polytrauma in traffic accidents

Igor Bogović, Robert Baronica, Andrija Vidović

POLYTRAUMA IN TRAFFIC ACCIDENTS

POLYTRAUMA IN TRAFFIC ACCIDENTS Igor Bogović, M. D., Faculty of Transport and Traffic Engineering, University of Zagreb, Zagreb, Vukelićeva 4 [email protected] Robert Baronica, M.D. Clinical Hospital Center "Zagreb", Zagreb, Kišpatićeva 12 [email protected] Andrija Vidović, B. Eng. Faculty of Transport and Traffic Engineering, University of Zagreb, Zagreb,Vukelićeva 4 [email protected] ABSTRACT Polytrauma represents a number of severe, life threatening injuries that lead to death, without active and intensive approach to diagnosis and treatment. In Republic of Croatia every day people are dying in traffic accidents. Most of the casualties are present in road traffic, almost two human lives per day. But polytrauma is not specific just for road traffic. It is present in all traffic branches and also in all other types of accidents. Injuries in polytrauma affect more than one organic system. Their character leads to rapid and dynamic development of severe clinical status as a result of vital function failure, massive hemorrhage and prolonged traumatic hypovolemic shock. As a final result there is decreased concentration of oxygen in blood with reduction of organ perfusion, cardiopulmonary insufficiency. Paper defines polytrauma and describes methods of medical treatments. Authors point at problems in healing of injured people and emphases the seriousness of this kind of injury and in time and correct way of emergency medical assistance. 1. INTRODUCTION Polytrauma is the most serious of all the injuries in general. There are several different definitions of the term. According to these definitions it could be said that polytrauma represents a set of serious, fatal injuries that without active intensive approach in diagnostics and treatment lead to the undesired end. The polytrauma injuries attack several organ systems. They are of such a character that they quickly and dynamically lead to the development of a serious clinical picture due to the failure of vital functions, massive haemorrhage and the development of a protracted traumatic hypovolemic shock. The end result is hypoxia with reduced perfusion of organs, cardio respiratory insufficiency, failure of all the organ functions and death(1). Unfortunately, polytrauma is present in traffic every day. The traffic participants are victims of injuries or even worse, of fatalities. This means that special caution and serious attention by everyone is needed. The number of the injured and of fatalities in the Republic of Croatia is presented for the period of ten years. The graph shows that the number of fatalities has been slightly decreasing whereas the number of the injured is growing. 1


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0 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 godina killed

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Graph: The injured and the killed in traffic in Croatia from 1992 to 2002 Source: Bulletin on road traffic safety 2002, Ministry of the Interior, Republic of Croatia, Cabinet of the Minister. Dpt. for Analytics and Development (2).

Polytrauma represents the most serious type of injury in general. Thus, it also is the most expensive one. The treatment of traffic participants - victims of such type of injury is extremely expensive and time-consuming. It includes a complete range of modern medical treatments including emergency medical assistance, often extensive surgery, intensive postoperative treatment and long-lasting physical therapy. The treatment costs include also the temporarily reduced capacity for work that in a certain number of cases turns into permanent, that is, into invalidity. 2. DEFINITION OF TERMS RELATED TO POLYTRAUMA The definition of polytrauma is correct only if, apart from the local injury, it also describes the general reaction of the organism, and if at least two organic systems or anatomic regions are affected (head, thorax, mobility system) out of which one organic system or one directly life-threatening region. Systems and injuries: craniocerebral injuries with increased intracranial pressure, spinal injuries with resulting tetra/paraplegia, injuries of the thorax accompanied by acute respiratory insufficiency as consequence of pneumothorax, hematothorax or other injuries of intrathoracic organs, injuries of the stomach with ruptures of organs or haemorrhages, pelvis fractures and complicated long-bone fractures, serious avulsion of skin and extensive burns of the 2nd and 3rd degree.

