[The polytrauma patient, triage and priorities in early treatment].
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Emergency Medical Services↗
Biomedical subjects
C Waydhas
Publications and source records attributed to C Waydhas.
[Transport trauma: fact or fiction?].
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Critical Care↗
[Effect of kinetic therapy on the treatment outcome in patients with post-traumatic lung failure].
Intermittent prone positioning (PP) is a promising therapy of patients with severe respiratory failure. Evaluations of patient outcomes can not, to dare, be found in the literature. This study was conducted to investigate the effects of intermittent PP on patients with posttraumatic respiratory failure (PaO2/FiO2 < 280 mmHg) in comparison with conventional therapy in suspine position. The collected data is part of our prospective polytrauma study. 136 polytraumized patients (mean ISS 23.4) were included and evaluated. 77 patients had a severe chest trauma with an AIS > or = 3. Of these, 47 patients developed a respiratory failure. 19 of these patients were treated conventionally in suspine position, 28 patients were intermittently turned prone. Having similar AIS (3.6 vs. 33), the PP-patients had a significantly severer trauma (ISS 35.8 vs. 24.5). Though the injury severity of the PP-patients was much higher, the time of ventilation (32 vs. 31 d) and the ICU stay (39 vs. 36 d) was similar to the patients treated in suspine position. The mortility of PP-patients was 0%, of suspine positioned patients 26%. After the first PP the PaO2/FiO2 ratio increased with an average of 82 mmHg (26-151 mmHg). The FiO2 was reduced from 0.45 (0.35-1.0) to 0.26 (0.21-0.35). Beside the beneficial effect of PP on the oxygenation we have, for the first time evidence that PP improves the outcome of patients with posttraumatic respiratory failure.
Adolescent↗
Scores in polytrauma--do they help?
BACKGROUND: The answer to the question "Scores in polytrauma - do they help ?" is discussed. DISCUSSION: One of the two sections deals with the role of scores used for clinical decision making in individual patients and, in the other, the significance of scores in improving patient care is analyzed. RESULTS: It is shown that scores may be helpful in both regards. However, certain methodological limitations of scores have to be considered.
Decision Making↗
Improvement in the therapy of multiply injured patients by introduction of clinical management guidelines.
A trauma algorithm representing the guidelines for the management of emergency treatment of severe blunt trauma was implemented at our institution in 1994. By comparison of two prospectively recorded cohorts of multiply injured patients, the clinical efficacy of these guidelines was analysed. The algorithm cohort comprised 74 patients over the period January 1994 to June 1996, and the Control cohort 126 patients over the period April 1988 to December 1993. To evaluate procedural quality of early clinical trauma management, nine criteria were applied. After implementation of the algorithm there was an improvement in all parameters reflected by a significant reduction of missed injuries and important time savings. Mortality rates in the cohorts were calculated after subdivision into three groups (I-III) with moderate (ISS: 18-24), high (ISS: 25-49) and very high (ISS: 50-75) injury severity. All cohort subgroups were comparable with respect to ISS values, age, initial loss of consciousness (GCS) and shock rate. In all subgroups of the algorithm cohort mortality rates were reduced: group I: 0 versus 20 per cent (p < 0.05); group II: 8 versus 24 per cent (p < 0.05); group III: 40 versus 71 per cent. Improvements in both therapeutic process and outcome were observed after implementation of the trauma algorithm.
Adult↗
Percutaneous computed tomographic-controlled ventriculostomy in severe traumatic brain injury.
OBJECTIVE: Percutaneous computed tomographic (CT)-controlled ventriculostomy (PCV) was introduced for the monitoring of intracranial pressure in patients with severe traumatic brain injury who did not require simultaneous decompressive trepanation. METHODS: PCV (n = 14) was compared with conventional burr hole ventriculostomy (n = 13) based on prospectively collected data. RESULTS: PCV proved to be a successful technique in all cases and also when a burr hole ventriculostomy was impossible previously. There were no complications. In burr hole ventriculostomy, there were one unsuccessful insertion and one catheter contamination. The main advantage of PCV over burr hole ventriculostomy was a significant (p < 0.05) reduction in the time required to perform the procedure. In ventriculostomy directly after the initial evaluation in the emergency department, the operation time was reduced from 45 +/- 11 to 22 +/- 14 minutes. The interval between cranial computed tomography and start of operation was reduced from 78 +/- 38 to 33 +/- 12 minutes, and between initial cranial computed tomography and intensive care unit admittance, from 138 +/- 37 to 73 +/- 28 minutes. For patients requiring ventriculostomy while being treated in the intensive care unit, the duration of the procedure (i.e., absence from the intensive care unit) was able to be reduced from 111 +/- 24 to 81 +/- 21 minutes. CONCLUSION: Distinct time savings are the major advantages of PCV, allowing exact catheter positioning even with very narrow ventricles.
