|Year : 2018 | Volume
| Issue : 2 | Page : 56-59
A retrospective study on the profile and outcome of polytrauma in the emergency department
Navin Clement, Divya Lovelin Regina, Kundavaram Paul Prabhakar Abhilash
Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||20-Jun-2018|
Dr. Kundavaram Paul Prabhakar Abhilash
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Polytrauma is a major cause of morbidity and mortality in developed and developing countries. This study aims to assess the prevalence and outcome of polytrauma patients, in a tertiary care hospital. Materials and Methods: This retrospective observational study was conducted in a large emergency department (ED) between January 2016 and December 2016. All patients >15 years presenting to the ED with polytrauma were included in the analysis. Results: Among 98 polytrauma patients, majority (86%) were male. The mean (standard deviation) age was 41.6 (±14.85) years. Less than one-third of the patients presented to the ED within 3 h of the time of injury. A quarter of the patients have severe traumatic brain injury. Plasma alcohol levels were sent in 22 patients and were found to be elevated in 12 (15%) patients. Majority (78%) of the patients required orthopedic evaluation and intervention. Forty-four patients required 1 unit packed cell blood, whereas 11 patients received two units packed cell blood and 4 patients needed three units packed cell for resuscitation in the ED. Focused assessment with sonography for trauma was done in 66 (85%) patients and was positive in 32 (41%) patients. The ED outcome is shown in [Figure 1]. The ED mortality rate was 15%. Conclusion: Less than one-third of the patients presented to the ED within 3 h of the time of injury which stresses the need to improve prehospital care and transport in our country. Aggressive resuscitation with crystalloids and blood products is of paramount importance in treating polytrauma victims.
Keywords: Emergencies, emergency department, polytrauma, trauma
|How to cite this article:|
Clement N, Regina DL, Abhilash KP. A retrospective study on the profile and outcome of polytrauma in the emergency department. Curr Med Issues 2018;16:56-9
|How to cite this URL:|
Clement N, Regina DL, Abhilash KP. A retrospective study on the profile and outcome of polytrauma in the emergency department. Curr Med Issues [serial online] 2018 [cited 2019 Dec 7];16:56-9. Available from: http://www.cmijournal.org/text.asp?2018/16/2/56/234827
| Introduction|| |
Worldwide, 16,000 people die every day as a result of injury. A polytrauma is a combined trauma, in which there are two or more severe injuries that affect at least two anatomical regions; rarely, two or more severe injuries in one anatomic area, whereas at least one of these is life-threatening. Polytrauma is a major cause of morbidity and mortality in developed and developing countries. Trauma is still the leading cause of death and disability in children and young adults. The majority of traumatic deaths occur within the 1st h following trauma, which is termed as “the golden hour of trauma.” Following the principle of “Time is Essence,” management during the 1st h of injury is vital.
In Vellore, there are many roads connecting the major State Highways and National highways which are the busy roads and most vulnerable for road traffic accident (RTA). In India, RTAs have increased dramatically in recent years due to widespread motor vehicle access and inadequate safety protocols. It has been reported that India has the highest mortality rates from RTA in the world, with 161,736 RTA deaths in 2010 (National Crime Records Bureau, India).,,, Polytrauma cases comprised 13.3% of all adult trauma cases. The majority of these (60.3%) were due to two-wheeler accidents. The management of polytrauma patients requires a multidisciplinary approach, usually managed by a trauma team, consisting of emergency physician, orthopedic surgeon, general Surgeon, neurosurgeon, and radiologist. This study aims to assess the prevalence and outcome of polytrauma patients, in a tertiary care hospital. The information from the study would help us improve the understanding and management of polytrauma patients.
| Materials and Methods|| |
This retrospective observational study was conducted in the Emergency Department (ED) of Christian Medical College Hospital (CMC), Vellore, South India, which is a 45-bedded ED, the largest in South India with an average of 200 admissions daily. The study recruited all polytrauma patients equal to and more than 15 years of age presenting to the ED between January 2016 and December 2016. Patients presenting with traumatic injuries involving only one system were excluded. The charts were reviewed and the relevant details of history, clinical findings, laboratory investigations, and focused assessment with sonography for trauma (FAST) findings were documented in a semi-validated questionnaire. All outcomes from the ED, ward, ICU (stable and discharged, mortality, and discharge against medical advice) were assessed.