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Today, literature often uses the terms major trauma (serious trauma) and multi trauma (multiple injuries of one organic system that may also result in death) (3). The term golden hour was introduced by Dr. R. Adams Cowley (Institute for Emergency Medical Services), who is regarded as the pioneer of modern trauma treatment. Dr. Cowley found out that the majority of polytrauma patients die of traumatic shock which is the consequence of poor or absent circulation and the resulting biochemical changes in the body. He believed that the majority of polytraumatized patients can be saved if the haemorrhage is stopped and sufficient blood pressure is reached within a period of one hour. The patients who suffer of polytrauma shock for more than one hour will most probably die, therefore, the surgical intervention within this period of time is the most important reason to improve the survival chances of the polytraumatized patients. This period of one hour which starts from the moment of injuring is called the golden hour (4). During the first five minutes of the golden hour, the persons in the vicinity (usually laypersons) should recognize the traumatic injury and call the emergency service (in Croatia the telephone numbers 92, 93, 94, in the future: 112). The first aid procedures for laypersons or BTLS (Basic Trauma Life Support) procedures should follow within the next five minutes. At the dispatch centre of the responsible services of the Emergency Medical Assistance (Hitne medicinske pomoći - HMP) the call should be forwarded immediately upon being received (1-2 min), and the arrival of HMP to the accident site should follow within 10 minutes. Staying at the accident site should not exceed 10 minutes. The transport to hospital as short as possible, and should take about 10-15 minutes. The last 20 – 30 minutes of the golden hour should see the start of hospital treatment by adequate diagnostic and surgical procedures (5). The term golden hour is often related to the platinum minutes. The term marks the time, that is, part of the golden hour that those who administer emergency medical assistance are allowed to stay at the accident site, that is, the time from arrival to until departure from the site of medical assistance. The recommended time is a maximum of 10 minutes. Within the 10 platinum minutes the rescuers should evaluate the accident site, that is, determine the possible existence of any danger for the rescuer or the injured person (e.g. danger from fire, explosion, collision by another vehicle etc.), the demand for special equipment necessary to treat the injured (e.g. in case of spinal injuries), additional vehicles (e.g. in massive accidents with a greater number of polytraumatized patients) and the mechanism that caused the injury (collision of motor vehicles, motorcycles, car-pedestrian collision, etc.). The very mechanism of causing the injury allows evaluation and prediction of certain injuries. The evaluation at the scene of accident should take about 30 seconds. In the medical part of the intervention the primary examination (1.5 – 2 min.) should be carried out, the injured should be pulled out of the vehicle, serious life-threatening injuries should be identified and correctly treated, reanimation procedures should be started, and functions stabilized, the extent of other injuries determined and if necessary these should be immobilized, adequate analgesic therapy should be provided and the injured should be prepared for final treatment (the remaining time within the platinum minutes). According to the algorithms of the American College of Surgeons Committee on Trauma (1997) the life support system of the traumatized patient, the Advanced Trauma Life Support (ATLS) should consist of: primary examination (ABCDE algorithm), reanimation procedure (related to the primary examination), secondary examination (from ″head to toe″, i.e. detailed anamnesis, physical status, diagnostics), 3



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final treatment (operating theatre or intensive treatment unit) (5).

