Transcript Trauma Overview Avery B. Nathens MD PhD MPH Division of General Surgery & Trauma St.

Trauma Overview
Avery B. Nathens MD PhD MPH
Division of General Surgery & Trauma
St. Michael’s Hospital
Objectives




Trauma epidemiology
Prehospital care
Triage
Long term outcomes after injury
Trauma Epidemiology
The Burden of Injury



Leading cause of death in first 4 decades of life
Third leading cause in all age groups
12% of hospital beds are consumed by injury
Trauma Mortality: 1985-2009
12%
10%
8%
6%
4%
2%
0%
1984
1988
1992
1996
2000
2004
2008
2012
Injury mortality rate
US, 1998: 53 per 100 000 pop’n
70
Deaths per 100k pop'n
65
60
55
50
45
40
80
82
84
86
88
90
92
94
96
98
http://www.cdc.gov/ncipc/wisqars/
The Burden of Injury



Nearly ½ of all traumatic incidents involve the
use of alcohol, drugs or other substance abuse
60% of all injuries are preventable
Disease of the young and carries potential for
permanent disability
Years of Potential Life Lost
(YPLL) Before Age 65
All Others
23%
Liver Disease
2%
Cerebrovascular
2%
HIV
3%
Congenital
4%
8%
Perinatal Period
Heart Disease
12%
Cancer
17%
Injury
29%
100%
All Causes
0
2
4
6
8
10
12
http://www.cdc.gov/ncipc/wisqars/
Distribution of injury by age
Number of Patients by Age
Number of Patients
30,000
25,000
20,000
15,000
10,000
5,000
0
1
6
11
16
21
26
31
36
41
46
51
56
Age (years)
61
66
71
76
81
86
91
96 101 106
Mechanism of injury
Number of Patients
Patients by Mechanism of Injury
500,000
Motor vehicle traffic
450,000
Fall
400,000
Struck by, against
350,000
Firearm
300,000
Transport, other
250,000
Cut/pierce
200,000
Fire/burn
150,000
100,000
Pedal cyclist, other
50,000
Other specified and
classifiable
Machinery
0
Mechanism of Injury
Mechanism ≠ Intent
Make no assumptions about intent
Mechanism of injury by age
Number of Patients
Mechanism of Injury by Age
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Motor Vehicle Traffic
Fall
Struck by
Firearm
Transport, other
1
8
15 22 29 36 43 50 57 64 71 78 85 92 99 106
Age (years)
Deaths by mechanism of injury
Deaths by Mechanism of Injury
Motor vehicle traffic
Fall
25,000
Number of Patients
Struck by, against
20,000
Firearm
Transport, other
15,000
Cut/pierce
10,000
Fire/burn
5,000
Pedal cyclist, other
0
Other specified and
classifiable
Machinery
Mechanism of Injury
Mortality as a function of age
Case Fatality by Age
12.0%
Case Fatalities (%)
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
1
6
11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101
Age (years)
Grading Injury Severity

Abbreviated Injury Scale (AIS)
6 body regions (head, neck, chest, abdomen, pelvis,
external)
 Each injury coded from 1 to 6
 AIS>=3 is severe


Injury Severity Score (ISS)
Most common means of classifying injury severity
 Ranges from 1 to 75
 ISS>=16 – severe multisystem trauma

