OR~IGINALCONTRIBUTION
Major Trauma in the Rural Mountain West Bruce A. Houtchens, MD Salt Lake City, Utah
A disproportionately high p e r c e n t a g e of t r a u m a fatalities occur in rural areas. Almost half of these fatalities o c c u r after arrival at a c o m m u n i t y hospital. A r e v i e w of the initial e v a l u a t i o n and m a n a g e m e n t of major trauma victims in rural c o m m u n i t y hospitals in the i n t e r m o u n t a i n West revealed a surprisingly high i n c i d e n c e of departure from well defined standards. R e d u c i n g the m a g n i t u d e of this rural hospital c o m p o n e n t of trauma facilities will require application of the same standards of initial e v a l u a t i o n and m a n a g e m e n t w h i c h h a v e p r o v e d e f f e c t i v e in major medical center e m e r g e n c y d e p a r t m e n t settings. Houtchens BA: Major trauma in the rural mountain west. JACEP 6:343-350, August, 1977. trauma, emergency care, rural. INTRODUCTION Although s u s t a i n e d efforts of professional a n d lay groups h a v e resulted in the recognition of t r a u m a as a major n a t i o n a l h e a l t h problem, the component made up of t r a u m a occurring in r u r a l areas has yet to be appreciated. Even though 70% of the population lives in u r b a n areas, up to 7 0 % of t r a u m a f a t a l i t i e s occur i n r u r a l areas.1 Almost h a l f of such fatalities are r e l a t e d to m o t o r v e h i c l e accidents. 2 S t u d i e s a d e c a d e ago i n California3,4 showed a four to fivefold greater f a t a l i t y r a t e for r u r a l motor vehicle accident injuries compared to injuries s u s t a i n e d i n u r b a n area accidents. C u r r e n t data 5 i n the i n t e r m o u n t a i n West s h o w the situa-
From the Department of Surgery, College of Medicine, University of Utah, Salt Lake City, Utah. Address for reprints: Bruce A. Houtchens,
Department of Surgery, College of ~ D;. ealcine University of Utah, Salt Lake
City, Utah 84132.
J I] P 6:8 (Aug)
tion unimproved: the r u r a l area fat a l i t y d e n s i t y (per population a n d per miles d r i v e n ) exceeds the n a t i o n a l average by a factor as great as six. I n his r u r a l studies, Waller3,4, ~ •concluded t h a t deficiencies in emergency t r a n s p o r t a t i o n p e r s o n n e l a n d e q u i p m e n t , a n d i n a d e q u a t e medical f a c i l i t i e s , c o r r e l a t e d m o s t immediately w i t h the d e m o n s t r a t e d decreased chance for survival. C u r r e n t l y , federally funded emerg e n c y m e d i c a l service (EMS) programs are specifically addressing the p r o b l e m of a v a i l a b i l i t y of properly equipped and manned emergency transportation systems in rural areas, v W i t h the long distances between towns i n the w e s t e r n U n i t e d States, most r u r a l t r a u m a survivors are s t i l l g o i n g to be d e l i v e r e d by g r o u n d a m b u l a n c e to t h e n e a r e s t c o m m u n i t y hospital. W i t h improved ground ambulance and emergency m e d i c a l t e c h n i c i a n (EMT) c a p a b i l i t i e s , it c a ~ e anticipated that more victims - - and more critically i n j u r e d v i c t i m s - - will now live to reach a c o m m u n i t y hospital.
The analysis of potentially correctable factors affecting s u r v i v a l of critically i n j u r e d p a t i e n t s i n o u t l y i n g areas must, therefore, focus on the study of i n i t i a l e v a l u a t i o n and mana g e m e n t in existing r u r a l hospitals• In such a study, the logical group of p a t i e n t s to review is t h e a c c i d e n t s u r v i v o r s who arrive alive b u t die in the hospital. Previous studies of such deaths s-12 are c o m p i l e d from d a t a on u r b a n hospital cases and include subjective a s s e s s m e n t s as to " p o t e n t i a l salvageability." Similar studies in r u r a l hospitals are limited by the b r e v i t y of medical records and absence of autopsies. Although it is difficult to obj e c t i v e l y e s t i m a t e p o t e n t i a l salvageability, it should be valid to assess the adequacy of t h a t e v a l u a t i o n a n d m a n a g e m e n t r e c o r d e d i n reference to the findings and diagnoses described. METHODS AND MATERIALS In 1974, 20 r u r a l c o m m u n i t y hospitals in U t a h , Nevada and W y o m i n g were visited w i t h a d v a n c e permission. T h e h o s p i t a l s v a r i e d i n size from 9 to 97 beds (median, 31 beds; m e a n , 36 beds). In each c o m m u n i t y , d e a t h c e r t i f i c a t e s d u r i n g t h e twoy e a r period from mid-1972 to mid1974 were reviewed to identify those p a t i e n t s who died in the hospital as a r e s u l t of i n j u r y with a physician in attendance. For each such case identified, the h o s p i t a l m e d i c a l record was scrut i n i z e d a n d n o t e s m a d e on a prep r i n t e d form. P a r t i c u l a r a t t e n t i o n 343/9