3. PRIMARY EXAMINATION AND REANIMATION PROCEDURES IN TRAFFIC ACCIDENTS Airway - maintenance of respiratory path with the control of cervical spine The maintenance of the respiratory path and adequate oxygenation represent the basis in all reanimation procedures. At the beginning one tends to achieve this by the basic activities to sustain the respiratory path such as: head tilt, chin lift, triple grip (head tilt, chin lift, mouth opening) or just jaw lift without head tilt. In practice, every polytraumatized patient or serious trauma patient is assumed to suffer from spinal injury until this can be eliminated by appropriate diagnostic and clinical procedures. This means that the patient needs to be examined by an experienced clinician, and that adequate radiological tests should be performed. If the patient has suffered a serious head injury, if he is intoxicated, or suffers from disturbance of consciousness due to any reason, and if he is suffering from strong pain due to the injuries of some other part of the body, one may find it difficult to clinically determine with certainty whether the spine has been injured or not. After the initial maintenance of the respiratory path, whenever possible, the patient should be endotracheally intubated. The attempt at intubation should not exceed the period of 30 seconds (″intubation is not an end in itself″). Frequent mistake in pre-hospital conditions is the insistence on obligatory intubation and its excessive duration when the ventilation of the patient is forgotten. If there is any doubt regarding the position of the tube, it has to be taken out, the patient needs to be re-oxygenated and re-intubated.

Picture 1 - Endotracheal intubation Source: http://www.usuhs.mil/psl/endo.html

In case the cervical spine is injured, for the endotracheal intubation an assistant needs to be present (sometimes, even two). Generally, it may be said that every polytraumatized patient, who can take it well, should be intubated if the rescuer has the necessary skill.

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When none of these methods can be used to maintain the respiratory path, the more invasive methods are those that remain to be used: conicotomy and tracheotomy. These methods are rarely applied in Croatia although in case of conicotomy this is not justified, since the method is relatively simple and can be performed with minimal equipment (I.V. cannula of a greater diameter, scalpel, and tracheal cannula or a conicotomy set, surgical knife, tracheal cannula with guide, connector for connection with the self-inflating balloon or respirator, tapes to secure the cannula) (6).

Picture 2 – Emergency treatment of injured from a airplane accident Source: http://www.nyerrn.com/er/tpics.htm

Breathing – treatment of life-threatening conditions that make breathing difficult or impossible Out of the conditions that directly threaten life the obstruction of respiratory path by a foreign body, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, cardiac tamponade may be mentioned as the most endangering ones. In removing a foreign body from the respiratory system one should use the Magil's pliers and high-quality aspirators that should be found in the reanimation box. Artificial respiration is performed in several ways: mouth to mouth – the blown in volume should amount to 700-1000ml per inhalation and should be delivered within 1.5-2 seconds (not faster due to the risk of regurgitation of the undigested food from the stomach due to the opening of the gullet). The rescuer breathes in every 10-12 minutes; mouth to nose – more difficult to perform, applied only when mouth has been injured or cannot be opened; mouth to mask – avoiding direct contact with the patient; mouth to stoma – nose and mouth are closed, the skin around the stoma is cleaned and the inhaling is performed into the stoma; artificial respiration by means of self inflating balloon – allows controlled or assisted breathing, may be connected to a mask, tube, laryngeal mask, Combitube or tracheal cannula. The volume of the balloon for adults ranges

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from 1.1 l to 2.2 l, and for children from 0.2 l to 0.9 l. Only air can be blown in, or variable share of oxygen with air; transport fans- instruments driven by the air pressure in the oxygen bottle, serving for mechanical inhaling of oxygen or oxygen-air mixture. They are used in case of intubated patients.

