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“Dr. Josip Benčević” General Hospital, Slavonski BrodDepartment of Aensthesiology, Reanimatology and Intensive Care
POLYTRAUMA CARE IN
ICU
I. Matić, M. Jurjević, B. Hrečkovski, I. Lučić
Definition
Polytrauma is defined as two or more injuries to physical regions or organ systems, one of which may be life threatening A syndrome of multiple injuries of defined severity [injury severity score (ISS) ≥ 16] with consecutive systemic reactions, which may lead to dysfunction of remote organs
Champion HR. J Trauma. 1990
R. Lefering. European Journal of Trauma 2002
Clinical prognosis
30% death of irreversible shockwithin 4h
20% primary survival
50% death within minutes
Improved survival using ATLS
Improved clinical outcome using advancedtreatment methods
Zander et al. 1992.
Importance
Leading cause of death
Quality of treatment – best indicator od medical care in a specific region
High mortality, long-lasting treatment and rehabilitation with substantial expenses
High incidence of invalidity
McKeown DW. Intensive Care Britain 1994
Goals of polytrauma care
Mortality reduction through increased quality and
reduced diagnostic time, improved surgical technique
and shock treatment, using precise algorithms and
adequate therapy and monitoring.
Edwin A. CCM. 2006
Russel R. J Trauma. 2004
Scoring systems
based on exact numbering of specific injuries
assesment of injury severity
different injuries combined in a single score
used as a language for communication in
literature
results are comparable
prognosis – survival probability for a specific
score result
Scoring systems GCS (Glasgow Coma Score) – eye opening, best motorical and verbal response
RTS (Revised Trauma Score) – physiological score. Sum of GCS, systolic BP and respiratory frequency
ISS (Injury Severity Score) – anatomical score. Based on the AIS (Abbreviated Injury Scale) The 3 most severely injured body regions have their score squared and added together to produce the ISS score .
TRISS = RTS + ISS
NISS – new ISS – three most severe injuries squared regardless of the body region Senkowski CK et al. J Am Call Surg 1999
Aharonson DL. J Trauma. 2006
Patients and methods
Retrospective study
ICU - “Dr. J. Benčević” General Hospital, Sl. Brod
Multi-disciplinary ICU, total 560 patients
67 (11,96%) polytrauma patients
Monitoring:
GCS
ECG, RR, pulse-oksimetry
Blood gases, ventilation parameters
Blood samples, microbiology cultures
diuresis
Ultrasound, RTG, CT
Central venous catheter, arterial line,PICCO …
ICP, IAP
Patients and methods
General data (sex, age)
Time from injury to ICU admittance
Procedures performed before ICU arrival (venous access, intubation, cardio-pulmonary resuscitation)
Procedures performed immediately on ICU arrival
Patients and methods
Severity of injury was assesed using:
GCS, RTS, ISS, TRISS and NISS
Based on ISS and NISS score patients were divided in 4 groups (0-15, 16-26, 27-44, >45 points).
Patients and methods
ICU treatment: Number of surgicaly treated patients Time from ICU arrival to surgery Patients that had to be transferred to a tertiary centre for treatment
continuation Application of mechanical ventilation (MV) as well as total MV
duration Incidence of hospital pneumonia and life-threathening complications Need for tracheostomy ICU mortality Time spent in ICU
Patients and methods
Results
Gender : male n (%)
female n (%)
56 (83.6)
11 (16.4)
Age (years): 39.4 (5 – 94)
Time from injury to ICU admittance:1 (0.5 – 2) h
Procedures performed before ICU arrival :Venous access n (%)
Intubation n (%)
CPR n (%)
15 (22.3)
2 (2.9)
0
Procedures performed immediately on ICU arrival:
Venous access n (%)
Intubation n (%)
CPR n (%)
67 (100)
41 (61.2)
2 (2.9)
Age – 39.4 (5-94) years
<10 11-30 31-50 51-70 >70
5 (7.5%) 23 (34.3%)
17 (25.4%)
15 (22.4%)
7 (10.4%)
Results
GCS 9.97 (3 – 15) (≤8 = 28 patients – 41.8 %)
Systolic blood pressure mmHg
125.9 (0 – 250)
Respiratory frequency n/min
11.25 (0 – 25)
RTS score: 9.7 (0 –12)
ISS score: 24 (3 – 75)
TRISS score: 34 (16 – 79)
NISS score: 31.7 (6 – 75)
Results
RTS score: 9.7 (0 –12)
0-6 7-10 11-12
11 (16.4%) 18 (26.9%) 38 (56.7%)
ISS score: 24 (3 – 75)
≤15 16-26 27-44 >45
22 (32.8%) 11 (16.4%) 30 (44.8%) 4 (6%)
NISS score: 31.7 (6 – 75)
≤15 16-26 27-44 >45
17 (25.4%) 13 (19.4%) 17 (25.4%) 20 (29.8%)
Results
Surgically treated n (%): 36 (53.7)
Time to surgery: 1.2 (1 – 6) h
Transfer to tertiary centre n (%): 4 (6)
Mechanical ventilation n (%): 51 (76.1)
Mechanical ventilation duration: 3.57d (6h – 34d)
Hospital pneumonia n (%): 6 (9)
Life threathening complications n (%):
13 (19.4)
Tracheostomy n (%): 4 (6)
ICU mortality n (%): 9 (13.4)
Time spent in ICU: 5d (1 h – 34 d)
Results
Mortality rates in 3 age groups for diff. ISS
Dob
(godine)
ISS=15
(%)
ISS=25
(%)
ISS=35
(%)
ISS=45
(%)
ISS=55
(%)
0 – 49 3 8 32 61 89
50 – 69 5 21 56 68 100
> 70 16 45 82 100 100
(35.827 patients in a retrospective study, 10 hospitals, 5 years)
J Trauma. 2006
German Surgery Congress 2001.:
5353 polytrauma patients (median age - 38 years)
ISS 24.8
Time to MD arrival 22.4 min, stay 32.9 min, transport 18.3 min
intubated 58.3 %
Hospital stay 31.1 dan
Discussion
Polytrauma patients require long-lasting treatment and substantial financial resources
Mortality and invalidity reduction can be achieved only through application of specific algorithms, quality diagnostic and monitoring and a multidisciplinary therapeutic approach.
Conclusion
Thank you
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