My opinion
 

By Dr. Tanweer Karim
Corresponding Author Dr. Tanweer Karim
Department of Surgery, MGM Medical College, Navimumbai, - India 400706
Submitting Author Dr. Tanweer Karim
TRAUMA

Trauma care, Atls, Definitive care in trauma

Karim T. Definitive Care for Trauma Patients in a Developing Nation. WebmedCentral TRAUMA 2011;2(11):WMC002477
doi: 10.9754/journal.wmc.2011.002477
No
Click here
Submitted on: 15 Nov 2011 04:02:01 PM GMT
Published on: 16 Nov 2011 06:31:55 AM GMT

Abstract


Trauma care management is in a phase of evolution in India, a developing nation. The incidence of trauma related deaths has almost doubled during last decade. Many of these deaths are occurring as a result of poor decision and inappropriate interventions. We believe that most of the trauma cases can be managed effectively with existing resources in a developing nation and General Surgeons will have central role in making it successful.

Introduction


Hundreds of thousands are injured on our roads, some of whom become permanently disabled. The vast majority of these occur in developing countries. Emergency services and trauma care is a neglected area in India. The lack of infrastructure, knowledge and initiative leave these patients unattended and under-served in the cases of calamities, accidents and disasters.  Most if not all victims are in the 15-45 age-group: the most productive segment of our people.
 Many of these patients die even after reaching to the hospital because of inappropriate interventions. Head injury is one of the major causes of trauma-related death and disability worldwide. Minimization of secondary brain injury through the maintenance of cerebral perfusion and oxygenation is an essential goal as most (65%) of the mortality from head injury is associated with secondary brain injury.  20-25% deaths occur due to chest injury and additional 25% deaths due to complications related to chest. 85% of chest injury can be managed without major surgical intervention. Significant abdominal trauma is present in 12–15 % of trauma patients and usually occurs in association with multisystem injury.
Immediate management of such injuries requires care of impending or existing upper airway compromise and / or profuse hemorrhage. The definitive management of bone and soft tissue injuries should be deferred until life threatening injuries have been properly managed. The outcome depends upon the severity of injury, concomitant systemic injury, prompt and multidisciplinary management.
Protocols have shifted their emphasis away from aggressive fluid resuscitation to surgical control of haemorrhage. There is no doubt that availability of ultrasonography and computerized tomography has improved the outcome of trauma management. However, most of the goals of trauma management is still achievable even without these investigation.
Our Experience:
In our institution, a tertiary care hospital, almost 50 percent of surgical emergency admissions are of patients with severe trauma. In our hospital trauma patients are primarily managed by General Surgeons with support of Anesthesiologists.  Significant abdominal trauma is usually present in 20% of trauma patients and occurs in association with multisystem injury. Majority of trauma patients are managed conservatively. Those who die during first few hours following admissions have significant intra-abdominal organ injury and actually remain unattended at the site of accident for a considerable period of time. The patients who get operated have refractory hypotension in the absence of visible blood loss and don’t respond to fluid challenge during first few hours. The line of management of blunt abdominal trauma is primarily guided by the haemodynamic status of the patient at the time of presentation in emergency department and during first few hours and findings on ultrasonography [Focussed Assessment by Sonography for Trauma]. Spleen is the most common intra-abdominal organ injured due to trauma, followed by liver. Injury to the bowel is infrequent. The extent of bowel injury can range from focal mural hematomas to complete transection. Injury more commonly involves the duodenum, primarily the second and third segments. We have encountered two cases of duodenal perforation and equal no complete transaction at duodeno-jejunal flexure following road traffic accidents  Colonic injury is less common than duodenal or small bowel involvement. Rectal injury with or without per rectal bleed is common associated injury, often missed during initial assessment. Out of six cases of rectal injury twice we missed it during initial evaluation. We have come across significant number of cases of urinary tract injuries. Urethral injury with haematuria with or without bladder injury is invariably seen in cases of significant pelvic fracture.[1] Only once we got a case of significant renal trauma where surgical intervention was performed due to refractory hypotension. In our study ofliver injury, exploratory laparotomy was performed for hemoperitoneum (1200–2500 ml, mean: 1739.29 ml) and grade III to grade V liver injury. Those patients who underwent surgery usually required 3-5 units of blood transfusion during first 24 hours and their hospital stay was 9–15 days.  Those patients, who were managed non-operatively, had grade I or II organ injury, hemoperitoneum was less than 900 ml and less than three units of blood were transfused. There has been a significant association between line of management and volume of hemoperitoneum and number of blood transfusion. [2]

Discussions and Conclusion


Trauma outcomes have improved following the advance trauma life support program. [3] Pre-hospital care is almost non-existent in most of the developing countries.  Transfer time to definitive care facilities is too long. There is an urgent need to establish and strengthen pre-hospital care. [4] We are in a phase of transition where Trauma Surgeons are evolving out of General Surgeons as they are the one who manage these cases in a referral centre. Despite dearth of trained manpower, infrastructure and modern equipments, most of the trauma patients are managed on the basis of clinical parameters by general surgeons. [5] It is essential to share our clinical experiences in order to evolve a consensus on definitive care.  Effective and optimal management of head and neck is no possible without computerized tomographic (CT) scan. Requirement is a little different when it comes to the management of blunt abdominal trauma.  Irrespective of the presence or absence of an indication, it has been observed that fewer than half of abdominal trauma patients are in a condition which allows diagnosis by CT. However, radiologic examination is of paramount importance and should be performed to identify and classify the injury and to plan surgical repair, but should not hinder hemodynamic stabilization of the patient.  Prompt surgical intervention with principles of damage control surgery is crucial for optimal outcome in haemodynamically unstable patients.

References


1. Tanweer Karim, Margaret Topno Bedside Sonography to Diagnose Bladder Trauma in the Emergency Department. Journal of Emergency Trauma and shock, 2010,Volume 3 issue 3: 305.
2. Tanweer Karim, Margaret Topno, Ali Reza, Kundan Patil, Raj Gautam et al Hepatic trauma management and outcome; Our experience. Indian J Surg (May–June 2010) 72:189–193 189.
3. Ali J, Adam R, Butler AK, et al. Trauma outcomes improves following the advanced trauma life support program in a developing country. J Trauma. 1993;34:890–898; discussion 898–899.
4. David T. Harrington, MD, Michael Connolly, MD, Walter L. Biffl, MD, et al Transfer Times to Definitive Care Facilities Are Too Long A Consequence of an Immature Trauma System. Ann Surg. 2005 June; 241(6): 961–968.
5. Pryor JP, Reilly PM, Schwab CW, Kauder DR, Dabrowski GP, et al Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-71; discussion 471-3.

Source(s) of Funding


none

Competing Interests


none

Disclaimer


This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

Reviews
1 review posted so far

Review on
Posted by Dr. Sujit K Tripathy on 20 Nov 2011 02:56:25 PM GMT

Comments
0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.

 

Author Comments
0 comments posted so far

 

What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
Where
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)