Adolescent↗
High-dose antithrombin III treatment of severely injured patients: results of a prospective study.
BACKGROUND: Antithrombin III (AT III) treatment has been shown to reduce disseminated intravascular coagulation and to inhibit thrombin, which plays a central role in the activation of platelets and other inflammatory systems in conditions with severe inflammation. The objective of this study was to evaluate the influence of early and high-dose administration of AT III to patients with severe multiple injuries on the inflammatory response and outcome. METHODS: In a placebo-controlled, double-blind study, 40 consecutive patients with Injury Severity Scores of 29 or greater who met the inclusion criteria were randomized to receive either AT III or placebo within 360 minutes after trauma. Twenty patients were administered AT III for a period of 4 days, aiming to achieve AT III concentrations of 140% of normal. RESULTS: The AT III and placebo groups were comparable with respect to Injury Severity Score, age, incidence of blood pressure less than 80 mm Hg on admission, initial base deficit, and start of the test drug. The patients in the AT III group received a total of about 20,000 IU during the first 4 days. AT III levels of 130 to 140% could be achieved by this regimen, whereas in the control group the AT III concentration averaged about 70%. In the AT III group prothrombin tended to be elevated and prothrombin fragment F1+2 as well as thrombin-AT III complex tended to be lower on the first day. No differences between groups, however, could be observed with respect to partial thromboplastin time, prothrombin time, platelets, plasminogen activator inhibitor I, soluble tumor necrosis factor receptor II, neutrophil elastase, interleukin (IL)-1 receptor antagonist, IL-6, and IL-8. Mortality (15 vs. 5%), incidence of respiratory failure (55 vs. 55%), duration of mechanical ventilation (13 vs. 12 days), and length of stay in the surgical intensive care unit (19 vs. 21 days) were also similar in both treatment groups. The duration of organ failure, however, was shorter in the patients receiving AT III. CONCLUSION: The early and high-dose administration of AT III to patients with severe blunt trauma appears not to attenuate the posttraumatic inflammatory response or to significantly improve outcome.
Adult↗
[Effect of kinetic therapy on the course of treatment of patients with post-traumatic lung failure].
This study was conducted to investigate the effects of intermittent prone positioning of patients with post-traumatic respiratory failure (paO2/FiO2 < 280 mm Hg) in comparison with conventional therapy in a supine position. Although the severity of injury of the prone-positioned patients was much higher (ISS 35.8 vs 24.5), the ventilation time (32 vs 31 days) and ICU stay (39 vs 36 days) were similar to patients treated in the supine position. Besides the beneficial effect of prone positioning on oxygenation, for the first time we have evidence that prone positioning improves the outcome of patients with post-traumatic respiratory failure.
Adult↗
[Minimal invasive, percutaneous ventriculostomy in therapy of severe craniocerebral trauma].
From May 1996 until April 1997 percutaneous CT-controlled ventriculostomy (PCV) was performed in 19 patients with severe traumatic brain injury and no indication for decompressive craniotomy. There was a significant reduction in the duration of the procedure compared to burr-hole ventriculostomy with no complications. Because of further advantage of PCV CT-controlling is the possibility of puncturing even very narrow ventricles.
Brain Edema↗
[Shock room diagnosis in polytrauma. Value of thoracic CT].
OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest X-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information obtained influences subsequent decisions on therapy in the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiply injured patients with chest trauma, 9 patients with isolated chest trauma) who had an average ISS of 30 and an average AIS thorax of 3, initial CXR and TCT were compared after the first assessment in our emergency department (a level I trauma center). Mortality in this group was 10% (n = 10). RESULTS: In 67 patients (65%) TCT revealed major complications of chest trauma that had been missed on CXR: lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax ((n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1); in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT; and in 14 patients CXR and TCT showed identical pathologic results. In 11 patients neither CXR nor TCT revealed pathologic findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (P < 0.001), pneumothorax (P < 0.005) and hemothorax (P < 0.05). In 42 patients (41%) the additional TCT findings did affect, the therapy selected: chest tube placement or chest tube correction in mostly anteriorly located pneumothoraces or large hemothoraces (n = 31), influence on ventilation mode and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1). CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions and pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work-up of multiple injured patients with suspected chest trauma, because early and accurate diagnosis of all thoracic injuries along with acceptance of the implications for therapy may reduce complications and improve the outcome in polytraumatized patients with blunt chest trauma.
