If a Patient Presents to the Ed With a Traumatic

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Dtsch Arztebl Int.
2017 Jul; 114(29-30): 497–503.

Review Article

Multiple Trauma and Emergency Room Management

Michael Frink

1Center for Orthopedics and Trauma Surgery, Gießen and Marburg University Hospital, Marburg Campus, Marburg

Philipp Lechler

iCenter for Orthopedics and Trauma Surgery, Gießen and Marburg Academy Hospital, Marburg Campus, Marburg

Florian Debus

1Center for Orthopedics and Trauma Surgery, Gießen and Marburg University Hospital, Marburg Campus, Marburg

Steffen Ruchholtz

1Center for Orthopedics and Trauma Surgery, Gießen and Marburg University Hospital, Marburg Campus, Marburg

Received 2016 October xvi; Accustomed 2017 April 24.

Abstract

Background

The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment.

Methods

We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German language S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016.

Results

The goal of initial emergency room intendance is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial cess includes physical examination and ultrasonography according to the FAST concept (Focused Cess with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating breast injuries, massive hematothorax, and/or astringent injuries of the eye and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemodynamically stable, the almost of import diagnostic procedure that must exist performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient’s physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the firsthand goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such equally intra-intestinal contamination or compartment syndrome. It likewise involves the temporary handling of fractures with external fixation and the planning of definitive care one time the patient’southward organ functions accept been securely stabilized.

Conclusion

The care of the severely injured patient should exist performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.

The principal cause of life-threatening injuries in Deutschland is edgeless trauma, predominantly from road traffic accidents of all kinds or falls from height (ane). Furthermore, the demographic trend towards an aging population means that more elderly patients are suffering severe caput injuries in falls from continuing top (2).

The incidence of severe trauma in Germany (20 000 to 35 000 cases/year) is a subject of recent debate, merely regardless of the actual numbers the direction of these patients represents a claiming from the medical, logistical, and socioeconomic viewpoints. The treatment algorithms for severe trauma are continually reviewed and updated to take account of new research findings.

The aim of this review is to present the current state of knowledge on what we, the authors, encounter as key aspects of trauma management. To this terminate, we carried out a selective survey of the literature in the PubMed/Medline database to place publications relevant to imaging in the emergency room, the Harm Control Surgery concept, and optimization of coagulation in the seriously injured. We included publications which, in our subjective opinion, have an important impact on diagnostic or therapeutic algorithms. Furthermore, this article presents some recent developments in the Trauma Network of the German Society for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU), including the integration of rehabilitation facilities, and the newly revised S3 guideline.

Challenges in the emergency room

There is still no uniformly applied classification of astringent trauma, very severe trauma, and multiple trauma. Internationally, patients with an Injury Severity Score (ISS) of 16 or higher (on a scale of 0 to 75) are defined every bit severely injured. A diagnosis of “multiple trauma” implies the presence of 2 or more split up injuries, at to the lowest degree 1 or a combination of which endangers the patient’due south life. Considerable costs are involved in maintaining the structures and staffing levels necessary for 24-h/365-day readiness to treat severely injured patients in the over 600 trauma centers throughout Germany.

The prove-based interdisciplinary treatment guidelines (S3 Guideline Trauma Management [v]) and the verification of adequate structures and staffing levels in and so-called certified trauma centers enable early hospital handling of the seriously injured in all parts of the country.

The initial treatment of a patient with severe trauma is crucial for the long-term outcome. The “daze room” is the interface betwixt prehospital direction and inpatient intendance. The criteria for handling in the shock room are based on the patient’s physiological parameters (recommendation grade A), the injury pattern (recommendation grade A), and the trauma mechanism (recommendation grade B) (table 1) (5, vi). Depending on the care level of the infirmary concerned, each member of the stupor room team has clearly divers responsibilities (tabular array 2). It was recognized that implementation of standardized diagnostic and therapeutic algorithms is necessary to eliminate treatment errors, avoid overlooking important diagnoses, and cut out delay.


Tabular array ane

Circumstances in which activation of the daze room squad is recommended*

Physiological parameters Injury patterns Mechanisms of injury
Systolic claret pressure
<90 mm hg after trauma
Penetrating injuries of cervix and trunk Fall from height >3 chiliad
Glasgow Blackout Scale score
<9 after trauma
Gunshot injuries of neck and trunk Road traffic accident
Animate disturbance/need for intuba‧tion after trauma Fractures of more than than two proximal basic Frontal collision with intrusion of more than than fifty to 75 cm
Unstable thorax Changes in velocity of
delta >30 km/h
Unstable pelvic fracture Pedestrian/motorbike standoff
Amputation proximal to hands/anxiety Death of a passenger
Injuries with neurological signs of paraplegia Ejection of a rider
Open cranial injury
Burns >20% of grade ≥ 2b
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*Patients fulfilling any of these criteria should be admitted via the shock room (two).