was given to t h e record of v i t a l signs; s t a t e of consciousness on arrival; ini t i a l a n d follow-up p h y s i c a l e x a m inations; diagnostic a n d t h e r a p e u t i c ~tubes" placed; admission and follow-up l a b o r a t o r y studies; x - r a y f i l m s t u d i e s ; i n t r a v e n o u s infusion; blood t r a n s f u s i o n ; a l l m e d i c a t i o n s administered; surgery and other major procedures; consultations and/or a t t e m p t s to transfer; resuscit a t i o n efforts; a n d autopsy. All components of t h e record were used as reference. "Credit" was given for a n y record of specific physical exa m i n a t i o n , ie, ~'clear" q u a l i f i e s as c h e s t e x a m i n a t i o n ; '~pupils e q u a l " qualifies as neurologic e x a m i n a t i o n . C r e d i t was given for a n y evidence a procedure had been done or a form of t h e r a p y e m p l o y e d , ie, l a b o r a t o r y slips, x-ray slips, hospital bills, nurse's notes - - even if not m e n t i o n e d in physician's notes or orders. E v i d e n c e for, a n d d i a g n o s e s of, specific injuries and aggravating conditions and actions t a k e n was in no case s u r m i s e d , b u t in e v e r y case t a k e n o n l y from specific c h a r t entries_ RESULTS
In 15 of these 20 hospitals for this t w o - y e a r period, records were found for a total of 65 accident victims who were s h o r t - t e r m i n h o s p i t a l survivors. T h e i r ages r a n g e d from 2 to 79 y e a r s w i t h a m e d i a n of 35. One t h i r d of the p a t i e n t s w a s from o u t of state, ano t h e r t h i r d was from out of town. Survival time ranged from ten m i n u t e s to e i g h t days w i t h a m e d i a n i n h o s p i t a l s u r v i v a l t i m e of four hours. For convenience in a s s e s s i n g the data, the p a t i e n t s were divided into three groups based on s u r v i v a l t i m e after h o s p i t a l i z a t i o n (Table 1). This division has some r a t i o n a l e in t e r m s of w h a t m i g h t be expected to be accomplished in most facilities. Two hours is about twice as long as i t should t a k e to have completed all preliminary evaluation, have intravenous lines and all o t h e r t u b e s placed, and h a v e t y p e - s p e c i f i c blood r e a d y . Six h o u r s is a t l e a s t t w i c e as l o n g as should be r e q u i r e d to i n s t i t u t e needed major s u r g e r y or is enough time to effect a t r a n s f e r to a t e r t i a r y care c e n t e r for more t h a n h a l f the interm o u n t a i n west. 1~344
Table 1 SURVIVAL TIME
Group
Survival T i m e (Hours)
Number
Percent of Total
I
0-2
20
31
II
2 - 6
17
26
III
6 -
28
43
For a n y m u l t i p l y injured patient, r a r e l y are problems ~'isolated." Yet, in r e v i e w i n g c r i t i c a l i n j u r y t r a u m a cases, c e r t a i n errors of omission and c o m m i s s i o n m a y be found to occur w i t h r e g u l a r i t y in each of the following areas: 1. E v a l u a t i o n and m a n a g e m e n t of t h e m a j o r h e a d i n j u r y patient. 2. E v a l u a t i o n and m a n a g e m e n t of t h e unconscious p a t i e n t . 3. E v a l u a t i o n and m a n a g e m e n t of the profoundly hypotensive patient w i t h m u l t i p l e injuries. 4. E v a l u a t i o n and m a n a g e m e n t of t h e p r o b a b l e a b d o m i n a l i n j u r y patient. 5. E v a l u a t i o n and m a n a g e m e n t of t h e probable chest injury patient. 6. M a n a g e m e n t of t h e m a s s i v e chest injury patient. 7. E v a l u a t i o n and m a n a g e m e n t of u r i n a r y t r a c t and pelvic injuries. 8. Focus on superficial lacerations. 9. I m m o b i l i z a t i o n of l i m b fractures. 10. E a r l y r e m o v a l of t h e critical p a t i e n t to the radiology d e p a r t m e n t . 11. F a i l u r e to o b t a i n consultation; failure to transfer. 12. G i v i n g up - - l a c k of resuscitation a t t e m p t s ; l a c k of autopsy. In c o m p r e h e n s i v e e m e r g e n c y dep a r t m e n t s and t r a u m a units of major u r b a n t e a c h i n g h o s p i t a l s , protocols h a v e evolved to p r e v e n t common errors in t h e s e areas. O u t of t h e success of these protocols in increasing the chances of s u r v i v a l of the critically i n j u r e d p a t i e n t s h a v e evolved s t a n d a r d s of i n i t i a l e v a l u a t i o n and m a n a g e m e n t described by n a t i o n a l l y recognized a u t h o r i t i e s in widely circ u l a t e d j o u r n a l s 13-~5 a n d t e x t books.l~-t9 The d a t a in our s t u d y are organized u n d e r t h e s e 12 h e a d i n g s . F o r each p r o b l e m the accepted s t a n d a r d of i n i t i a l e v a l u a t i o n a n d m a n a g e m e n t is first reviewed, t h e n the r e c -
o r d of c u r r e n t p e r f o r m a n c e in the r u r a l I n t e r m o u n t a i n W e s t is pre, s e n t e d . F o r each p r o b l e m a r e a the performance recorded is compared to the s t a n d a r d described in reference to t h e specific c o n d i t i o n recorded. This p e r m i t s identification of factors a d v e r s e l y affecting s u r v i v a l without h a v i n g to excuse incomplete records or e n t e r the v a l u e j u d g m e n t of over. all p o t e n t i a l s u r v i v a b i l i t y .
