“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