Table 2

Medical specialties required at local and regional trauma centers

Specialty Local trauma center Regional trauma center Supraregional trauma centre
Trauma surgery/orthopedics + special trauma surgery X X 10
Anesthesiology X 10 10
Visceral surgery X Ten X
General surgery 10 X X
Radiology X 10 X
Neurosurgery Ten X
Vascular surgery X X
Thoracic surgery X
Otorhinolaryngology X
Ophthalmology Ten
Oral and maxillofacial surgery X
Urology Ten
Cardiac surgery X
Pediatrics/pediatric surgery optional
Gynecology optional
Mitt or plastic surgery optional

Various grooming courses in initial shock room management are bachelor for both physicians and nurses, e.g, the Avant-garde Trauma Life Support (ATLS) program and the European Trauma Course. The grooming goal is to return shock room staff able to gather relevant information without delay or further take chances to the patient and to treat life-threatening injuries. Such systems tin can amend the procedures in the shock room after their implementation, as has been shown for the ATLS (7). While no impact on overall mortality has nevertheless been demonstrated, one study reported a reduction in the rate of death within i h afterwards inflow at the hospital from 24.2% to 0% (viii). Although participation in preparation of this nature by all members of staff seems a good thought, no loftier-quality studies have evaluated the influence of preparation on the bloodshed or other outcome parameters of severely injured patients (9).

The ATLS course contains elements of theoretical tuition but focuses mainly on practical exercises and simulations of shock room procedures. In the primary survey, each patient is examined systematically according to the A-B-C-D-E scheme, in which the defined goals are:

  • A – Airway: secure/constitute airway, immobilize cervical spine

  • B – Animate: secure adequate gas exchange

  • C – Apportionment: secure adequate tissue perfusion

  • D – Disability: identify neurological deficits, intoxication, etc.

  • Eastward – Environment: examine whole body of completely unclothed patient, keep patient warm, manage non-life-threatening injuries

Participation in such a form is non an obligatory component of specialist medical training in Germany, but in Switzerland, for example, physicians cannot obtain a specialist qualification in surgery without having attended a course. However, no German center tin join the DGU Trauma Network without staff members having completed relevant training programs.

Control of bleeding

Hemorrhagic shock is one of the primal problems in patients with multiple trauma and a common cause of decease. Increasing clinical and inquiry interest in the specific role of posttraumatic coagulopathy culminated in the foundation of the European Initiative Task Strength for Advanced Bleeding Care in Trauma in 2004. The resulting guidelines, first published in 2007 and well-nigh recently updated in 2016 (10), state that the first step is to identify the source of haemorrhage. If the patient does not respond to nonsurgical measures (volume replacement, compensation of acidosis, etc.), surgical hemostasis is recommended. During the shock room phase the patient’s coagulation parameters (prothrombin time, partial thromboplastin time, thrombocyte count, fibrinogen and/or viscoelastic procedures) should be determined and any necessary corrective treatment initiated. Nonetheless, improvement of coagulation must not be delayed by laboratory analyses.

The target systolic blood force per unit area in seriously injured patients with hemorrhagic shock is 80 to 90 mm Hg. In the presence of severe head injury, the systolic blood pressure level should exist kept >80 mm Hg. Restrictive volume replacement with the above-mentioned target values should be carried out using crystalloid solutions. Packed blood-red cells (PRC) and fresh frozen plasma (FFP) should be transfused in a fixed ratio of 2:1 to achieve hemoglobin concentration of 70 to 90 g/Fifty. Alternatively, fibrinogen and PRC tin exist given. The initial dose of fibrinogen should exist 3 to 4 k in the presence of pathological viscoelasticity or a plasma fibrinogen level <1.5 to ii.0 g/L.

The thrombocyte count should generally exist 50 × 109/50; with persistent hemorrhage or in the presence of head injury the target is 100 × 109/L.

With regard to antifibrinolytic medication, early assistants of tranexamic acid in the daze room is recommended for all patients with manifest or threatened hemorrhagic shock. Initial infusion of 1 g tranexamic acid over 10 minutes should be followed by assistants of a farther 1 yard over the side by side 8 hours.

In patients with persistent bleeding and thrombocyte function disorders (disease-related or drug-induced), thrombocyte function should be determined and thrombocytes transfused if required. Administration of desmopressin in a dose of 0.3 µg/kg is reserved for patients with von Willebrand–Jürgens syndrome and those being treated with thrombocyte aggregation inhibitors.