I. Initial Evaluation and Management of the Major Head Injury Patient. T h e Standard.14,15,17-19 Following e s t a b l i s h m e n t of a n adequate airway and control of e x t e r n a l hemorrhage, a gross neurological evaluation should be done. All p a t i e n t s unconscious from h e a d t r a u m a or w i t h inj u r i e s to b e a d , f a c e or s h o u l d e r s s h o u l d be s u s p e c t e d of h a v i n g associated cervical spine injuries. Care should be used in m o v i n g such patients. The h e a d a n d neck should be i m m o b i l i z e d u n t i l c e r v i c a l spine r a d i o g r a p h s can be obtained. The level of consciousness is the single most i m p o r t a n t i n d i c a t o r of t h e p a t i e n t ' s condition. Evidence of d e t e r i o r a t i o n , p a r t i c u l a r l y without l a t e r a l i z i n g signs, calls for special studies. Open fractures of t h e skull usually r e q u i r e reduction. It is r a r e for the course of t r e a t m e n t of a closed head i n j u r y to be influenced by presence or absence of a s k u l l fracture, 17 (P 91) but a fracture line crossing t h e course of the middle m e n i n g e a l a r t e r y or the s a g i t t a l or t r a n s v e r s e sinus m a y lead to t h e d i a g n o s i s of a n e x t r a d u r a l h e m o r r h a g e . In m o s t cases, radiographic s t u d y of the s k u l l should be d e f e r r e d u n t i l o t h e r m a j o r medical problems are u n d e r control. T h e u s e of n a r c o t i c s avoided_
is to be
H y p o t e n s i o n is to be a t t r i b u t e d to 6:8 (Aug) 1977 J ~ P
a cause o t h e r t h a n t h e head injury until proven otherwise. The R e c o r d . Of the 65 s h o r t - t e r m survivors, 47 (72%) h a d diagnoses of major head i n j u r i e s (Table 2).
II. Initial Evaluation and Management of the Unconscious Patient. T h e S t a n d a r d . 13-18'~° T h e f i r s t consideration is e s t a b l i s h m e n t of an adequate a i r w a y . E n d o t r a c h e a l intubation is one m e t h o d of accomplishing this. A cuffed e n d o t r a c h e a l tube is desirable so t h a t positive pressure v e n t i l a t o r y a s s i s t a n c e (bag, r e s p i r a t o r ) c a n be a c c o m p l i s h e d as needed. A s p i r a t i o n is a frequent cause of rapid d e a t h in unconscious or severely injured patients.~mp 532),17(pp s3, 84) Frequent suctioning of the a i r w a y is essential- A i r w a y complications are such a common source of m o r b i d i t y and m o r t a l i t y t h a t in some m a j o r emergency d e p a r t m e n t s it has been protocol to i n t u b a t e all unconscious accident victims. T h e R e c o r d . Of the 65 s h o r t - t e r m inhospital survivors, t h e r e were 51 (78%) who were unconscious or semicomatose (all causes) on a r r i v a l (Table 3).
III. Initial Evaulation and Management of the Profoundly Hypotensive Patient with Multiple Injuries; the Probable Abdominal Injury Patient; and the Probable Chest Injury Patient. T h e S t a n d a r d . 13-~9 After i n s u r i n g an adequate a i r w a y and controlling external hemorrhage, hypovolemic shock is best prevented, or r e v e r s e d , by s t a r t i n g two, preferably, l a r g e bore (14-18 gauge) i n t r a v e n o u s i n f u s i o n catheters. Blood for t y p e a n d ' c r o s s m a t c h is drawn a t the t i m e t h e i n t r a v e n o u s catheters a r e i n s e r t e d . A b a l a n c e d saline solution, such as Ringer's lactate, is infused u n t i l blood is available. In case of profound h y p o t e n sion, c r y s t a l l o i d infusion is administered at a r a t e of a l i t e r every 20 to 30 m i n u t e s . Should t h e p a t i e n t initially r e s p o n d to r a p i d crystalloid infusion b u t s u b s e q u e n t l y b e c o m e hypotensive, a d m i n i s t r a t i o n of type specific whole blood is u s u a l l y indicated. S h o u l d t h e p a t i e n t n o t initially r e s p o n d to r a p i d infusion of two liters of b a l a n c e d saline solution, J~P
6:8 (Aug) 1977
Table 2 D I A G N O S E D AS M A J O R HEAD I N J U R Y Group Total*(%) I II III 12 (26%) 14 (30%) 21 (44%) 47
Record Level of consciousness - - not recorded - - unconscious - - semiconscious - - alert No neurologic/neck exam recorded
7 2 3 --
4 6 1 3
3 11 6 1
14 19 10 4
(30) (40) (21) (09)
9
10
7
26 (55)
No skull film
11
9
6
26 (55)
Skull film - - no fracture
--
4
10
14 (30)
No neck film No other neurologic diagnostic procedure
12
13
20
45 (96)
12
13
21
46 (98)
Narcotics/sedatives given
4
7
4
15 (32)
Steroid given
1
2
12
15 (32)
*percent of total with head injuries.