INJURY SEVERITY SCORE
Example
Abbreviated Injury Scale
Small subdural haematoma
Parietal lobe contusion
Major liver laceration
Upper tibial fracture (displaced)
ISS = 42 + 42 + 32 = 41
4
3
4
3
Injury severity
Percentage of Patients and Injury Severity Score (ISS)
70
Percentage of Patients
60
50
ISS 1 - 9
40
ISS 10 - 15
ISS16 - 24
30
ISS > 24
Unknown
20
10
0
Mortality as a function of ISS
Case Fatality by Injury Severity Score (ISS)
35
30
Case Fatality (%)
25
ISS 1 - 9
ISS 10 - 15
20
ISS 16 - 24
15
> 24
Unknown
10
5
0
Injury Severity Score
American College of Surgeons National Trauma Data Bank ® 2006. Version 6.0
Patients by Intent
Other
Undeterm ined
Self-inflicted
Assault
Unintentional
Figure 26A
Proportional distribution of patients, grouped by intent.
© American College of Surgeons 2006. All Rights Reserved Worldwide
American College of Surgeons National Trauma Data Bank ® 2006. Version 6.0
Deaths by Intent
Unintentional
Assault
Self-inflicted
Other
Undeterm ined
Figure 27A
Proportional distribution of deaths, grouped by intent. Total N = 48,149.
© American College of Surgeons 2006. All Rights Reserved Worldwide
Geographic variations in
MVC-mortality: Baker et al, 1987
Population density (persons/sq mile)
MVC mortality (per 100 000 persons)
558
0.2
64000
Esmerelda, NV versus Manhattan, NY
2.5
Trimodal Distribution of Trauma
Deaths
Epidemiology of Trauma Deaths
Acute
Early
( <48 hrs) (48 hr to 7d)
Late
(> 7 d)
CNS injury
40%
64%
39%
Blood loss
55%
1%
9%
18%
0%
61%
MOFS
*Sauaia et al, J Trauma, 1995
Prehospital care
Clinical scenario

64 yo female running for bus






Leg catches on bumper
Dragged 20 feet
Unconscious with occasional respiratory efforts
Systolic blood pressure – 80
Heart rate 140
45 minutes from trauma center
Clinical scenario
Prehospital transport times

Urban





Houston - 32.6 minutes
Portland ~ 25 min
Chicago - 35 minutes
Tucson - 21 min
Definitive Care
Rural



Georgia - 42 min
Northern California - 55 min
WA (Okanogan County) - 49 min
Any Hospital
Controversies in Prehospital
Trauma Care
 ALS
vs BLS
 Airway management
 Fluid resuscitation
ALS vs BLS “packages”

Basic life support


Splinting, spine immobilization, hemorrhage
control
Advanced life support
Establish a definitive airway
 Provide intravenous access
 Administer pharmacologic agents


“Load and go” or “stay and play”?
Stay and Play:
Pre-hospital care - SAMU


French EMS - SAMU
(Service d'Aide Médicale
Urgente)
Physicians attend to patient
at scene
Stabilize at scene, en route
 Identify receiving center

Stay and Play

August 31, 1997






Mercedes S-280 - 122 mph
 4 occupants, 2 dead at scene with torn
aortas
SAMU dispatch: 00:26
SAMU scene arrival: 00:32
Extrication complete: 01:00
ER arrival, Pitie Salpetriere hospital 02:06
Pronounced dead - 04:30
Stay and Play




Paris, 2 am
Distance: 6.2 km
Transport time: 66
min
Avg speed: 5.6
km/hr
Load and Go







Ronald Reagan
March 30, 1981, 2:30 pm
Shot in right chest
Thrown in back of limo and
left the scene within 10
seconds of initial shots fired
Hemoptysis
Transported directly to
George Washington
University Hospital
Collapsed in ED
Load and Go




Washington DC, 2:30 pm
Distance: 2 km
Transport time: Unknown
In OR by 3:24 pm - thoracotomy
for pulmonary laceration
ALS vs BLS “packages”

No prospective RCT documenting the
effectiveness of ALS in trauma
...yet ALS available in 98.5% of the 200 largest
US cities
ALS vs BLS in Trauma



Ontario Prehospital Advanced Life Support
(OPALS) Major Trauma Study (CMAJ, 2008)
Pre-post design, n=2867
Mean ISS ~23, GCS<9: 25%, mortality 8%


High speed
rollover
35 yo
restrained
driver


Epigastric
stab wound
Stable





50 yo male
Had been drinking
Falls down flight of stairs
Transient LOC
Now awake, alert, GCS
15
Triage of the Major
Trauma Patient
Triage: the sorting out and classification of casualties of
war or other disaster, to determine priority of need and
proper place of treatment
“Get the right patient to the right place at the right time”
A tale of two counties
West & Trunkey, 1979

Orange County


Trauma patients transported to nearest of 39
facilities
Preventable deaths: 43%
San Francisco County

