New aspects in the emergency room management of critically injured patients: A multi-slice CT-oriented care algorithm Intern:盧彥廷
Introduction • “Golden hour”- Cowley • Surgical care during the first hour is of the utmost importance to increase the chances of survival. • Many injured patients could be saved if bleeding could be stopped and blood pressure stabilised during the first hour of shock. • Treatment of the seriously injured should always be considered a time-critical process.
Introduction • Lethality in polytrauma can be reduced by decreasing the time of treatment. • Time taken to complete diagnostic tests and initiate definitive therapy is frequently mentioned in the care of seriously injured patients.
Introduction • Goal ( of this algorithm) : Reduction of primary treatment time- (1)Elimination of redundant diagnostic studies (initial ultrasound and plain film radiography) (2) The use of multi-slice CT scanners • Time taken to identify life-threatening injuries
Methods • Tools: Multi-slice CT(16 slices) into trauma room • Victims(severity of the accident):High velocity road traffic accidents suspected of having serious injuries (Injury Severity Score [ISS]>15).
Methods • Provision of care : (1)Transfer patient to emergency vehicle (2)anaesthesia team and trauma surgeon In the trauma room: (1)a brief examination of the undressed patient is made by the trauma surgeon, (2)patient is put onto the gantry of the CT table, which is especially designed for this purpose • Further measurement • Arrange to surgery or other treatment • Transferred to ICU care
Methods • Obvious life-threatening A,B or C problem • Resuscitative fluid • A non-contrast CT of the head is done first, followed by a contrast medium supported spiral CT.
Results: • Duration: Jan-Dec 2004 • Patient: 139 patients(30male/109female) • Mean age:42.2 y/o • Mean ISS: 26.93
Results: Length of stay in the trauma room : (from the time of patient arrival at the clinic up to relocating thepatient to the operating room or ICU) reduced from 87 min (own data from 2000 and 2001) to 38 min (S.D. 19.1) on average.
Discussion • Diagnosis of a critically injured patient: (1)life-threatening injuries (2)relevant dysfunction threatening organ lesions (3)systemic distress • Structured and time-critical procedure • Multiple slice CT(ER-CT)
Discussion • Benefit of this algorthim: • (1)time sparing: only requiring 2-4 min (CT scan) 45-60min(total time) • (2)quality of CT image is excellent • (3)Elimination the need to move patient • (4)Parallel involvement of all department
Discussion • Radiation dose? (basic radiologic diagnosis vs. ER-CT ) (1)Many conventional X-rays can be avoided with rapid CT (2)Newer generation CT scanners can obtain high resolution images at much lower total radiation and contrast doses than previously required.
Discussion • Phase ZERO ( prior to arrival of the patient alerting the trauma room team) (1)preparation of CT and trauma room equipment (2)Availability of surgical capacity. • Phase ONE (1)receiving the patient in the emergency vehicle, (2)continuation of therapy initiated by the emergency doctor, (3)application of life-saving measures (if necessary), (4)brief physical examination (ABCDE-ATLS1).
Discussion • Phase TWO • (1)complete CT diagnostics with contrast medium, and should take approximately 4 min. • Phase THREE • (1)Combines ongoing anaesthetic care (start of invasive monitoring,resuscitation and stabilisation measures) • (2)Review of the diagnostic information by the radiologist and trauma surgeon • (3)planning of necessary therapeutic procedures.
Discussion • Phase FOUR • (1)surgery is initiated and if surgery is not required the patient is transferred to the ICU.
Conclusion • Rapid and complete initial CT diagnosis reduces the length of time in the trauma room markedly, and should significantlyimprove clinical outcomes. • A prerequisite for the employment of the concept introduced is the integration of a multi-slice CT into the trauma room, transforming it into a ‘‘one stop shop’’ for diagnosis and therapy.
ABBREVIATED INJURY SCALE(AIS) : • The Abbreviated Injury Scale (AIS) is an anatomical scoring system first introduced in 1969. • AIS is monitored by a scaling committee of the Association for the Advancement of Automotive Medicine. • Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe, and 6 a nonsurvivable injury. • It represents the 'threat to life' associated with an injury.
Injury severity score(ISS) • The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. • Each injury is assigned an AIS and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities (including Pelvis), External). • Only the highest AIS score in each body region is used.
Injury severity score(ISS) • The 3 most severely injured body regions have their score squared and added together to produce the ISS score. • The ISS score takes values from 0 to 75. • If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75. • The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity. • Its weaknesses are that any error in AIS scoring increases the ISS error.