Kees J. Ponsen

Assessment of a new trauma workflow concept implementing a sliding CT scanner in the trauma room: the effect on workup times.

INTRODUCTION We developed a new shockroom resuscitation setting that includes a moveable, multislice computed tomography (CT) scanner capable of scanning patients during the initial trauma resuscitation phase without (multiple) patient transfers that previously were necessary. This enables us to perform a complete diagnostic trauma workup, without leaving the shockroom. In this study, we assess the effect of the new Trauma Workflow Concept on the initial diagnostic workup times in the trauma room. MATERIALS Data of 100 consecutive trauma patients were collected prospectively (2005 cohort) and compared with 100 consecutive trauma patients seen in our previous trauma resuscitation setting (2003 cohort). For all patients, time management was evaluated using video registration and complemented with electronic imaging times. Patients with and without CT scanning were compared with the effect of CT scanning on complete workup time, defined as time from admission to the trauma room to time of completion of diagnostic workup. RESULTS Patient demographics, including appliance of CT imaging were similar. Complete diagnostic workup for patients who underwent CT imaging took an average of 79 minutes (standard deviation +/- 29 minutes) in the 2005 cohort and 105 minutes (standard deviation +/- 48 minutes) in the 2003 cohort. Complete diagnostic workup without CT imaging took 56 minutes and 53 minutes for the 2005 and 2003 cohorts, respectively. There was no difference found for nonscanned patients, whereas there was a significant difference between 2005 and 2003 for scanned patients (p < 0.01). CONCLUSION Our new trauma workflow concept with a sliding CT scanner was significantly faster for completing the initial diagnostic workup, especially when CT imaging was required.

Literature Review of the Role of Ultrasound, Computed Tomography, and Transcatheter Arterial Embolization for the Treatment of Traumatic Splenic Injuries

IntroductionThe spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series.DiagnosticsImproved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM.Angiography and EmbolizationThe optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries.

Trauma outcome analysis of a Jakarta University Hospital using the TRISS method: validation and limitation in comparison with the major trauma outcome study. Trauma and Injury Severity Score.

BACKGROUND In this prospective study, the TRISS methodology is used to compare trauma care at a University Hospital in Jakarta, Indonesia, with the standards reported in the Major Trauma Outcome Study (MTOS). METHODS Between February 24, 1999, and July 1, 1999, all consecutive patients with multiple and severe trauma were included in the study (n = 105). Survival analysis was completed for 97 (92%) patients. RESULTS The majority of patients were men (81%), and the average age was 28 years. Ninety-five patients (98%) sustained blunt trauma, with motor vehicle crashes being the most common (68%). The predicted mortality was 14% and the observed mortality was 29%. The Z and M statistics were 7.87 and 0.843, respectively. CONCLUSION We conclude that in developing countries both institution-bound factors and specific limitations in the TRISS methodology are responsible for the difference between predicted and observed mortality, indicating the need for a regional database.

Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs.

BackgroundIn recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization.AimThe purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney.ResultsThe management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the literature is whether a whole body MDCT survey should be implemented in the primary survey.ConclusionsThe progress in imaging techniques has contributed to NOM being currently the treatment of choice for hemodynamically stable patients. Angioembolization can be used as an adjunct to NOM and has increased the success rate to 95%. However, to date many controversies exist about the optimum patient selection for NOM, the proper role of angioembolization in NOM, the best technique and material to use in angioembolization, and the right follow-up strategy of patients sustaining blunt abdominal injury. Conducting a well-designed prospective clinical trial or a Delphi study would be preferable.