Circulation – stopping the hemorrhage and treating hypovolemia The bleeding is stopped in one of the four basic ways: by exerting direct pressure on the wound, by exerting pressure on the supply blood vessel, by means of compressive bandage or by tying off the blood vessel. These methods of stopping the bleeding belong to the basic life support methods (Basic Life Support - BLS), and they should be routinely well-known and applied by the laypersons as well. When the bleeding has been stopped, the rescuer continues with the correction of hypovolemia caused in the majority of cases by massive external and internal hemorrhage. Hypovolemia is the most frequent cause of shock in polytrauma. The hypovolemic shock can be divided into four groups according to the amount of blood loss and the respective symptoms and signs. 1st group – loss of 750ml of blood or less than 15%, RR unchanged, mild tachycardia, normal capillary filling, breathing frequency normal, diuresis greater than 30ml/h, colour of skin of extremities normal, complexion normal, neurologically composed; 2nd group – loss 800-1500ml of blood or 15-30%, systolic pressure unchanged, diastolic pressure higher, tachycardia 100-120/min, capillary filling slowed down (>2s), breathing frequency tachypneic, diuresis 20-30ml/h, colour of the skin of the extremities paler, complexion paler, neurologically anxious or aggressive. 3rd group – loss of 1500-2000ml of blood or 30-40%, systolic pressure reduced, diastolic pressure reduced, tachycardia 120/min, pulse weakened, capillary filling slowed down (>2s), breathing frequency tachypneic greater than 20/min, diuresis 10-20ml/h, colour of the skin of extremities pale, complexion pale, neurologically anxious, aggressive or sleepy. 4th group – loss of blood greater than 2000ml or more than 40%, systolic pressure very low, diastolic pressure immeasurable, tachycardia more than 120/min, pulse extremely weak, capillary filling immeasurable, breathing frequency tachypneic greater than 20/min, diuresis 0-10ml/h, skin of extremities pale, cold and moist, complexion ashcoloured, neurologically sleepy, confused, somnolent, soporous or unconscious. The resuscitation objectives in case of a polytraumatized patient before the bleeding is stopped include: - systolic pressure 80 mmHg, mean arterial pressure 50-60 mm Hg - heart rate < 120/min - SpO2 > 96% - diuresis > 0.5 ml/kg/h - lactates < 1.6 mmol/L - deficit base > -5 - Hgb > 9.0 g/dL - normal neurological status.

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In case there are no signs of circulation (impalpable pulse on the carotid artery), it is necessary to start closed cardiac massage. Before starting the massage, the position for the cardiac massage needs to be precisely determined (lower third of the sternum). The frequency should be about 100/min, and the artificial breathing/massage ratio should be 2:15. If reanimation is performed by laypersons, a single person should massage the heart and perform artificial breathing. In case of qualified first aid providers, one person can perform artificial breathing and another can massage the heart. If the patient has been intubated, artificial breathing and cardiac massage are performed independently, but respecting the recommended frequencies (10-12 blow-ins and 100 pressures on the chest per minute). Disability – fast neurological evaluation Fast neurological evaluation is performed by examining the size, shape and reaction of the eye pupils to light. The level of consciousness may be checked by AVPU approach: A (alert) – alertness, V (vocal) – reaction to calls, P (painful) – reaction to painful stimulus, U (unresponsive) – lack of reaction. It is also necessary to determine the GCS. Exposure – adjust to the environmental conditions The patient should be completely undressed and then protected against hypothermia by warmed covers or blankets. Apart from the mentioned procedures, attention should be paid to the very pulling of the polytraumatized patient out of the vehicle (in case of spinal injury at least three rescuers or special instruments for pulling out of the patients with spinal injuries), carriage of the patient to the place of immobilisation and the immobilisation itself. During transport the patient should be placed in the transportation position specific for the individual injury (which can be difficult in case of a polytraumatized patient), and adequate analgesic therapy should be applied. The hospital must be informed about the arrival of such a patient in order to prepare the trauma team (if such exists) (7). 4. PROBLEMS IN TREATING POLYTRAUMATIZED PATIENTS Regarding the diversity of mechanisms that lead to body trauma, individual body constitution and condition, the problems encountered by the rescuers laypersons and qualified medical staff are numerous. Let us mention the major ones only: absence of or insufficient knowledge of the first aid (BTLS) by the laypersons and by the staff of those services that would be expected to be familiar with it (police, security services, fire-fighters...); lack of experience or poor training of the emergency medical service staff (ATLS); few members in the paramedics team (practically only the physician and the technician, the driver is not trained to perform more demanding medical procedures);