Table 3 U N C O N S C I O U S OR S E M I C O M A T O S E ON ARRIVAL
Record
I
Group II
III
Total (%) 51
No e n d o t r a c h e a l tube
16
10
15
41 (80)
O b v i o u s respiratory distress
10
7
5
22 (54)*
Blood or vomitus in the mouth
4
4
6
14 (34)*
13
9
7
29 (57)
6
5
4
15 (30)
No neurological exam recorded Narcotics and/or sedatives given *percent of those not intubated.
a d m i n i s t r a t i o n of u n c r o s s m a t c h e d t y p e O, R h n e g a t i v e blood is indicated.
Use of v a s o p r e s s o r s in t r e a t i n g h y p o v o l e m i c shock has also f a l l e n into disfavor recently.
In r e c e n t years, p l a s m a e x p a n d e r s such as h u m a n plasma, a l b u m i n and d e x t r a n have fallen into disfavor for use as p r i m a r y volume r e p l a c e m e n t vehicles, p a r t i c u l a r l y when used to the exclusion of infusion of b a l a n c e d saline solutions, is Used alone, t h e y a r e less effective t h a n rapid crystalloid infusion. 19 T h e y offer no increase in oxygen c a r r y i n g capacity; t h e y expose the p a t i e n t to r i s k of hepatitis, a n t i g e n - a n t i b o d y r e ~ t i o n s , and defects in c l o t t i n g mecKanism; and t h e y are r a p i d l y d e g r a d e d and/or equilibr a t e d w i t h t o t a l e x t r a c e l l u l a r fluid.
Two u n c o m p l i c a t e d and r e l i a b l e p a r a m e t e r s to monitor the adequacy of volume r e p l a c e m e n t in a p a t i e n t w i t h hypovolemic shock are c e n t r a l venous p r e s s u r e and urine output. It is helpful to m a k e one of the first two l a r g e bore, u p p e r body i n t r a v e n o u s c a t h e t e r s a c e n t r a l venous line. In shock s t a t e s not r e a d i l y responsive to ( a p p a r e n t l y a d e q u a t e ) v o l u m e replacement, monitoring left heart filling pressure with a Swan-Ganz c a t h e t e r should be done early. W h e n p l a c i n g a CVP or Swan-Ganz cathet e r cannot be e a s i l y accomplished by 345/11
a percutaneous entry, the delay involved in a cutdown, and the risks of a r t e r i a l i n j u r y and p n e u m o t h o r a x with subclavian and internal jugular sticks, should be weighed against the s k i l l s of t h e p h y s i c i a n before attempting the procedures, especially when other r e s u s c i t a t i v e measures will be delayed. U r i n a l y s i s should be done on all multiply injured patients to check for h e m a t u r i a before t h e y l e a v e t h e emergency department. All patients in hypovolemic shock, except possibly infants who respond to volume replacement almost immediately, should have an indwelling urethral catheter inserted as part of the initial r e s u s c i t a t i o n protocol and should have urine output carefully monitored. Though oxygen saturation is normal in the majority of patients with uncomplicated hypovolemic shock, a small but significant fraction of patients in hypovolemic shock will be found to be desaturated. For such patients, initial use of increased oxygen concentration can be very important since decreased cardiac o u t p u t acc o m p a n y i n g shock m a y compound existing defects in oxygenation due to pre-existing chronic lung disease or acute p u l m o n a r y injury. When any doubt exists as to the adequacy of oxygenation and an endotracheal tube is not already in place, oxygen should be administered by face mask. A "baseline" hematocrit reading and arterial blood gas measurement are very h e l p f u l in a s s e s s i n g r e l a t i v e oxygen c a r r y i n g capacity, a r t e r i a l oxygen tension, adequacy of ventilation, and acid-base balance. Inadequate oxygenation/ventilation may be due to primary chest/ lung injuries and shock may be cardiogenic: as from cardiac tamponade, tension pneumothorax, and hypoxic cardiac dysfunction; as well as hypovolemic. These problems can be r a p i d l y fatal, and i m m e d i a t e diag, nostic and corrective measures may be required. Marked dyspnea and decreased breath sounds over the hemithorax, p a r t i c u l a r l y in the presence of rib fractures, s u g g e s t s p n e u m o t h o r a x . Shift of the t r a c h e a from m i d l i n e suggests tension pneumothorax. Immediate needle aspiration can both 12/346
EMERGENCY
Table 4 PATIENTS -- PROBLEM
No % *
Group II No % *
III No %*
Total (%)
14 (35)
13 (32.5)
13 (32)
40 (62)
12 (32)
10 (26)
16 (42)
38 (58)
9 (30
9 (30)
12 (40)
30 (46)
I Record
Systolic BP
Major Trauma in the Rural Mountain West Bruce A. Houtchens, MD Salt Lake City, Utah