Data were entered using Microsoft Excel software (Microsoft Office Excel 2010). Continuous variables are presented as mean. Categorical and nominal variables are presented as percentages. This study was approved by the Institutional Review Board and patient's confidentiality was maintained using unique identifiers and password-protected data entry software with restricted users.
| Results|| |
A total of 6624 trauma patients presented to the ED of CMC Hospital, Vellore, during the period of 1 year from January 2016 to December 2016. Among 98 polytrauma patients, 12 did not meet the inclusion criteria and 8 charts were missing. Hence, 78 patients were included in the study [Figure 2]. Majority (86%) were male. The mean (standard deviation [SD]) age was 41.6 (±14.85) years. Less than one-third of the patients presented to the ED within 3 h of the time of injury. The baseline characteristics are shown in [Table 1]. A quarter of the patients have severe traumatic brain injury. Plasma alcohol levels were sent in 22 patients and were found to be elevated in 12 (15%) patients [Table 2]. Bleeding parameters (prothrombin time and activated partial thromboplastin time) were sent in 38 patients and were found to be abnormal in 11 (14%) patients. The specialist departments involved in the management of polytrauma cases are shown in [Figure 3]. Majority (78%) of the patients required orthopedic evaluation and intervention. Forty-four patients required one unit packed cell blood, whereas 11 patients received two units packed cell blood and 4 patients needed three units packed cell for resuscitation in the ED. FAST was done in 66 (85%) patients and was positive in 32 (41%) patients. The ED outcome is shown in [Figure 1]. The ED mortality rate was 15%.
| Discussion|| |
Polytrauma is one of the major causes of death and disability in the world around, knowing how to tackle and dealing with the causes and managing the patients inflicted with polytrauma can greatly reduce the morbidity and mortality that it carries with it. Trauma is inevitable in our times, but it can be prevented, and even if it has occurred, it can still be managed and treated.
In the study, males were more predisposed to have trauma than females, this is consistent with other studies that showed a more male predominant sex ratio. This can be because males are more outgoing and are engaged in operating motorized vehicles and tough manual work which makes them at risk for severe trauma. In our study, the mean (SD) age was calculated to be 41.6 (±14.85), and majority of injuries were sustained by the patients of age group 30–50. Most of the elderly walked about on the streets unattended or were without any relatives or bystander to look after them, this coupled with the rashful and erratic behavior of motor vehicle drivers usually leave the elderly in a painful heap on the floor. Kamel et al. narrowed down the risk factors of elderly trauma in his study to living alone, chronic diseases, medications, physical deficit, and having a high nutritional risk. The finding was similar to that of the study done by Nilanchal et al. which shows the majority of trauma fell into 26–40 age group.
Time is precious, especially for victims of polytrauma (1st h being the golden hour) the “golden hour” summarized by the 3R rule of Dr. Donald Trunkey, an academic trauma surgeon, “Getting the right patient to the right place at the right time.” However, the concept of golden hour is still questionable in most of the countries. In India, our emergency medical services are neither equipped nor developed. It takes at least 1–2 h for victims to arrive at a health-care facility. Victims are usually first found by bystanders and helped to get to a hospital. No one waits for the ambulance usually a taxi cab serves that purpose most of the times. Pathak et al. noted in his study that there was a time delay of 30–60 min in his study. Our institution is a tertiary care center and most of the patients coming here were either referred or discharged from other small centers. A bulk of our patients came within 3–10 h after the injury which is distressing and shows the need for specific protocols to be designed for the peripheral centers for early referral to higher centers.
In our study, the maximum number of trauma had occurred between 8 AM and 4 PM. This could be explained by the fact of having busy roads during these hours. Another factor adding to this will be the construction sites having their active functioning hours leading to slips and falls occurring maximum during these hours. This finding is quite different from that of the retrospective study done by Choudry SM, which revealed distinct peaks between 1600 h and 2000 h.
In an advanced tertiary care center like ours, the trauma teams operating in the ED are highly specialized. Unlike in many hospitals, trauma cases after initial resuscitation by the ED team are managed by higher specialty departments such as plastic surgery, HLRS, vascular surgery, cardiothoracic surgery, and spine surgery. Our study showed that orthopedics department had intervened majority percentage of patients, followed by the general surgical team. This pattern is consistent with Nilanchal et al. and also similar to the pattern in another advanced tertiary care ED in North India.,
The most common associated injury with RTA is a head injury, especially in those victims that operated a motorized two wheelers. This is in concordance with the studies done by Patil et al. The laws and rules in this part of the country are blatantly not being followed, even after the Madras High Court had made it mandatory to wear protective headgear since July 2015, majority of the people are still driving motorized two wheelers without any protective equipment. In our study, the majority of those with traumatic brain injury had mild head injury (Glasgow Coma Scale: 13–15), followed by severe head injury. This is a serious concern and stresses the need to make use of helmets compulsory across the country. Compulsory use of helmets must be strictly enforced not only just by the government authorities such as the police but also voluntarily encouraged by the institutions people work for. Many roads in India are unsafe and traffic regulations are rarely followed by drivers and seldom strictly enforced by the police.