Adolescent↗
[Quality management in early clinical multiple trauma care. Documentation of treatment and evaluation of critical care quality].
Quality management in early clinical care of patients with multiple injuries (description of actual process, identification of problems, implementation of quality improvement) is not possible without sufficient baseline data about the present situation of medical treatment. This study investigates whether the current documentation of treatment in the emergency room is appropriate to judge upon the quality of the process and to detect problems. In addition, a set of baseline data is presented. The performance in the treatment of 126 multiple injured patients was prospectively recorded from 1988 to 1993 and compared with an idealized process based upon an algorithm. The quality of present data recording was analysed, and criteria for judgement of quality of care were assessed. The algorithm was divided into 117 possible steps (one step consisting of a single decision criterion, the decision and the corresponding procedure). Per patient, only 61% +/- 12% of these steps were sufficiently documented to allow judgement. Using several criteria for assessment, the following baseline data could be observed (times shown refer to admission to the trauma room): (1) trauma room time of 129 +/- 55 min; (2) completion of basic radiological and sonographic diagnostics in 91% of patients; (3) first blood collection after 17 +/- 11 min; (4) cranial computerised tomography after 55 +/- 20 min; (5) missed injuries during the trauma room period in 32% of patients; (6) intubation after 20 +/- 19 min; (7) insertion of a chest tube after 30 +/- 17 min; (8) first blood transfusion in shock after 32 +/- 17 min; (9) transfused blood within the first hour of 4.2 +/- 2.8 units and within the second hour of 8.5 +/- 4.7 units; (10) emergency operations in shock after 98 +/- 55 min; (11) early operations after 156 +/- 69 min; (12) craniotomy after 124 +/- 37 min; (13) unplanned surgery within 24 hours after admission to the intensive care unit in 11% of patients. The study presented here supplies information on timing and other process data of the acute clinical care of seriously injured patients. In particular, the data represent indicators for the quality of emergency room management, which may be used as baseline to compose improvement measures of structure and process. The quality of data collection has to be improved for carrying out an exact analysis of the process.
Adolescent↗
[Quality management in early clinical polytrauma management. II. Optimizing therapy by treatment guidelines].
To enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed, comparing two prospectively recorded collectives of polytraumatized patients 4/1988-12/1993 (A; n = 126) and 1/1994-6/1996 (B; n = 74). Nine specifically defined parameters were used to assess the therapeutic process of early clinical trauma management. All parameters showed an improvement after implementation of the algorithm (group B): (1) Complete radiological and sonographic basic diagnostics in 97% vs. 92% of patients; (2) time interval of 38 min vs. 55 min until cranial CT was done after severe head injury (GCS < 10); (3) reduction of delayed diagnosis of lesions to 5% vs. 24%; (4) duration of 16 min vs. 20 min until intubation; (5) period of 23 min to 30 min to pleural drainage; (6) duration of 18 min vs. 32 min until transfusion in shock; (7) period of 79 min vs. 98 min until emergency operation in shock; (8) duration of 95 min vs. 124 min until trepanation, and (9) operation rate within 24 h after admission to ICU in 3% vs. 12%. The lethality rates of each collective were assessed after subdivision in three groups (I-III) with middle (ISS: 18-24), high (ISS: 25-49) and extreme (ISS: 50-75) injury severity. In all groups of both collectives ISS values, age, initial loss of consciousness (GCS) and shock were comparable (except the higher injury severity of collective B in group I). In all groups a reduction of lethality could be shown for collective B: Group I, 0% vs. 20% (P < 0.05); group II, 8% vs. 24% (P < 0.05); and group III, 40% vs. 71%, not significant because of the small group in B (n = 5). The implementation of therapeutic management guidelines led to an improvement of both treatment processes and outcome. In order to regularly reassess validity and practicability of such guidelines as well as further enhance therapeutic quality, a continuous evaluation programme representing a quality management system should be inaugurated.
Adult↗
[Algorithms in trauma management].
A well-controlled, meticulous process has a far higher probability of resulting in a high quality of medical care than improvization and unstructured creativity. Algorithms display decision-making treatment processes and problem-solving strategies by giving clearly defined and formalized guidelines. The flow chart for decision-making follows the yes/no dichotomy of binary logic. The systematic ordering of decision points and consequent actions is guided by medical priority and thus regulates the time-frame and sequence of each single step in a logical manner. With the help of clinical algorithms highly complex processes such as the management of the severely injured patient can be translated into a clearly structured, logical pathway. Clinical algorithms represent scientifically recognized treatment rules, indicate a solution for solving problems and help users to organize ideas and recognize connections. They delineate a consistent and valid guideline, while allowing deviations in proven exceptions. The use of algorithms allows a systematic search for errors in the process of quality management. In emergency situations they suggest a structured means of problem solving for the less experienced user. Algorithms are useful instruments in the teaching of medical decision-making.