A disproportionately high p e r c e n t a g e of t r a u m a fatalities occur in rural areas. Almost half of these fatalities o c c u r after arrival at a c o m m u n i t y hospital. A r e v i e w of the initial e v a l u a t i o n and m a n a g e m e n t of major trauma victims in rural c o m m u n i t y hospitals in the i n t e r m o u n t a i n West revealed a surprisingly high i n c i d e n c e of departure from well defined standards. R e d u c i n g the m a g n i t u d e of this rural hospital c o m p o n e n t of trauma facilities will require application of the same standards of initial e v a l u a t i o n and m a n a g e m e n t w h i c h h a v e p r o v e d e f f e c t i v e in major medical center e m e r g e n c y d e p a r t m e n t settings. Houtchens BA: Major trauma in the rural mountain west. JACEP 6:343-350, August, 1977. trauma, emergency care, rural. INTRODUCTION Although s u s t a i n e d efforts of professional a n d lay groups h a v e resulted in the recognition of t r a u m a as a major n a t i o n a l h e a l t h problem, the component made up of t r a u m a occurring in r u r a l areas has yet to be appreciated. Even though 70% of the population lives in u r b a n areas, up to 7 0 % of t r a u m a f a t a l i t i e s occur i n r u r a l areas.1 Almost h a l f of such fatalities are r e l a t e d to m o t o r v e h i c l e accidents. 2 S t u d i e s a d e c a d e ago i n California3,4 showed a four to fivefold greater f a t a l i t y r a t e for r u r a l motor vehicle accident injuries compared to injuries s u s t a i n e d i n u r b a n area accidents. C u r r e n t data 5 i n the i n t e r m o u n t a i n West s h o w the situa-
From the Department of Surgery, College of Medicine, University of Utah, Salt Lake City, Utah. Address for reprints: Bruce A. Houtchens,
Department of Surgery, College of ~ D;. ealcine University of Utah, Salt Lake
City, Utah 84132.
J I] P 6:8 (Aug)
tion unimproved: the r u r a l area fat a l i t y d e n s i t y (per population a n d per miles d r i v e n ) exceeds the n a t i o n a l average by a factor as great as six. I n his r u r a l studies, Waller3,4, ~ •concluded t h a t deficiencies in emergency t r a n s p o r t a t i o n p e r s o n n e l a n d e q u i p m e n t , a n d i n a d e q u a t e medical f a c i l i t i e s , c o r r e l a t e d m o s t immediately w i t h the d e m o n s t r a t e d decreased chance for survival. C u r r e n t l y , federally funded emerg e n c y m e d i c a l service (EMS) programs are specifically addressing the p r o b l e m of a v a i l a b i l i t y of properly equipped and manned emergency transportation systems in rural areas, v W i t h the long distances between towns i n the w e s t e r n U n i t e d States, most r u r a l t r a u m a survivors are s t i l l g o i n g to be d e l i v e r e d by g r o u n d a m b u l a n c e to t h e n e a r e s t c o m m u n i t y hospital. W i t h improved ground ambulance and emergency m e d i c a l t e c h n i c i a n (EMT) c a p a b i l i t i e s , it c a ~ e anticipated that more victims - - and more critically i n j u r e d v i c t i m s - - will now live to reach a c o m m u n i t y hospital.
The analysis of potentially correctable factors affecting s u r v i v a l of critically i n j u r e d p a t i e n t s i n o u t l y i n g areas must, therefore, focus on the study of i n i t i a l e v a l u a t i o n and mana g e m e n t in existing r u r a l hospitals• In such a study, the logical group of p a t i e n t s to review is t h e a c c i d e n t s u r v i v o r s who arrive alive b u t die in the hospital. Previous studies of such deaths s-12 are c o m p i l e d from d a t a on u r b a n hospital cases and include subjective a s s e s s m e n t s as to " p o t e n t i a l salvageability." Similar studies in r u r a l hospitals are limited by the b r e v i t y of medical records and absence of autopsies. Although it is difficult to obj e c t i v e l y e s t i m a t e p o t e n t i a l salvageability, it should be valid to assess the adequacy of t h a t e v a l u a t i o n a n d m a n a g e m e n t r e c o r d e d i n reference to the findings and diagnoses described. METHODS AND MATERIALS In 1974, 20 r u r a l c o m m u n i t y hospitals in U t a h , Nevada and W y o m i n g were visited w i t h a d v a n c e permission. T h e h o s p i t a l s v a r i e d i n size from 9 to 97 beds (median, 31 beds; m e a n , 36 beds). In each c o m m u n i t y , d e a t h c e r t i f i c a t e s d u r i n g t h e twoy e a r period from mid-1972 to mid1974 were reviewed to identify those p a t i e n t s who died in the hospital as a r e s u l t of i n j u r y with a physician in attendance. For each such case identified, the h o s p i t a l m e d i c a l record was scrut i n i z e d a n d n o t e s m a d e on a prep r i n t e d form. P a r t i c u l a r a t t e n t i o n 343/9