Trauma patients transported to 1 centrally
located trauma facility
Preventable deaths: 1%
National Evaluation of the Effect of
Trauma Center Care on Mortality
N Engl J Med, 2006
14
Mortality (%)
12
N=15,000 patients
10
25% lower
risk of death
at one year in
trauma centers
8
6
NTC
TC
4
2
0
In hospital
30 d
90 d
Time from injury
365 d
Ideal Triage

Direct patients with serious injuries to centers
with available resources and personnel

Direct those with less serious injuries to all other
centers within same geographic area
Field triage goals – a balance

Undertriage – major trauma patient triaged to
center with inadequate resources


Patient incurs risk
Overtriage – minimally injured trauma patient
triaged to regional trauma center

System incurs risk


Utilization of limited material, financial and human
resources
Inconveniences family/patient
Field Triage Tools - Overview

Physiologic criteria

Anatomic criteria

Mechanism of injury

Modifiers
Physiologic criteria - ACS field
triage

Pros




GCS<14
SBP<90
RR<10 or >29



Objective, quantifiable
Easily assessed
Predictive of death
Cons

Time dependent
Anatomic criteria - ACS field
triage









Penetrating injury proximal
to elbow or knee
Flail Chest
Trauma with burns
>2 proximal long-bone #
Pelvic #
Open & depressed skull #
Paralysis
Amputation proximal to wrist
or ankle
Major burns

Pros


Accurate if injury obvious
Cons

Physical exam not predictive of
injuries

Time consuming exam
Mechanism of injury - ACS field
triage


Falls >20 ft
High risk crash







Pros
 Estimate of type, amount,
direction of force applied
 Readily assessed by EMS
personnel

Cons
 Estimate of potential, not
actual injury
 Limited value when used
alone
Ejection
Death in same compartment
Intrusion > 12 in occupant
compartment
Intrusion > 18 in anywhere
Auto-pedestrian/cyclist >20 mph
MCC > 20mph
Modifiers: permissive criteria ACS field triage




Age <5 or >55
Anticoagulation
Burns
Pregnancy

Pros


Good predictor of adverse
outcomes
Cons


Cannot be ascertained in field
Underutilized
Field Triage Decision Scheme:
ACS COT, Resources for Optimal Care,
2007
Physiologic
criteria
Anatomic
criteria
Transport to highest
level of trauma care
available: alert trauma
team
Mechanism
Consider transport to a
trauma center
Modifiers
(Permissive)
Toronto Field Trauma Triage
Guidelines


Directs injured patients to trauma centres
Criteria
Physiologic
 Anatomic
 Mechanism

Toronto Field Trauma Triage
Guidelines: Physiologic criteria


GCS<=10 OR
Two or more of
Any alteration in level of consciousness.
 A pulse rate less than 50 or more than 120.
 A blood pressure less than 80 or an absent radial pulse
 A respiratory rate less than 10 or greater than 24

Toronto Field Trauma Triage
Guidelines

Anatomic
Spinal Cord injury with paraplegia or quadriplegia.
 Penetrating injury to head, neck, trunk or groin, OR
 Amputation above the wrist or ankle

Toronto Field Triage Criteria
Diversion to closest hospital

Divert if anticipate won’t survive




Complete airway obstruction
Absence of spontaneous respirations
Absence of a palpable carotid pulse
Estimated transport time>30 minutes
Organized Systems of Trauma Care
Ongoing
•Prevention
•Training
•Evaluation
Prehospital
•Notification/EMS Access
•EMS response
•Triage
•Transport
Trauma Center
•Most severely injured
Interfacility
Transfer
Rehabilitation
Non-Trauma Center
•Other injured persons
Effect of legislative initiatives on
MVC-mortality
Nathens et al, JAMA, 2000
Legislation
Effect on crash mortality
State trauma system
Primary restraint laws
 9% (6-11)
 13% (11-16)
Secondary restraint laws
 3% (0-5)
65 mph (vs 55 mph) speed limit
 7% (3-10)
Administrative revocation laws
 5% (3-7)
Access time & trauma-mortality rates
3486 deaths
Field deaths
54% (1882)
Reached hospital
46% (1604)
ED deaths
21% (732)
ED 45%OR deaths
4% (139)
OR 8%
Other in hospital
22% (733)
Other 47%
Patient KL