Recombinant factor VIIa should be given to patients with heavy bleeding and persistent coagulopathy only afterwards exhaustion of all culling measures.

Imaging in the emergency room

The fundamental challenge for the shock room team is swift identification and treatment of injuries requiring urgent intervention. Together with immediate treatment of intrathoracic trauma with implications for cardiorespiratory office, detection and treatment of intra-intestinal injuries are of vital importance in the care of severely injured patients (eleven). Focused Assessment with Sonography in Trauma (FAST) is the established primary diagnostic imaging test. FAST is sufficiently sensitive for important intraperitoneal hemorrhage and tin also yield information on the presence or otherwise of cardiac tamponade or hemothorax/pneumothorax. Secure insertion of a thoracic bleed remains the cardinal therapeutic intervention in the acute phase of edgeless thoracic trauma, while patients with penetrating thoracic trauma, massive hemothorax, and serious injuries of the cardiorespiratory organs receive emergency thoracotomy.

In hemodynamically unstable patients with demonstrated hemoperitoneum, immediate hemostasis by ways of emergency laparotomy is indicated; in the case of negative FAST, extra-abdominal bleeding sources accept to be excluded. The subsequent computed tomography (CT) scan with intravenous dissimilarity medium in the hemodynamically stable patient is currently the about of import process in the initial diagnostic work-upward of severe trauma. Even so sure limitations in the visualization of lesions of the intestinal hollow organs, the pancreas, and the diaphragm, CT helps to paint a comprehensive and accurate picture of the patient’due south injuries.

Appropriately, CT is an indispensable component of the current algorithms (figure 1). Retrospective analysis of data from the German national trauma registry, maintained by the DGU, showed that whole-torso CT was associated with a higher survival rate in seriously injured patients with blunt trauma (12). The relative reduction in mortality was calculated every bit 13% on the footing of the Revised Injury Severity Classification and 25% using the Trauma and Injury Severity Score (12).

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Three-dimensional rendering of computed tomography in a multiple trauma victim with a type C pelvic fracture

This is presumably due to a reduction in the number of relevant diagnoses that become undetected, along with the depiction of the overall injury pattern. The latter permits timely priority-oriented planning of further diagnostic and therapeutic procedures.

Nonsurgical [email protected],@Early Total [email protected],@and Damage Control Surgery

Due in no modest part to the dramatic improvements in abdominal imaging, nonsurgical treatment is currently standard in the direction of hemodynamically stable patients with no signs of hollow organ lesions later edgeless trauma. Nevertheless, diagnostic laparotomy remains the procedure of option for perforating abdominal injuries and in patients with clinical signs of peritonitis. There is currently no consensus on the importance of diagnostic or therapeutic laparoscopy in patients with astringent trauma. Laparoscopy is not, at nowadays, the clinical standard for the treatment of intestinal injuries. Nonetheless, a recent analysis of the handling and effect data from the DGU trauma registry showed that laparoscopic diagnosis and intervention was carried out in 0.7% of a population of severely injured persons with intestinal trauma (13). Emergency laparotomy remains the preferred surgical treatment option in hemodynamically unstable patients or when at that place are signs of hollow organ perforation. Depending on the extent of local and systemic trauma, the treating physician has to determine whether Early Full Care (ETC) and Impairment Command Surgery (DCS) principles need to be applied. While ETC has the goal of main definitive handling of the injury with immediate restoration of organ construction and role, the DCS strategy in the astute phase is restricted to hemostasis and prevention of secondary damage (e.chiliad., intra-abdominal contagion, development of compartment syndrome, or anastomotic insufficiency), with the aim of minimizing surgical trauma and operating time. Definitive wound treatment follows in the “window of opportunity” around v days after, after the patient has been stabilized and the posttraumatic inflammation has receded. Examples of primary care co-ordinate to DCS principles are application of an external fixator for injuries of the extremities, temporary bullheaded closure of damaged bowel segments, and leaving the abdominal wall open in the context of surgically treated intestinal trauma.

Even in complex injuries of the extremities and the pelvis, use of an external fixator permits rapid, minimally traumatic fracture reposition and subsequent hemostasis with reduction of secondary soft-tissue trauma (figure 2). Comparative studies accept shown advantages of management according to DCS principles for both musculoskeletal (xiv) and abdominal (xv) injuries. However, the benefits seem to be limited to the surgical care of patients with run a risk factors such as hemorrhagic shock, persistent bleeding, astringent head injury, coagulopathy, hypothermia, acidosis, and complex injuries that would be extremely time consuming to reconstruct (x).