Fluid resuscitation and achievement of hemostasis are the priority in a patient with polytrauma in hemorrhagic shock. The choice of the resuscitation fluid is equally important. Although crystalloid administration in the form of normal saline or Ringer's lactate is the immediate means of resuscitation at most centers, careful titration of the quantity infused is required to avoid the negative consequences of overinfusion. Only about 30% of infused crystalloid remains intravascular, and therefore, the volume required to be infused is about three times that of the lost blood. In our study, majority of polytrauma patients required 2 l of 0.9% normal saline for resuscitation.
Blood loss >25% to 30% usually requires transfusion of packed red blood cells in addition to crystalloids. Owing to the importance of golden hour, in our hospital, well-established blood bank ensures a ready supply of type “O”-negative blood that can be immediately delivered to the bedside, without the need of cross-matching, which is lifesaving in the rapidly exsanguinating patient. Our study shows that the maximum number of patients received one unit of packed cell blood for controlling hypotension and hemorrhage.
In our tertiary care hospital, emergency physicians are well trained to perform FAST in the resuscitation room, for the polytrauma patients, saving the time for the arrival of radiologist, hence ensuring timely recognition of free fluid in the abdomen and resuscitation. Our study reveals that FAST screening was done in 66 patients among which 41% had FAST positive. The finding was not similar with the study done by Ben-Ishay et al. showing 17.5% positivity.
The retrospective nature of our study was a major limitation. Many charts were missing or had incomplete documentation and hence could not be analyzed. Another limitation is driven by the fact that this study was conducted in a large tertiary care hospital, and hence, the patient population may be biased by patient selection and referral pattern.
| Conclusion|| |
Less than one-third of the patients presented to the ED within 3 h of the time of injury which stresses the need to improve prehospital care and transport in our country. Aggressive resuscitation with crystalloids and blood products is of paramount importance in treating polytrauma victims.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Payal P, Sonu G, Anil GK, Prachi V. Management of polytrauma patients in emergency department: An experience of tertiary care center of Northern India. World J Emerg Med 2013;4:15-9.
Kroupa J. Definition of “polytrauma” and “polytraumatism”. Acta Chir Orthop Traumatol Cech 1990;57:347-60.
D'Amours SK, Sugrue M, Deane SA. Initial management of the poly-trauma patient: A practical approach in an Australian major trauma service. Scand J Surg 2002;91:23-33.
Government of India, Ministry of Home Affairs National Crime Records Bureau: 2010 Accidental Deaths and Suicides in India. Government of India, Ministry of Home Affairs; 2010.
Nilanchal C, Abhilash KP, Gautham RP, Vineet SD, Bhanu TK, Krishna P. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. J Family Med Prim Care 2016;5:558-63.
Gururaj G, Uthkarsh PS, Rao GN, Jayaram AN, Panduranganath V. Burden, pattern and outcomes of road traffic injuries in a rural district of India. Int J Inj Contr Saf Promot 2016;23:64-71.
Kiran ER, Saralaya KM, Vijaya K. A prospective study on road traffic accidents. J Punjab Aced Forensic Med Toxicol 2004;4:12-6.
Roy N, Murlidhar V, Chowdhury R, Patil SB, Supe PA, Vaishnav PD, et al.
Where there are no emergency medical services-prehospital care for the injured in Mumbai, India. Prehosp Disaster Med 2010;25:145-51.
Brumback RJ, Ellison TS, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part III: Long-term effects of static interlocking fixation. J Bone Joint Surg Am 1992;74:106-12.
Chowdhury S, Navsaria PH, Edu S, Nicol AJ. The effect of emergency medical services response on outcome of trauma laparotomy at a level 1 trauma centre in South Africa. S Afr J Surg 2016;54:17-21.
Patil SS, Kakade R, Durgawale P, Kakade S. Pattern of road traffic injuries: A study from Western Maharashtra. Indian J Community Med 2008;33:56-7.
] [Full text]
Guerado E, Bertrand ML, Valdes L, Cruz E, Cano JR. Resuscitation of polytrauma patients: The management of massive skeletal bleeding. Open Orthop J 2015;9:283-95.
Ben-Ishay O, Daoud M, Peled Z, Brauner E, Bahouth H, Kluger Y, et al.
Focused abdominal sonography for trauma in the clinical evaluation of children with blunt abdominal trauma. World J Emerg Surg 2015;10:27.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]