Impact of Splenic Artery Embolization on the Success Rate of Nonoperative Management for Blunt Splenic Injury

IntroductionNonoperative management (NOM) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury. Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States. This study was designed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center.MethodsAn analysis of a prospective trauma registry was performed for a 6-year period before (period 1) and after the introduction and implementation of splenic artery embolization (SAE) (period 2). Primary outcome was the failure rate of initial treatment.ResultsA total of 151 patients were reviewed. An increased use of SAE and a reduction of splenic operations during the second period was observed. Compared with period 1, the failure rate after observation in period 2 decreased from 25% to 10%. The failure rate after SAE in period 2 was 18%. The splenic salvage rate (SSR) after observation increased from 79% in the first period to 100% in the second period. During the second period, all patients with failure after observation were successfully treated with SAE. The SSR after SAE in periods 1 and 2 was respectively 100% and 86%.ConclusionsSAE of patients with blunt splenic injuries is associated with a reduction in splenic operations. The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers. Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United States.

Functional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomized trial

BackgroundElbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow.Methods/DesignThe design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness.DiscussionThe successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations.Trial RegistrationThe trial is registered at the Netherlands Trial Register (NTR2025).

An evaluation of a Shockroom located CT scanner: a randomized study of early assessment by CT scanning in trauma patients in the bi-located trauma center North-West Netherlands (REACT trial)

BackgroundTrauma is a major source of morbidity and mortality, especially in people below the age of 50 years. For the evaluation of trauma patients CT scanning has gained wide acceptance in and provides detailed information on location and severity of injuries. However, CT scanning is frequently time consuming due to logistical (location of CT scanner elsewhere in the hospital) and technical issues. An innovative and unique infrastructural change has been made in the AMC in which the CT scanner is transported to the patient instead of the patient to the CT scanner. As a consequence, early shockroom CT scanning provides an all-inclusive multifocal diagnostic modality that can detect (potentially life-threatening) injuries in an earlier stage, so that therapy can be directed based on these findings.Methods/designThe REACT-trial is a prospective, randomized trial, comparing two Dutch level-1 trauma centers, respectively the VUmc and AMC, with the only difference being the location of the CT scanner (respectively in the Radiology Department and in the shockroom). All trauma patients that are transported to the AMC or VUmc shockroom according to the current prehospital triage system are included. Patients younger than 16 years of age and patients who die during transport are excluded. Randomization will be performed prehospitally.Study parameters are the number of days outside the hospital during the first year following the trauma (primary outcome), general health at 6 and 12 months post trauma, mortality and morbidity, and various time intervals during initial evaluation. In addition a cost-effectiveness analysis of this shockroom concept will be performed.Regarding primary outcome it is estimated that the common standard deviation of days spent outside of the hospital during the first year following trauma is a total of 12 days. To detect an overall difference of 2 days within the first year between the two strategies, 562 patients per group are needed. (alpha 0.95 and beta 0.80).DiscussionThe REACT-trial will provide evidence on the effects of a strategy involving early shockroom CT scanning compared with a standard diagnostic imaging strategy in trauma patients on both patient outcome and operations research.Trial registrationISRCTN55332315

Failure rate and complications of angiography and embolization for abdominal and pelvic trauma.

BACKGROUND Angiography and embolization have become the treatment of choice after abdominal trauma or pelvic injury in hemodynamically stable patients with a suspicion of internal hemorrhage (contrast extravasation, pseudo-aneurysm, or a vessel cutoff diagnosed on computed tomographic scanning). Some studies, however, report a high incidence of rebleeding (failure) or complications. The aim of this study was to evaluate the failure rate and the complications in trauma patients undergoing such procedures. METHODS All consecutive patients (n = 97) admitted to our Level I trauma center between January 2002 and December 2008 in whom angiography with or without embolization was performed were analyzed. Complications were classified as organ specific, puncture site related, and systemic. Additional interventions, required to treat complications, were documented. RESULTS The overall failure rate was 12%. Overall, 48 complications were documented in 28 patients. Organ-specific complications were observed in 18 patients (19%), especially abscess formation and infarction of the liver. Puncture site–related complications occurred in three patients. The incidence of contrast-induced nephropathy was 24%. Three patients developed renal failure. Nine of the 15 patients with rebleeding could be managed with reembolization or operative packing, resulting in an organ salvage rate of 93%. Most (83%) of the organ-specific complications and all of the puncture site–related complications could be managed conservatively or with percutaneous treatment. CONCLUSION In the present study, the failure rate and incidence of organ-specific and procedure-related complications were low and often could be managed with nonoperative minimally invasive interventions. Trauma patients undergoing angiography have a high chance (24%) of developing contrast-induced nephropathy and should therefore receive optimal prophylactic measures to avoid this complication. LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic/epidemiologic study, level III.