An external file that holds a picture, illustration, etc.
Object name is Dtsch_Arztebl_Int-114-0497_002.jpg

Temporary management of a pelvic fracture with a supra-acetabular fixator and of an open lower-leg fracture with an external fixator and a vacuum bandage for the accompanying wound

Because the liver is a large organ in an exposed position, xvi% (16) to 25.2% (17) of seriously injured patients have liver lesions. The severity of liver damage has been identified every bit an important prognostic factor (18– xx). In contrast to the limited evaluability of abdominal hollow organs and the pancreas, both sonography and CT provide excellent visualization of the organ and let assessment of the extent of hepatic trauma. In hemodynamically stable patients, even loftier-grade liver contusions and lacerations are now treated by nonsurgical ways (21). Together with reliable monitoring of the cardiorespiratory condition, liver office, and coagulation condition, this comprises interventional measures such as angioembolization and endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP). Ane precondition for prophylactic nonsurgical treatment is the immediate availability of blood products and the possibility of operative intervention if required (11). A recent systematic analysis identified six risk factors for failure of nonsurgical management of blunt hepatic trauma (21):

  • Reduced blood pressure

  • High requirement for book replacement or packed ruddy cells

  • Peritoneal irritation

  • High ISS

  • Additional intra-intestinal injuries

Owing to the poor outcome and loftier mortality when nonsurgical management fails, primary surgical treatment should exist considered in patients with these risk factors (22).

While success rates of over 90% have been reported for nonsurgical management of liver injuries, nonsurgical handling of splenic lesions is afflicted past failure rates of up to 31% (18, 23). Together with the dissimilar structural properties of the spleen, the historically adamant lower threshold to surgical handling seems to exist a factor in the lower success charge per unit for bourgeois direction of splenic trauma. Severe fractures and disruptions of the pelvic girdle are frequently associated with injuries to the intra-abdominal (58.ix%) and urogenital organs (46.6%) (24). Moreover, in the presence of severe pelvic trauma one must conceptualize hemodynamically relevant bleeding especially from the presacral venous plexus. Post-obit preclinical stabilization by means of a pelvic belt, pinch of unstable pelvic fractures is achieved with an external fixator (figure 3) or a pelvic clamp. Radiological intervention and vascular embolization have become important in the management of persistent bleeding (25). Definitive surgical management of pelvic girdle fractures ensues according to DCS principles following stabilization of the patient.


An external file that holds a picture, illustration, etc.
Object name is Dtsch_Arztebl_Int-114-0497_003.jpg

Iii-dimensional computed tomography rendering of an unstable pelvic fracture (bilateral fracture of anterior pelvic girdle, left-sided fracture of posterior pelvic girdle)

Construction of the DGU Trauma [email protected],@White [email protected],@S3 Guideline Multiple Trauma/Serious Injury Management

The DGU founded its Trauma Network Initiative in 2004, thus answering the call for provision of regionally based structures for the direction of severely injured patients. With the aim of improving the care of the seriously injured by introducing nationwide standards for staffing, equipment, and organization, also as linking individual hospitals, the first regional trauma networks were certified in 2009. A total of 615 hospitals are now certified equally trauma centers. These trauma centers form 52 certified regional networks (efigure).


An external file that holds a picture, illustration, etc.
Object name is Dtsch_Arztebl_Int-114-0497_004.jpg

The trauma networks in Germany and neighboring areas

(crimson: supraregional trauma centers; blue: regional trauma centers; green: local trauma centers)

Foundation of the DGU Trauma Network was followed in 2006 by publication of the DGU Whitebook Medical Care of the Severely Injured. A revised version of this certificate was published in 2012 (6). The Whitebook contains recommendations on the construction, organization, and equipment of hospitals of various care levels that participate in the Trauma Network. Furthermore, the S3 Guideline Multiple Trauma/Serious Injury Management, originally published in 2011 and revised in 2016, represents the most important chemical element in the electric current care concept (5).

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Rehabilitation in the DGU Trauma Network

Not least owing to its inclusion in the 2nd edition of the Whitebook, the topic of rehabilitation is attracting increasing attention. Because severely injured patients are oftentimes young and otherwise healthy, the physical, mental, and socioeconomic consequences may be drastic (26, 27). To meliorate cooperation between acute hospitals and rehabilitation facilities, the DGU and the German Insurance Association (Gesamtverband der Versicherer, GDV) combined to initiate the project “Postacute Rehabilitation later Severe Trauma”.

Acknowledgments

Translated from the original High german by David Roseveare

Footnotes

Disharmonize of involvement statement

The authors declare that no conflict of interest exists.

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If a Patient Presents to the Ed With a Traumatic

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569556/