was given to t h e record of v i t a l signs; s t a t e of consciousness on arrival; ini t i a l a n d follow-up p h y s i c a l e x a m inations; diagnostic a n d t h e r a p e u t i c ~tubes" placed; admission and follow-up l a b o r a t o r y studies; x - r a y f i l m s t u d i e s ; i n t r a v e n o u s infusion; blood t r a n s f u s i o n ; a l l m e d i c a t i o n s administered; surgery and other major procedures; consultations and/or a t t e m p t s to transfer; resuscit a t i o n efforts; a n d autopsy. All components of t h e record were used as reference. "Credit" was given for a n y record of specific physical exa m i n a t i o n , ie, ~'clear" q u a l i f i e s as c h e s t e x a m i n a t i o n ; '~pupils e q u a l " qualifies as neurologic e x a m i n a t i o n . C r e d i t was given for a n y evidence a procedure had been done or a form of t h e r a p y e m p l o y e d , ie, l a b o r a t o r y slips, x-ray slips, hospital bills, nurse's notes - - even if not m e n t i o n e d in physician's notes or orders. E v i d e n c e for, a n d d i a g n o s e s of, specific injuries and aggravating conditions and actions t a k e n was in no case s u r m i s e d , b u t in e v e r y case t a k e n o n l y from specific c h a r t entries_ RESULTS
In 15 of these 20 hospitals for this t w o - y e a r period, records were found for a total of 65 accident victims who were s h o r t - t e r m i n h o s p i t a l survivors. T h e i r ages r a n g e d from 2 to 79 y e a r s w i t h a m e d i a n of 35. One t h i r d of the p a t i e n t s w a s from o u t of state, ano t h e r t h i r d was from out of town. Survival time ranged from ten m i n u t e s to e i g h t days w i t h a m e d i a n i n h o s p i t a l s u r v i v a l t i m e of four hours. For convenience in a s s e s s i n g the data, the p a t i e n t s were divided into three groups based on s u r v i v a l t i m e after h o s p i t a l i z a t i o n (Table 1). This division has some r a t i o n a l e in t e r m s of w h a t m i g h t be expected to be accomplished in most facilities. Two hours is about twice as long as i t should t a k e to have completed all preliminary evaluation, have intravenous lines and all o t h e r t u b e s placed, and h a v e t y p e - s p e c i f i c blood r e a d y . Six h o u r s is a t l e a s t t w i c e as l o n g as should be r e q u i r e d to i n s t i t u t e needed major s u r g e r y or is enough time to effect a t r a n s f e r to a t e r t i a r y care c e n t e r for more t h a n h a l f the interm o u n t a i n west. 1~344
Table 1 SURVIVAL TIME
Group
Survival T i m e (Hours)
Number
Percent of Total
I
0-2
20
31
II
2 - 6
17
26
III
6 -
28
43
For a n y m u l t i p l y injured patient, r a r e l y are problems ~'isolated." Yet, in r e v i e w i n g c r i t i c a l i n j u r y t r a u m a cases, c e r t a i n errors of omission and c o m m i s s i o n m a y be found to occur w i t h r e g u l a r i t y in each of the following areas: 1. E v a l u a t i o n and m a n a g e m e n t of t h e m a j o r h e a d i n j u r y patient. 2. E v a l u a t i o n and m a n a g e m e n t of t h e unconscious p a t i e n t . 3. E v a l u a t i o n and m a n a g e m e n t of the profoundly hypotensive patient w i t h m u l t i p l e injuries. 4. E v a l u a t i o n and m a n a g e m e n t of t h e p r o b a b l e a b d o m i n a l i n j u r y patient. 5. E v a l u a t i o n and m a n a g e m e n t of t h e probable chest injury patient. 6. M a n a g e m e n t of t h e m a s s i v e chest injury patient. 7. E v a l u a t i o n and m a n a g e m e n t of u r i n a r y t r a c t and pelvic injuries. 8. Focus on superficial lacerations. 9. I m m o b i l i z a t i o n of l i m b fractures. 10. E a r l y r e m o v a l of t h e critical p a t i e n t to the radiology d e p a r t m e n t . 11. F a i l u r e to o b t a i n consultation; failure to transfer. 12. G i v i n g up - - l a c k of resuscitation a t t e m p t s ; l a c k of autopsy. In c o m p r e h e n s i v e e m e r g e n c y dep a r t m e n t s and t r a u m a units of major u r b a n t e a c h i n g h o s p i t a l s , protocols h a v e evolved to p r e v e n t common errors in t h e s e areas. O u t of t h e success of these protocols in increasing the chances of s u r v i v a l of the critically i n j u r e d p a t i e n t s h a v e evolved s t a n d a r d s of i n i t i a l e v a l u a t i o n and m a n a g e m e n t described by n a t i o n a l l y recognized a u t h o r i t i e s in widely circ u l a t e d j o u r n a l s 13-~5 a n d t e x t books.l~-t9 The d a t a in our s t u d y are organized u n d e r t h e s e 12 h e a d i n g s . F o r each p r o b l e m the accepted s t a n d a r d of i n i t i a l e v a l u a t i o n a n d m a n a g e m e n t is first reviewed, t h e n the r e c -
o r d of c u r r e n t p e r f o r m a n c e in the r u r a l I n t e r m o u n t a i n W e s t is pre, s e n t e d . F o r each p r o b l e m a r e a the performance recorded is compared to the s t a n d a r d described in reference to t h e specific c o n d i t i o n recorded. This p e r m i t s identification of factors a d v e r s e l y affecting s u r v i v a l without h a v i n g to excuse incomplete records or e n t e r the v a l u e j u d g m e n t of over. all p o t e n t i a l s u r v i v a b i l i t y .
