E dopo il ricovero il Trauma Team. Perugia, 23 maggio 2009

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1 E dopo il ricovero il Trauma Team Stefania Cimbanassi, SSD Trauma Team, Niguarda, Milano. Stefania Cimbanassi, SSD Trauma Team, Niguarda, Milano. Perugia, 23 maggio 2009

2 TRAUMA MAGGIORE Definizione evento traumatico che interessa uno o più distretti corporei con lesioni che determinano almeno in una sede un rischio immediato o potenziale per la sopravvivenza necessità di rispettare una sequenza di prio- rità di trattamento dalla scena all Ospedale secondo un approccio organizzato coinvolgendo diversi specialisti (ISS > 15)

3 Centrale Operativa 118 Milano DEA EAS, Niguarda

4 ORGANIZZAZIONE: ASSISTENZA PRE-OSPEDALIERA TRIAGE TRAUMA MAGGIORE, ALS SEGNI VITALI ALTERATI ANATOMIA DI LESIONE MECCANISMO ALTA ENERGIA Identificazione priorita. Supporto vitale avanzato (AB and GO) Attivazione trauma team TRIAGE TRAUMA MINORE, BLS Identificazione priorita.supporto di base Visita MURG presso PS

5 AREA DI EMERGENZA 118 Coordinatore infermieristico Amb. OBI shock room Eli Area Triage TAC 1 angio ecografia TAC 2 Radiologia Codici bianchi

6 Shock Room

7 In House 24 hrs Trauma Team (SSD) 2S Oth di -2 Surgeons -Orthopedic surgeon ER -Anesthesiologist -Neurosurgeon -2 nurses -Nurse assistant -Radiology Technician -Radiologist i On Call Thoracic surgeon Interventional radiologist Plastic surgeon Cardiac surgeon Maxillo facial surgeon Pediatric surgeon Vascular larsurgeon Transplantation surgeon Gynecologist Oculist, Otolaringologyst

8 Pit-Stop Team Vs Emergency Team Mxxxxx Mxxxxx

9 Primary and secondary evaluatio (ATLS protocol) Resuscitation E FAST Chest and pelvis x ray

10 Emergency room AP CXR AP PELVIS ATLS resuscitation protocol: ABCDE O.R. Sutures, Chest drains, pelvic binder, c clamp, E FAST unstable Stable or stabilized Further evaluation

11 MR, 22 yrs, SBP 60/.., in ER 5 RBC, 3000 fluids DAMAGE CONTROL TORSO DAMAGE CONTROL TORSO INJURIES

12 Packing: mechanical bleeding compression

13 D.R, m. 27 ys Damage Control Pelvic Girdle

14 Sala di Emergenza Pli Pelvic Binder

16 Notification: multiple stab wounds of torso SBP 70 Notification: multiple stab wounds of torso SBP 70 mmhg, decreasing

18 E FAST: free fluid in left pleural space and in peritoneal cavity

19 Airwaysandhypotensive and resuscitation

20 OR left chest tube: massive hemothorax, laparotomy: massivehemoperitoneum hemoperitoneum. SBP50mmHg

21 Strategy: abdominal packing + resuscitative thoracotomy

22 Brain bleeding+spleen injury: splenectomy+icp

23 Splenectomy Frontal lobectomy

24 ICP 6

25 Within the first 24 hours fluids must be provided until acidosis is under control: Lactate < 2 mmol/l or Base deficit < 2 Targets for blood tests: Hemoglobin >7 <10 g/dl INR < 1.5, PT < 16 seconds, APTT < 30 sec DCS 2: ICU care General Targets: Temperature > 36 Fibrinogen > 1g/L Prevent compartimental 9 Platelets l t > 50 x 10 /L syndrome DCS 3: definitive repair

26 Definitive repair

27 Emergency room AP CXR AP PELVIS ATLS resuscitation protocol: ABCDE O.R. Sutures, Chest drains, pelvic binder, c clamp, E FAST unstable Stable or stabilized Further evaluation

28 STABLE PATIENT PROTOCOL Stable or stabilized Further evaluation Contrastenhanced CTscan If pelvis or parenchymal active bleeding Angiography and Angiography and embolization

29 LIVER ARTERIAL BLUSHING arterial phase VM, m, 36 ys OIS V

30 Arterial blushing

31 Selective embolization

32 COMPOSITION OF TRAUMA TEAM 24 hours on call: GENERAL SURGEONS (8+4 RESIDENTS) ORTHOPEDICS (7) NEUROSURGEON (6) RADIOLOGISTS (7) ANESTHESIOLOGISTS (9) DUTIES: EMERGENCY CARE OF MAJOR TRAUMA (461 in 2008) AND OF NON TRAUMA SURGICAL EMERGENCIES (938 general surgical procedures, 218 with other specialists, and consulences in 2008) CONTINUITY OF CARE: daily visit in Intensive care (general, neuro), Intermediate care, Wards (ortho, surgery, neurosurg.) COMPILATION OF TRAUMA REGISTRY AND PARTECIPATION TO WEEKLY TRAUMA AUDIT

33 VANTAGGI: MODELLO DIPARTIMENTALE DEL TRAUMA TEAM a. Costi inferiori b. Flessibilita del Personale c. Mantenimento skill nella rispettiva attivita elettiva SVANTAGGI: d. Acquisizione di mentalita e capacita interdisciplinari a. Mancanza di letti esclusivamente dedicati b. Maggiore difficolta ad assicurare la continuita terapeutica c. Costante necessita di confrontarsi con altre responsabilita apicali

34 MORTALITY: 172 (12.83%) 2002(3mts) total Survived Not survived Survived % Not Survived %

35 OVERALL MORTALITY: 172 (12.83%) 2002/ total Early deaths (ER, OR) % % % % % % Deaths within 24 h % % % % % % Deaths within 24 and 72 h % % % 5.41 % 2.56 % 9.88 % Late deaths % % % % % % Insufficient data % 0.00 % 7.89 % % % 9.88 % Total % % % % % %

36 Conclusions.. 1. polytrauma patient needs to be treated by a multidisciplinary team with an integrated approach 2. The intra hospital inclusive model of trauma team allows different specialists to work togheter following predefined protocols, while maintaining skills in elective jobs 3. Trauma team is a functional and unexpensive model of in hospital ltrauma and emergency surgical service 4. Centralization of multi trauma patients in few df definitive care facilities and a limited number of doctors in rotation allows a progressive increase of team expertise

37 TRAUMA TEAM.Grazie

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