34 yo male truck driver/mover
High speed MVC




Mild traumatic brain injury
Liver laceration, splenectomy
Bad pelvic fracture, femur fracture
Acetabular fracture

Angioembolization for pelvic
fracture bleeding

ICU stay ~7 days
What will happen to KL in 1 year
A) Working at full capacity
B) Desk job
C) Not working, milling about the house on disability
compensation, driving his wife crazy
D) Not working, in chronic pain
D) Nursing home
Why can’t he return to normal
function
A) Brain injury
B) Liver injury and lack of a spleen
C) Acetabular/femur and pelvic fracture
D) Bad dreams
What is his chance of re-injury
A) Less than the average person, he is a more
careful driver now
B) His injuries put him at slightly greater than
average risk
C) He is accident prone – he’ll likely get himself
into trouble
Functional Outcomes After Injury

Multisystem trauma

Specific injuries
Traumatic brain injury
 Severe extremity injuries


Post traumatic stress disorder &
functional outcomes
Employment Outcomes
Brenneman, J Trauma, 1997

N=195, ISS>10


Sampling bias – too well and too sick excluded
52% back at work at 1 year
Pre-injury
% employed at 1 year
White collar
82
Blue collar
43
Employment & Financial Outcomes
Michaels, J Trauma, 2000

Outcomes at 1 year (n=247)


Excluded head injury, SCI
Employment
64% had returned to work
 23% workers’ comp/disability


Financial

30% reported a decline income
Functional limitations & Disability
Enabling America: IOM, 1997
Pathology
Osteoarthritis of
the hip post
acetabular
fracture
Impairment
Functional
limitation
Disability
Limited range of
motion
Unable to climb
stairs
Cannot continue
employ as mover
Functional limitations following
multiple trauma
Mackenzie, Qual Life Res, 2002

Prospective cohort study: n=1240, 1 yr follow up

Functional capacity index (FCI)
Physical & cognitive function only
 Focuses on tasks necessary for ADL

Insensitive to socially defined roles “role performance”
 Less sensitive to personal/environmental influences
 Sensitive to specific medical interventions

Limitation in functions by FCI
dimension
FCI dimension
Bending/lifting
Ambulation
Cognitive
function
Hand/arm
function
Sexual function
% with
limitation
63
61
27
25
18
FCI dimension
% with
limitation
Vision
18
Excretory
function
8
Hearing
5
Eating
4
Speech
2
Functional outcomes following
traumatic brain injury

Dikmen, Arch Phys Med Rehabil, 2003
N=261, 80% followup at 3-5 years
 Moderate to severe TBI


Functional status examination

Physical, social, psychologic assessment
Functional Status in TBI

Glasgow Outcome Scale

Moderate-severe disability in 24%

Majority not institutionalized: 92%

Return to work after injury: 84%


Only 58% still working by 3-5 years
What percent are you “back to normal:” 80%
Functional Status in TBI:
Partial/complete dependency
Leisure/recreation
Major activity
Social integration
Cognitive competency
Financial independence
Travel
Home management
Standard of living
Ambulation
Personal care
0
10
20
30
% of patients
40
50
60
Functional impact of Orthopedic Injuries
Michaels, J Trauma, 2000
100
90
80
Baseline
Non-orthopedic
Orthopedic
70
60
50
40
30
20
10
Mental well being
Physical well being
ta
ci
lit
al
y
fu
nc
tio
ni
R
ng
ol
e
em
ot
io
na
M
l
en
ta
lh
ea
lth
en
G
Vi
So
al
th
he
Pa
in
Ph
ys
e
R
ol
Ph
ys
fn
0
Functional impact of Orthopedic Injuries
Michaels, J Trauma, 2000
100
90
80
Baseline
Non-orthopedic
Orthopedic
70
60
50
40
30
20
Mental well being
Physical well being
10
M
en
ta
lh
ea
lth
io
na
l
ot
em
ol
e
fu
nc
t
io
ni
ng
R
lit
y
ta
Vi
So
ci
al
he
al
th
in
G
en
Pa
ys
Ph
ol
e
R
Ph
ys
fn
0
Reconstruction or amputation of
limb threatening injuries?
Bosse, NEJM, 2002