Algorithms↗
Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries.
BACKGROUND: Most prognostic indices for severely injured patients are based on anatomical findings and the vital signs. The posttraumatic organ failure, however, is thought to be triggered by the initial inflammatory response. The objective of this study was to evaluate the correlation between the early activation of inflammation and the rate of organ failure and death. METHODS: Sixty-six patients with multiple injuries (Injury Severity Score > 18, age 18-70 years, admission within 6 hours after accident, survival > 48 hours) were included in this prospective study. During a 14-day observation period, serial blood samples were collected starting within 30 minutes after admission. Plasma levels of neutrophil elastase, lactate, antithrombin III, and interleukin-6 and -8 were determined. The clinical course and the degree of organ failure were recorded daily until death or transfer to a general ward. RESULTS: The 66 severely injured patients had a mean Injury Severity Score of 40 points. Eleven patients died from multiple organ failure (group 1), 38 subjects survived a single or multiple organ failure (group 2), and 17 patients had an uneventful recovery (group 3). The initial plasma concentrations for neutrophil elastase (650 vs. 355 ng/mL), lactate (5.0 vs. 3.1 mmol/L), antithrombin III (48 vs. 62% from normal), interleukin-6 (703 vs. 177 pg/mL), and interleukin-8 (1,101 vs. 301 pg/mL) were significantly different between groups 2 and 3 already in the initial posttraumatic period. Patients from group 1 presented with significantly higher levels of these parameters as early as 24 hours after trauma compared with group 2. Different patterns were identified with respect to early versus late posttraumatic organ failure. CONCLUSIONS: These data show that the degree of the initial inflammatory response corresponds with the development of posttraumatic organ failure. Besides anatomically and physiologically based trauma scores, these parameters might be used as indicators for the injury severity.
Adolescent↗
Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study.
OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest trauma (94 multiple injured patients with chest trauma, nine patients with isolated chest trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center. RESULTS: In 67 patients (65%) TCT detected major chest trauma complications that have been missed on CXR (lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005), and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement, chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of respiratory failure, adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with multiple trauma and with blunt chest trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group. CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualzing lung contusions, pneumothorax, and hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with multiple injuries and with suspected chest trauma because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.
Adolescent↗
[Can diagnosis and subsequent trauma management of the multiple trauma patient with blunt thoracic trauma be improved by early computerized tomography of the thorax?].
OBJECTIVE: The aim of this prospective study was to evaluate, whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work up of blunt thoracic trauma and whether these additional informations influence subsequent therapeutical decisions in the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiple injured patients with chest trauma, 9 patients with isolated chest trauma) with an average ISS of 30 and an average AIS thorax of 3 initial CXR and TCT were compared after first assessment in our emergency department of a level I trauma center. RESULTS: In 67 patients (65%) TCT detected major complications of chest trauma, that have been missed on CXR [lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)], in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT and in 14 patients CXR and TCT showed the same pathological results. 11 patients had both CXR and TCT without pathological findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005) and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement or chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1). CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions, pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work up of multiple injured patients with suspected chest trauma, because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.
Adolescent↗
[Evaluation and quality management in multiple trauma care].
In total quality management of polytraumatised patients, it is necessary to use analysis of structure, process and outcome quality to search for problem areas and improvement possibilities. The structure includes the attributes of material and human resources. The process denotes the real treatment course with the demand for treatment guidelines (algorithm) and an exact documentation of treatment. To prove the outcome quality, an internal and external judgement is possible. Our own results show that quality assessment, concerning the process as well as the internal and external quality outcome, brings a significant improvement to the care of polytrauma patients.
Algorithms↗
[A time and priority-oriented algorithm].
Algorithms represent a graphical display of decision-making by giving clearly defined and formalized guidelines. The systematic order of decisions and consequent actions is guided by medical priority and regulates the time frame and sequence of each single step in a logical manner. With the help of clinical algorithms highly complex processes such as the management of the severely injured patient can be translated into a clearly structured, logical pathway. They delineate a consistent and valid guideline but require aberrations in proven exceptions. The use of algorithms allows a systematic search for errors in the process of quality management. In emergency situations they suggest a structured way of problem-solving to the less experienced user. Algorithms are useful instruments in teaching medical decision-making.
Algorithms↗