The Association of Mobile Medical Team Involvement on On-scene Times and Mortality in Trauma Patients

OBJECTIVES Mobile medical teams (MMTs) provide specialized care on-scene with the purpose to improve outcome. However, this additional care could prolong the on-scene time (OST), which is related to mortality. The purpose of this study was to assess the effects of MMT involvement on the mortality rate and on the OST, in a Dutch consecutive cohort of Level I trauma patients. METHODS All patients who required presentation in the trauma resuscitation room in an urban Level I trauma center were included in this prospective study during the period of November 2005 till November 2007. For data collection, we used both pre- and in-hospital registration systems. Outcome measures were 30-day mortality and OST. RESULTS In total, 1,054 patients were analyzed. In 172 (16%) patients, the MMT was involved. Mortality was significantly higher in the MMT group compared with patients treated without MMT involvement; 9.9% versus 2.7%, respectively (p < 0.001). Significantly higher Injury Severity Scores, intervention rates, and a significantly lower Triage Revised Trauma Score were found in patients treated by MMT. After adjustment for patient and injury characteristics, no association could be found between MMT involvement and higher mortality (95% CI, 0.581-3.979; p = 0.394). In patients with severe traumatic brain injury (GCS score ≤ 8) in whom a MMT was involved, the mortality was 25.5%, compared with 32.7% in those without MMT involvement (p = 0.442). The mean OST was prolonged (2.7 minutes) when MMT was involved (26.1 vs. 23.4 minutes; p = 0.003). CONCLUSIONS In this study, OSTs were long compared with PHTLS recommendations. MMT involvement slightly prolonged the OST. Trauma patients with MMT involvement had a high mortality, but after correction for patient and injury characteristics, the mortality rate did not significantly differ from patients without MMT involvement.

Improved outcomes in the non-operative management of liver injuries

OBJECTIVES Non-operative management has become the treatment of choice in the majority of liver injuries. The aim of this study was to assess the changes in primary treatment and outcomes in a single Dutch Level 1 trauma centre with wide experience in angio-embolisation (AE). METHODS The prospective trauma registry was retrospectively analysed for 7-year periods before (Period 1) and after (Period 2) the introduction of AE. The primary outcome was the failure rate of primary treatment defined as liver injury-related death or re-bleeding requiring radiologic or operative (re)interventions. Secondary outcomes were liver injury-related intra-abdominal complications. RESULTS Despite an increase in high-grade liver injuries, the incidence of primary non-operative management more than doubled over the two periods, from 33% (20 of 61 cases) in Period 1 to 72% (84 of 116 cases) in Period 2 (P < 0.001). The failure rate of primary treatment in Period 1 was 18% (11/61), compared with 11% (13/116) in Period 2 (P= 0.21). Complication rates were 23% (14/61) and 16% (18/116) in Periods 1 and 2, respectively (P= 0.22). Liver-related mortality rates were 10% (6/61) and 3% (4/116) in Periods 1 and 2, respectively (P= 0.095). The increase in the frequency of non-operative management was even higher in high-grade injuries, in which outcomes were improved. In high-grade injuries in Periods 1 and 2, failure rates decreased from 45% (9/20) to 20% (11/55) (P= 0.041), liver-related mortality decreased from 30% (6/20) to 7% (4/55) (P= 0.019) and complication rates fell from 60% (12/20) to 27% (15/55) (P= 0.014). Liver infarction or necrosis and abscess formation seemed to occur more frequently with AE. CONCLUSIONS Overall, liver-related mortality, treatment failure and complication rates remained constant despite an increase in non-operative management. However, in high-grade injuries outcomes improved after the introduction of AE.