Prospective cohort study




545 high energy trauma below the femur
Baseline, 3, 6, 12, 24 mo assessment
84% f/u at 24 mos
Functional outcome measure: Sickness Impact Profile
Sickness Impact Profile

Measure of self reported health status



12 categories of function
2 major dimensions: physical health, psychosocial health
Score: 0-100



Population norms: 2-3
Differences of 2-3 are meaningful
Severe disability: >10
Outcomes:
Reconstruction vs amputation
12 months
24 months
Reconstruct
Amputate
Reconstruct
Amputate
Overall
15
14
12
13
Physical
13
12
10
10
Psychosocial
12
12
10
11
Work (%)
41
42
36
39
• Amputation equivalent to reconstruction
• Consider when determining care priorities in the critically
ill injured patient
Factors associated with poor outcome
Bosse, NEJM, 2002



Low educational level
Nonwhite
Poverty



Lack of private health
insurance
Smoking
Disability compensation
litigation
Focus should be on non clinical interventions and
psychosocial/vocational rehabilitation
Outcomes following Pelvic Fracture
Wright, J Urol 2006

Pelvic fractures associated with neurovascular and ligamentous
injury


Prospective cohort study


Impact on genitourinary, anorectal and sexual function never evaluated
298 patients with pelvic fracture; 862 without
Excluded patients with overt injuries known to impact on
genitourinary, anorectal or sexual dysfunction



GU injuries
Anorectal injuries
Spinal cord injury with deficit
Outcomes following Pelvic Fracture
Symphysis
Sacrum
Adjusted Risk of Male
Sexual & Excretory Dysfunction
Fracture
configuration
Sexual dysfunction
RR (95% CI)
Excretory
dysfunction
RR (95% CI)
Fracture involving the
SI joints
3.6 (1.7-7.8)
2.4 (0.5-12.3)
Open pelvic fracture
2.0 (1.1-3.8)
4.6 (1.7-13)
Symphyseal fracture
1.2 (0.5-2.9)
4.3 (1.1-17)
Closed pelvic fracture
1.7 (0.4-6.9)
3.1 (0.4-23)
Adjusted Risk of Female
Sexual & Excretory Dysfunction
Sexual
dysfunction
RR (95% CI)
0.6 (0.1-3.4)
Excretory
dysfunction
RR (95% CI)
1.3 (0.2-6.6)
0.8 (0.2-2.8)
N/A
Symphyseal fracture
2.4 (0.6-8.7)
6.2 (1.7-22)
Closed pelvic fracture
1.3 (0.3-6.8
N/A
Fracture involving the SI
joints
Open pelvic fracture
Post-Traumatic Stress Disorder

PTSD symptoms
Intrusive: flashbacks, memories, nightmares
 Avoidant: emotional detachment, restricted emotion,
avoidance of reminders
 Arousal: insomnia, irritability, vigilance


Common following traumatic injury

10-40% of all patients admitted following injury
“The PTSD Demon”
Predictors of PTSD
Zatzick, Am J Psych 2002

Longitudinal study (1 year)


Predictors





PTSD in 30-40% at 1, 4, or 12 mo post injury
PTSD symptoms at baseline
Greater prior trauma
+ve toxicology screen for stimulants
Female
Notable negatives

Injury severity or type, pre-event functioning, income,
education
PTSD & Functional outcomes
Zatzick, Arch Surg, 2002
PTSD : strongest predictor of poor functional outcome
No PTSD
lth
n
lh
ea
al
f
So
ci
lit
ea
al
h
er
en
Vi
ta
lth
n
Pa
i
na
l
ot
io
em
G
R
ol
e
ph
ys
ic
a
l
lf
n
ol
e
R
y
Mental well being
Physical well being
si
ca
Ph
y
PTSD
M
en
ta
90
80
70
60
50
40
30
20
10
0
Injury Recividism
Worrel & Nathens, J Trauma, 2006
Increasing age
Male
Alcohol abuse