 Ministry of Health
http://newzealand.govt.nz/
©Copyright
Published:
28/11/2011
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The ideal trauma system
John Kortbeek
Outline
Trauma: The ideal system a view form the West
Excerpt from April 2001 news release:
Potential Years of Life Lost (PYLL)
In Canada, there are approximately 1.04 million potential years of life lost prematurely due to all causes of death. Overall, deaths due to trauma are the second leading cause of potential years life lost (PYLL). There were 305,439 potential years life lost prematurely due to injury in 1996, representing 29% of the total Canadian PYLL in 1996.
For those aged 1 to 44 years, however, deaths due to trauma remain the leading cause of potential years life lost (PYLL). A total of 261,015 potential life years were lost in this age group due to injury accounting for almost half (47%) of the total Canadian PYLL in 1996.
41F Motor vehicle rollover
• Alert, Stable. Fellow passenger deceased at scene.
• 20 minutes from regional centre. 12 minutes from rural hospital.
• Destination?
• A) Rural hospital 12 min
• B) Regional hospital 20 min
• C) Tertiary trauma 90 min
• D) Mayo Clinic A long time
Pre-Hospital Index
Blood Pressure:
>100 0
86-100 1
75-85 2
0-74 3
Pulse:
>120 3
51-119 0
<50 5
Penetrating Trauma Abd/Chest:
No 0
Yes 4
Respiration:
Normal 0
Laboured / Shallow 3
<10 / min or needs intubation 5
Consciousness:
Normal 0
Confused / Combative 3
No Intelligible Words 5
0-20
Pre-Hospital Index
• PHI: 0 - 3
Surgery, 3%
Mortality, 0%
• PHI: 4 - 7
Surgery, 22%
Mortality, 0%
• PHI: 8 - 20
Surgery, 57.9%
Mortality, 53%
MOI Criteria With Positive Predictive Values
Predictive Value of Scores
Trauma System, CRHA
41F Motor vehicle rollover
• Arrives awake. BP 138/76. P 90
• C/o mild diffuse aches and pains.
• CBC, CXR
• Admitted
• Spines cleared.
• Day 1, Confused
• Repeat CBC, Hgb 66
• Transported by ground, BLS to tertiary trauma centre. 2 hours.
• Received by trauma Team. ED Physician, RN’s,RT, surgery, Radiology tech.
• BP 100/78, P105, GCS 14
• ABC,s. Spinal precautions, CXR,PXR,Complete spines, CT head C spine, abdomen/pelvis.
• Ongoing bleeding - Lap/packing for liver injury.
• Additional injuries
– C2 # - Halo
– Facial # - Non op
30M Motor bike crash
• Transported to regional centre
• 20 minutes by EMS, Spine board, IV’s, O2
• GCS 8
• 80/60, p130
• ABC’s by ED team, Intubated, 2 IV’s, crystalloid and blood, initial bloodwork, ABGs, CXR,PXR
• Obvious shock and extremity injuries.
• Trauma Team Activation - GS, Ortho
• To OR for persistent hypotention 88/60, p120 post 2 units PRBCs
• Laparotomy, Splenectomy, Damage control with pelvic packing for large retroperitoneal hematoma. Pelvis stabilized with Ant. Ext. Fix.
• Transport team activated, transport from ICU immediately post op to Tertiary trauma centre. Ongoing resuscitation and rewarming.
• Tertiary Trauma team receives patient. CT head, C spine, abdomen pelvis
• CT Head mild diffuse edema, no hemorrhage
• Angio-embolization of R int. iliac, repacked
• To ICU, correct coagulopathy,acidosis
• ORIF Pelvis day 2.
• ICU day 2-10, SIRS, Sepsis. ARDS, Coma
• Gradual recovery
• Day 11-20 Trauma Service. DVT - PE Anticoagulated. Gradual CNS recovery
• Day 21 transferred to MSSK rehab. Outpatient brain injury follow-up.
• Trauma and Ortho follow-up.
The Trauma Centre
• Complete, Coordinated Efficient Care
• Outreach / Education
• Research
• Registry
• Trauma Systems
• Accreditation / Verification
• Outcomes
Overview FMC
Trauma team Activation
• GCS < 9
• Hypotention with BP < 90
• Blood Transfusion en route or on arrival
• GS wound H&N & Trunk
• ED Discretion
• Intubated Patient or Acute Respiratory Failure
• Severe Hypothermia
How do we know we have good trauma centres?
• A) The region and ministry have designated your hospital a trauma center.
• B) The Federal government says we have the best health care system in the world.
• C) The lobby is very nice and shiny.
• D) Meets national minimum standards, (verified) and standard performance measures are published (and public).
Performance indicators & Questionnaire
• TTLs and ATLS?
• Road trip, who goes? Who admits? Trauma ward/unit? ICU access?
• Quality council, who, what, where and when?
• Pre-hospital times?
• Resuscitation times?
• Time to OR for shock, fractures, craniotomies?
• Outcomes, dead or alive?
• Unrecognized injuries, complications?
How Do We Perform?
OUTCOME
Evaluating Trauma Care: The TRISS Method
• Champion HR, Copes WS, Sacco WJ, et al. The Major Trauma Outcome Study: Establishing national norms for trauma care. J Trauma 1990; 30: 1356-1365.
• Champion HR, Sacco WJ, Copes WS. Injury severity scoring again. J Trauma 1995; 38: 94-95.
RESUSCITATIVE PHASE
DEFINITIVE CARE
What is a trauma system?
• Delivers access to the appropriate level of organized trauma care to the inhabitants of a defined geographic area.
• Right patient, right place, right time!
What Are The Issues?
• Time from injury to tertiary care can be up to 12 hours in Alberta
• Trauma care across Alberta variable
• Tertiary Trauma services are confined to large urban centres
• Golden hour of trauma care - Trauma patients must reach definitive care quickly to minimize death or disability.
Trauma
Organized trauma systems, which standardize care of the seriously injured, prioritize access to emergency, diagnostic and surgical services, and rigorously measure performance as part of a trauma quality improvement program have, again and again, reduced mortality and morbidity.
Triage systems are well defined. E.g. PHI and MOI.
National standards for Trauma care organization and infrastructure.
Trauma care processes can be defined and measured.
A Trauma system is much more than a great trauma hospital.
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