Time-management study of trauma resuscitation

Article Abstract:

After traumatic injury, deaths occur at three main time periods. The first is immediately, when the injury is overwhelming; the second time of death is minutes or hours later and is due to shock; and the third time of death is weeks later and is attributed to sepsis (systemic infection) and organ failure. Surgical intervention is effective during the second time period, and trauma resuscitation (TR) is essential for the best patient outcome. This consists of assessing and stabilizing vital functions, along with determining treatment priorities for the patient. A study of TR in the emergency room was conducted to evaluate timing and organization. Trained observers timed and described key elements of the TR procedure, using a hand-held stopwatch and standardized forms. Injury severity scores for airway, cervical spine, and shock, were assigned according to predetermined criteria. Results from 431 patients were analyzed. Most patients (89 percent) experienced blunt traumatic injury and 93 percent already had intravenous lines inserted prior to arrival at the emergency ward. Sixty-three percent of the patients for whom this information was available arrived at the emergency room via ambulance, and 37 percent arrived by helicopter. For the patients for whom injury severity scores were available, a positive correlation was found between the extent of their injuries and TR time. Thus, more severely injured patients received more resuscitation time. TR time was also affected by patient age and potential injury to the airway. The primary survey (initial assessment) period of TR usually required about three minutes. The secondary survey (a physical examination) took about 10 minutes. Disposition and completion of resuscitation required the remainder of the time, which took an average of 24 minutes. The level of training of the resident on the trauma service did not appear to affect the TR time. A 20 percent rate of inaccuracy in assessing airway functioning suggests the need for improvement in this area. Documentation of TR time is an important aspect of quality control. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Management, Wound care, Resuscitation, Emergency medical personnel

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Emergency department deaths

Article Abstract:

The experience of providing medical care in Vietnam has shown that early evacuation of injured persons to a trauma center equipped to give quick response and high quality surgical care can significantly reduce morbidity and mortality. An analysis was performed of 186 deaths resulting from trauma that were seen in the Emergency Department (ED) of a hospital Accident Room. The purpose of this study was to evaluate any problems in the prehospital period and ED, and to identify deaths that might have been prevented. The patients were mostly inner city residents and had a high incidence of penetrating trauma, which requires the 'scoop and run' approach. Autopsies were performed on all 186 patients. The most common cause of death was head injury, which was responsible for 44 percent of all deaths. Other causes included: injury to the heart, 16 percent, and injury to the aorta and great vessels, 7 percent. Of the 186 patients studied, 180 cases were found on autopsy to have injuries too severe to allow survival, regardless of the quality or timing of medical care. Of the remaining six cases, three deaths were explained by evidence in the medical record. These patients died of massive and prolonged blood loss and were dead at the time of arrival. Only three deaths were felt to have been preventable in the ED. The critical factor in minimizing preventable deaths is rapid transportation to a trauma center. Prior to arrival at the ED several things have to be done: securing an airway; immobilization of fractures; and administration of intravenous fluids. Upon arrival at the trauma center, immediate, appropriate and quick evaluation and diagnosis must be made, and resuscitation and definitive treatment begun. One person, preferably with trauma experience, should supervise and monitor the patient continually until treatment is begun. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Emergency medical services, Trauma centers, Ambulance service, Ambulance services

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Undetected injuries: a preventable cause of increased morbidity and mortality

Article Abstract:

Factors contributing to increased morbidity (illness) and mortality (death rate) of trauma patients include delayed diagnosis and inadequate or no surgical treatment. Most of these errors occur in patients with multiple trauma who need to have their most serious injuries treated first; however, some errors are the result of failure to follow outlined procedures. A prospective audit, carried out over a six-month period, was undertaken at a large, urban hospital in Durban, South Africa to identify errors in the treatment of trauma patients. In 18 patients delayed diagnosis of injuries missed at the time of operation resulted in increased morbidity and mortality. There were 16 male and 2 female patients, with an average age of 24 years. Twelve patients sustained penetrating wounds (2.6 percent of all patients with penetrating wounds); six had blunt injuries (4 percent of blunt trauma patients). For seven patients the diagnosis was delayed because a necessary procedure or test was not performed. Seven patients had undetected injuries as a result of inadequate exploration at the time of surgery. Four patients had unidentified retroperitoneal hematoma (mass of blood contained in the space behind the peritoneal sac). Treatment in the intensive care unit was necessary for 14 patients (78 percent). Eight patients (44 percent) died as a result of sepsis (gross infection caused by bacterial toxins) and multiple organ failure; seven of these deaths occurred in patients who had received inadequate surgical treatment. The authors conclude that failure to diagnose an injury is an important and avoidable cause of death in a dedicated trauma center. Strict adherence to well-proven standards of trauma care can reduce unnecessary morbidity and mortality. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Standards, Research, Diagnosis, Prevention, Diagnostic errors, South Africa, Durban, South Africa, Surgical errors

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