nursing staff for the care of injured patients. This applies to both urban and rural environments. For example, hospitals in rural areas along major roads receive large numbers of casualties, yet are often staffed by medical officer and nurses with no specific training in trauma care.
Inexpensive but effective solutions to such problems might include:
(i) country-wide plans to encourage those staff with more experience in trauma care to go to such hospitals; and
(ii) provision of continuing education courses on trauma care for medical officers and nurses in high-volume trauma hospitals.
Data show that there were prolonged times to emergency surgery, with a mean time of 12 hours between arrival at the casualty ward and start of the procedure. There was also low utilisation of chest tubes, even though they were physically available in the hospital. Only 0.6% of all trauma admissions had a chest tube inserted, in comparison with 6.3% at a hospital in a developed country. In addition to addressing such items individually, this study identified the implementation of basic quality improvement programmes (medical audit) as a possible way of addressing many such problems in the process of trauma care.
What needs to be done?
We have to improvise on essential services approach, planning of emergency medical services, pre-hospital triage, transfer criteria and transfer arrangements between hospitals. Most studies confirm a reduction in mortality with the improved organisation provided by a system for trauma management. Panel reviews show an average reduction in medically preventable deaths of 50% after the implementation of a system for trauma management.
The immediately life-threatening injuries are to be addressed in the initial evaluation and resuscitation, such as the management of airway, breathing and circulation. These are deemed essential at hospital-level facilities. Safety assurance also mandates that staff performing the various procedures be adequately trained to perform them successfully, with an acceptable rate.
Essential trauma services: Needs of the injured patient
These might be considered as the “needs of the injured patient.” These can be categorised into three broad sets of needs:
1. Life-threatening injuries are to be appropriately treated, promptly and in accordance with appropriate priorities, so as to maximise the likelihood of survival.
2. Potentially disabling injuries are to be treated appropriately, so as to minimise functional impairment and to maximise the return to independence and to participation in community life.
3. Pain and psychological sufferings are to minimised.
Goals to achieve:
* Obstructed airways are opened and maintained before hypoxia leads to death or permanent disability.
Within these three broad categories, mentioned above, there are several specific medical goals that are eminently achievable within the resources available in most countries.
* Impaired breathing is supported until the injured person is able to breathe adequately without assistance.
* Pneumothorax (air in chest cavity) and haemothorax (blood in chest cavity) are promptly recognised and relieved.
* Bleeding (external or internal) is promptly stopped.
* Shock is recognised and treated with intravenous (IV) fluid replacement before irreversible consequences occur.
* The consequences of traumatic brain injury are lessened by timely decompression of space occupying lesions and by prevention of secondary brain injury.
* Intestinal and other abdominal injuries are promptly recognised and repaired.
* Potentially disabling extremity injuries are corrected.
* Potentially unstable spinal cord injuries are recognised and managed appropriately, including early immobilisation.
* The consequences to the individual of injuries that result in physical impairment are minimised by appropriate rehabilitative services.
* Medications for the above services and for the minimisation of pain should be readily available when needed.
Dr Prashant Agrawal is a doctor based in Dhaka.
(R) thedailystar.net 2009