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
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)
Centrale Operativa 118 Milano DEA EAS, Niguarda
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
AREA DI EMERGENZA 118 Coordinatore infermieristico Amb. OBI shock room Eli Area Triage TAC 1 angio ecografia TAC 2 Radiologia Codici bianchi
Shock Room
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
Pit-Stop Team Vs Emergency Team Mxxxxx Mxxxxx
Primary and secondary evaluatio (ATLS protocol) Resuscitation E FAST Chest and pelvis x ray
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
MR, 22 yrs, SBP 60/.., in ER 5 RBC, 3000 fluids DAMAGE CONTROL TORSO DAMAGE CONTROL TORSO INJURIES
Packing: mechanical bleeding compression
D.R, m. 27 ys Damage Control Pelvic Girdle
Sala di Emergenza Pli Pelvic Binder
Notification: multiple stab wounds of torso SBP 70 Notification: multiple stab wounds of torso SBP 70 mmhg, decreasing
E FAST: free fluid in left pleural space and in peritoneal cavity
Airwaysandhypotensive and resuscitation
OR left chest tube: massive hemothorax, laparotomy: massivehemoperitoneum hemoperitoneum. SBP50mmHg
Strategy: abdominal packing + resuscitative thoracotomy
Brain bleeding+spleen injury: splenectomy+icp
Splenectomy Frontal lobectomy
ICP 6
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
Definitive repair
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
STABLE PATIENT PROTOCOL Stable or stabilized Further evaluation Contrastenhanced CTscan If pelvis or parenchymal active bleeding Angiography and Angiography and embolization
LIVER ARTERIAL BLUSHING arterial phase VM, m, 36 ys OIS V
Arterial blushing
Selective embolization
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 14211 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
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
MORTALITY: 172 (12.83%) 2002(3mts) 2003 2004 2005 2006 total Survived 56 262 257 219 369 1162 Not survived 18 52 26 36 39 172 Survived % 0.76 0.83 0.91 0.86 0.90 0.87 Not Survived % 0.24 0.17 0.09 0.14 0.10 0.13
OVERALL MORTALITY: 172 (12.83%) 2002/2003 2004 2005 2006 total Early deaths (ER, OR) 24 8 11 16 59 % 34.29 % 30.77 % 29.73 % 41.03 % 34.30 % Deaths within 24 h 22 7 10 4 43 % 31.43 % 26.92 % 27.03 % 10.26 % 25.00 % Deaths within 24 and 72 h 11 3 2 1 17 % 15.71 % 11.54 % 5.41 % 2.56 % 9.88 % Late deaths 13 6 8 9 36 % 18.57 % 23.08 % 21.62 % 23.08 % 20.93 % Insufficient data 0 2 6 9 17 % 0.00 % 7.89 % 16.22 % 23.08 % 9.88 % Total 70 26 37 39 172 % 40.70 % 15.12 % 21.51 % 22.67 % 100.00 %
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
TRAUMA TEAM.Grazie