I. Initial Evaluation and Management of the Major Head Injury Patient. T h e Standard.14,15,17-19 Following e s t a b l i s h m e n t of a n adequate airway and control of e x t e r n a l hemorrhage, a gross neurological evaluation should be done. All p a t i e n t s unconscious from h e a d t r a u m a or w i t h inj u r i e s to b e a d , f a c e or s h o u l d e r s s h o u l d be s u s p e c t e d of h a v i n g associated cervical spine injuries. Care should be used in m o v i n g such patients. The h e a d a n d neck should be i m m o b i l i z e d u n t i l c e r v i c a l spine r a d i o g r a p h s can be obtained. The level of consciousness is the single most i m p o r t a n t i n d i c a t o r of t h e p a t i e n t ' s condition. Evidence of d e t e r i o r a t i o n , p a r t i c u l a r l y without l a t e r a l i z i n g signs, calls for special studies. Open fractures of t h e skull usually r e q u i r e reduction. It is r a r e for the course of t r e a t m e n t of a closed head i n j u r y to be influenced by presence or absence of a s k u l l fracture, 17 (P 91) but a fracture line crossing t h e course of the middle m e n i n g e a l a r t e r y or the s a g i t t a l or t r a n s v e r s e sinus m a y lead to t h e d i a g n o s i s of a n e x t r a d u r a l h e m o r r h a g e . In m o s t cases, radiographic s t u d y of the s k u l l should be d e f e r r e d u n t i l o t h e r m a j o r medical problems are u n d e r control. T h e u s e of n a r c o t i c s avoided_
is to be
H y p o t e n s i o n is to be a t t r i b u t e d to 6:8 (Aug) 1977 J ~ P
a cause o t h e r t h a n t h e head injury until proven otherwise. The R e c o r d . Of the 65 s h o r t - t e r m survivors, 47 (72%) h a d diagnoses of major head i n j u r i e s (Table 2).
II. Initial Evaluation and Management of the Unconscious Patient. T h e S t a n d a r d . 13-18'~° T h e f i r s t consideration is e s t a b l i s h m e n t of an adequate a i r w a y . E n d o t r a c h e a l intubation is one m e t h o d of accomplishing this. A cuffed e n d o t r a c h e a l tube is desirable so t h a t positive pressure v e n t i l a t o r y a s s i s t a n c e (bag, r e s p i r a t o r ) c a n be a c c o m p l i s h e d as needed. A s p i r a t i o n is a frequent cause of rapid d e a t h in unconscious or severely injured patients.~mp 532),17(pp s3, 84) Frequent suctioning of the a i r w a y is essential- A i r w a y complications are such a common source of m o r b i d i t y and m o r t a l i t y t h a t in some m a j o r emergency d e p a r t m e n t s it has been protocol to i n t u b a t e all unconscious accident victims. T h e R e c o r d . Of the 65 s h o r t - t e r m inhospital survivors, t h e r e were 51 (78%) who were unconscious or semicomatose (all causes) on a r r i v a l (Table 3).
III. Initial Evaulation and Management of the Profoundly Hypotensive Patient with Multiple Injuries; the Probable Abdominal Injury Patient; and the Probable Chest Injury Patient. T h e S t a n d a r d . 13-~9 After i n s u r i n g an adequate a i r w a y and controlling external hemorrhage, hypovolemic shock is best prevented, or r e v e r s e d , by s t a r t i n g two, preferably, l a r g e bore (14-18 gauge) i n t r a v e n o u s i n f u s i o n catheters. Blood for t y p e a n d ' c r o s s m a t c h is drawn a t the t i m e t h e i n t r a v e n o u s catheters a r e i n s e r t e d . A b a l a n c e d saline solution, such as Ringer's lactate, is infused u n t i l blood is available. In case of profound h y p o t e n sion, c r y s t a l l o i d infusion is administered at a r a t e of a l i t e r every 20 to 30 m i n u t e s . Should t h e p a t i e n t initially r e s p o n d to r a p i d crystalloid infusion b u t s u b s e q u e n t l y b e c o m e hypotensive, a d m i n i s t r a t i o n of type specific whole blood is u s u a l l y indicated. S h o u l d t h e p a t i e n t n o t initially r e s p o n d to r a p i d infusion of two liters of b a l a n c e d saline solution, J~P
6:8 (Aug) 1977
Table 2 D I A G N O S E D AS M A J O R HEAD I N J U R Y Group Total*(%) I II III 12 (26%) 14 (30%) 21 (44%) 47
Record Level of consciousness - - not recorded - - unconscious - - semiconscious - - alert No neurologic/neck exam recorded
7 2 3 --
4 6 1 3
3 11 6 1
14 19 10 4
(30) (40) (21) (09)
9
10
7
26 (55)
No skull film
11
9
6
26 (55)
Skull film - - no fracture
--
4
10
14 (30)
No neck film No other neurologic diagnostic procedure
12
13
20
45 (96)
12
13
21
46 (98)
Narcotics/sedatives given
4
7
4
15 (32)
Steroid given
1
2
12
15 (32)
*percent of total with head injuries.