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conditions under which a certain accident happened (often ″unfriendly″ atmosphere of the people at the accident site before the paramedics arrive), weather and atmospheric conditions (cold, night, rain, snow …); difficult access to the patient (crashed vehicle or vehicle on an inaccessible terrain); inadequate calls to emergency services (incorrect address, incorrect data on type of injury, number of the injured, etc. even in case the call is made by the police); small space in the ambulance vehicle, access only from one side of the patient which makes almost any procedure during transport impossible (difficult or impossible measuring of blood pressure, opening of the vein path, intubation, etc.) poor heating or lack of air-conditioning, poor shock absorption; lack or non-application of algorithms in treatment procedures of such injuries; poor communication and lack of understanding between the pre-hospital and hospital physicians; different approaches, ″scoop and run ″ or ″stay and play″.

The mentioned problems encompass several resources. Those organisational ones should be the easiest to solve. Efficient models already exist and they should be accepted and applied in full, rather than adapted to the existing conditions. This is mainly the tendency in our regions, and rarely leads to any results. The problems of staff education are always present. The education should be permanent during the whole working life. The problem emphasised here is the resistance of people towards anything new, and to learning and studying in general. The last group of problems are of technical i.e. financial nature. The obsolete transport fleet of the ambulance service, lack of life-sustaining instruments are just some of them. One of the main problems is the lack of ideal vehicles in the ambulance fleet, the helicopters. 5. CONCLUSION Polytrauma represents a set of serious life-threatening injuries that result in the death of the patient unless active intensive approach in diagnostics and care are performed. These are the most serious types of injuries that occur as the result of traffic accidents and accidents in general. All the persons who participate in the treatment should attend permanent training. This includes also the laypersons, people in non-medical professions through various first aid courses starting in primary schools and continuing later as obligatory subjects in training the drivers at driving schools. The terms "golden hour" and "platinum minutes" are related to the term of polytrauma. The golden hour begins at the moment of trauma incidence. The majority of the polytraumatized patients can be saved if the bleeding is stopped and a satisfactory blood pressure achieved within one hour after the trauma. The platinum minutes mark the time, i.e. that part of the golden hour that the first aid providers may spend at the scene of the accident. The recommendation is a maximum of 10 minutes. The system should be established of keeping the traumatized patient alive. This should consist of the primary examination, reanimation procedures, secondary examination, and final treatment. The problems of treating such patients are numerous. Improved organization, education of the personnel, investments into medical instruments and suitable vehicles would reduce the 8



number of the encountered difficulties. Moreover, one should consider also the injured person as a biologically completely diverse entity and the possibilities of different responses both to polytrauma and to the treatment methods. It is precisely for this reason that the treatment of polytraumatized patients will always remain one of the most difficult tasks in the modern medicine. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.

Latorre F, Nolan J, Robertson C, Chamberlain D, Baskett P. Provider Manual 4th Edition. The European Resuscitation Council Guidelines 2000 for Adult ALS. Bilten o sigurnosti cestovnog prometa 2002, Ministarstvo unutarnjih poslova, Republika Hrvatska, Minister's Cabinet. Odjel za analitiku i razvoj. Grba-Bujević M. Prehospitalno zbrinjavanje politraume. Zbornik radova. III. hrvatski kongres hitne medicine s međunarodnim sudjelovanjem, November 2003. Nanković V, Cvjetko M. Politrauma. Proceedings. II stručni dani HMP, 1994. Barash M. Anaesthesiology, Lippincott 2000. Janevski Z. Trauma prsišta-dijagnostika i liječenje. Zbornik radova. III. hrvatski kongres hitne medicine s međunarodnim sudjelovanjem, November 2003. Allman K, Wilson I. Oxford Handbook of Anaesthesia. Oxford University Press 2003. Bačić A. et al. Anesteziologija, intenzivno liječenje i reanimatologija, August 2003.

INTERNET 1. 2.

http://www.usuhs.mil/psl/endo.html http://www.nyerrn.com/er/tpics.htm

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