Table 3 U N C O N S C I O U S OR S E M I C O M A T O S E ON ARRIVAL
Record
I
Group II
III
Total (%) 51
No e n d o t r a c h e a l tube
16
10
15
41 (80)
O b v i o u s respiratory distress
10
7
5
22 (54)*
Blood or vomitus in the mouth
4
4
6
14 (34)*
13
9
7
29 (57)
6
5
4
15 (30)
No neurological exam recorded Narcotics and/or sedatives given *percent of those not intubated.
a d m i n i s t r a t i o n of u n c r o s s m a t c h e d t y p e O, R h n e g a t i v e blood is indicated.
Use of v a s o p r e s s o r s in t r e a t i n g h y p o v o l e m i c shock has also f a l l e n into disfavor recently.
In r e c e n t years, p l a s m a e x p a n d e r s such as h u m a n plasma, a l b u m i n and d e x t r a n have fallen into disfavor for use as p r i m a r y volume r e p l a c e m e n t vehicles, p a r t i c u l a r l y when used to the exclusion of infusion of b a l a n c e d saline solutions, is Used alone, t h e y a r e less effective t h a n rapid crystalloid infusion. 19 T h e y offer no increase in oxygen c a r r y i n g capacity; t h e y expose the p a t i e n t to r i s k of hepatitis, a n t i g e n - a n t i b o d y r e ~ t i o n s , and defects in c l o t t i n g mecKanism; and t h e y are r a p i d l y d e g r a d e d and/or equilibr a t e d w i t h t o t a l e x t r a c e l l u l a r fluid.
Two u n c o m p l i c a t e d and r e l i a b l e p a r a m e t e r s to monitor the adequacy of volume r e p l a c e m e n t in a p a t i e n t w i t h hypovolemic shock are c e n t r a l venous p r e s s u r e and urine output. It is helpful to m a k e one of the first two l a r g e bore, u p p e r body i n t r a v e n o u s c a t h e t e r s a c e n t r a l venous line. In shock s t a t e s not r e a d i l y responsive to ( a p p a r e n t l y a d e q u a t e ) v o l u m e replacement, monitoring left heart filling pressure with a Swan-Ganz c a t h e t e r should be done early. W h e n p l a c i n g a CVP or Swan-Ganz cathet e r cannot be e a s i l y accomplished by 345/11
a percutaneous entry, the delay involved in a cutdown, and the risks of a r t e r i a l i n j u r y and p n e u m o t h o r a x with subclavian and internal jugular sticks, should be weighed against the s k i l l s of t h e p h y s i c i a n before attempting the procedures, especially when other r e s u s c i t a t i v e measures will be delayed. U r i n a l y s i s should be done on all multiply injured patients to check for h e m a t u r i a before t h e y l e a v e t h e emergency department. All patients in hypovolemic shock, except possibly infants who respond to volume replacement almost immediately, should have an indwelling urethral catheter inserted as part of the initial r e s u s c i t a t i o n protocol and should have urine output carefully monitored. Though oxygen saturation is normal in the majority of patients with uncomplicated hypovolemic shock, a small but significant fraction of patients in hypovolemic shock will be found to be desaturated. For such patients, initial use of increased oxygen concentration can be very important since decreased cardiac o u t p u t acc o m p a n y i n g shock m a y compound existing defects in oxygenation due to pre-existing chronic lung disease or acute p u l m o n a r y injury. When any doubt exists as to the adequacy of oxygenation and an endotracheal tube is not already in place, oxygen should be administered by face mask. A "baseline" hematocrit reading and arterial blood gas measurement are very h e l p f u l in a s s e s s i n g r e l a t i v e oxygen c a r r y i n g capacity, a r t e r i a l oxygen tension, adequacy of ventilation, and acid-base balance. Inadequate oxygenation/ventilation may be due to primary chest/ lung injuries and shock may be cardiogenic: as from cardiac tamponade, tension pneumothorax, and hypoxic cardiac dysfunction; as well as hypovolemic. These problems can be r a p i d l y fatal, and i m m e d i a t e diag, nostic and corrective measures may be required. Marked dyspnea and decreased breath sounds over the hemithorax, p a r t i c u l a r l y in the presence of rib fractures, s u g g e s t s p n e u m o t h o r a x . Shift of the t r a c h e a from m i d l i n e suggests tension pneumothorax. Immediate needle aspiration can both 12/346
EMERGENCY
Table 4 PATIENTS -- PROBLEM
No % *
Group II No % *
III No %*
Total (%)
14 (35)
13 (32.5)
13 (32)
40 (62)
12 (32)
10 (26)
16 (42)
38 (58)
9 (30
9 (30)
12 (40)
30 (46)
I Record
Systolic BP
