History and development of trauma care in the United States

Damage control surgery in the abdomen: An approach for the management of severe injured patients

Damage control is well established as a potentially life-saving procedure in a few selected critically injured patients. In these patients the 'lethal triad' of hypothermia, acidosis, and coagulopathy is presented as a vicious cycle that often can not be interrupted and which marks the limit of the patient's ability to cope with the physiological consequences of injury. The principles of damage control have led to improved survival and to stopped bleeding until the physiologic derangement has been restored and the patient could undergo a prolong operation for definitive repair. Although morbidity is remaining high, it is acceptable if it comes in exchange for improved survival. There are five critical decision-making stages of damage control: I, patient selection and decision to perform damage control; II, operation and intraoperative reassessment of laparotomy; III, resuscitation in the intensive care unit; IV, definitive procedures after returning to the operating room; and V, abdominal wall reconstruction. The purpose of this article is to review the physiology of the components of the 'lethal triad', the indication and principles of abdominal damage control of trauma patients, the reoperation time, and the pathophysiology of abdominal compartment syndrome.

The Delaware Trauma System: Impact of Level III Trauma Centers

BACKGROUND

In 2000, Delaware instituted a trauma system that included establishing four Level III trauma centers in counties previously without trauma centers. The purpose of this study was to analyze whether implementation of this inclusive trauma system reduced the injury-related mortality rates in these counties.

METHODS

Using the state trauma registry, patients with trauma admitted to all acute care hospitals in Delaware from January 1, 1995 through December 31, 2004 were identified and categorized into two groups: preimplementation of an inclusive trauma system (1995-1999), and postimplementation (2000-2004). These groups were compared in aggregate and by individual counties for age, sex, mechanism of injury, Abbreviated Injury Score, injury-related mortality rate, mean Injury Severity Score (ISS), acute transfers out, and acute transfers in (Level I only). chi test and Mann-Whitney U test were used where indicated. Significance was determined to be p < or = 0.05.

RESULTS

After implementation, mortality rates significantly decreased (5.3%-2.8%) and rate of acute transfers out increased (14.7%-19.5%) in the counties served by the Level III centers. The ISS of patients in the Level I trauma center significantly increased (mean ISS = 10) when compared with the Level III trauma centers (mean ISS = 6), reflecting increased transfers of patients with severe injuries.

CONCLUSION

An inclusive state trauma system that included the establishment of Level III trauma centers in previously underserved counties led to a decrease in trauma-related mortality rates in these counties. In the county served by the Level I trauma center, mortality remained unchanged despite an increase in admissions and the injury severity of these admissions.

Trauma System Development in a Theater of War: Experiences From Operation Iraqi Freedom and Operation Enduring Freedom

BACKGROUND

Medical lessons learned from Vietnam and previous military conflicts led to the development of civilian trauma systems in the United States. Operation Iraqi Freedom represents the first protracted, large-scale, armed conflict since the advent of civilian trauma systems in which to evaluate a similar paradigm on the battlefield.

METHODS

Collaborative efforts between the joint military forces of the United States initiated development of a theater trauma system in May 2004. Formal implementation of the system occurred in November 2004, the collaborative effort of the three Surgeons General of the U.S. military, the United States Army Institute of Surgical Research, and the American College of Surgeons Committee on Trauma. One trauma surgeon (Trauma System Director) and a team of six trauma nurse coordinators were deployed to theater to evaluate trauma system component issues. Demographic, mechanistic, physiologic, diagnostic, therapeutic, and outcome data were gathered for 4,700 injured patients using the Joint Theater Trauma Registry. Interview and survey methods were utilized to evaluate logistic aspects of the system.

RESULTS

System implementation identified more than 30 systemic issues requiring policy development, research, education, evaluation of medical resource allocation, and alterations in clinical care. Among the issues were transfer of casualties from point of injury to the most appropriate level of care, trauma clinical practice guidelines, standard forms, prophylactic antibiotic regimens, morbidity/mortality reporting, on-line medical evacuation regulation, improved data capture for the trauma registry, and implementation of a performance improvement program.

CONCLUSIONS

The implementation of a theater trauma system demonstrated numerous opportunities to improve the outcome of soldiers wounded on the battlefield.

The impact of trauma centre accreditation on patient outcome

Trauma centre accreditation originated as a North American initiative in the 1970's with the aim of standardising and improving care for injured patients. This system of grading a hospital's ability to receive serious trauma has subsequently spread, most notably to Australasia. Many studies have focussed on determing whether this accreditation results in improved patient outcomes. We review the evidence to date, which suggests significant mortality reductions albeit from mainly Class III studies and reflect on the future sustainability of this initiative given mounting financial pressures.

Extremity injury in war: a brief history

The complex history of treating traumatic injury in Western warfare consistently included issues such as proximity to surgical care, the organization of medical systems, and the progressive development of technologies and procedures used to treat military service members who are injured in battle. Significant advances have been made in each of these areas, as evidenced in the changes in medical care in conflicts involving US forces. These advances include, among others, organized attempts to improve sanitation; panels of surgeons to assess optimal surgical approaches; the introduction of triage, wound débridement, and delayed wound closure; the development of chemotherapeutics and antibiotics; and increasingly more timely treatment. Perhaps the least recognized historical contribution to military medical care, however, is the compiled medical statistic, which informs bold research and response.

Optimizing the use of blood products in trauma care

Blood transfusion has been used to treat the injured since the US Civil War. Now, it saves the lives of tens of thousands of injured patients each year. However, not everyone who receives blood benefits, and some recipients are injured by the transfusion itself. Effective blood therapy in trauma management requires an integration of information from diverse sources, including data relating to trauma and blood use epidemiology, medical systems management, and clinical care. Issues of current clinical concern in highly developed trauma systems include how to manage massive transfusion events, how to limit blood use and so minimize exposure to transfusion risks, how to integrate new hemorrhage control modalities, and how to deal with blood shortages. Less developed trauma systems are primarily concerned with speeding transport to specialized facilities and assembling trauma center resources. This article reviews the factors that effect blood use in urgent trauma care.

Transport and centralization of acute coronary syndrome care

Primary percutaneous coronary intervention (PCI) is the optimal treatment for patients presenting with ST-elevation myocardial infarction (STEMI). But PCI facilities are not widely available, and the majority of patients who receive reperfusion therapy are treated with thrombolytic therapy. However, with significant improvements in the procedural success of PCI, there has been a concomitant reduction in the need for emergency bypass surgery and there is evidence to support primary PCI without on-site cardiac surgical facilities. Others have proposed immediate transfer to a suitable hospital for immediate primary PCI. An alternative treatment strategy is facilitated PCI, which might combine the early benefits of thrombolysis with the higher patency rates and superior clinical outcomes of primary PCI, although this remains unproven. Finally, rescue PCI remains a reasonable treatment option for patients with failed thrombolysis, but there is insufficient evidence to support this option as a preferred treatment strategy for patients with STEMI.

Trauma system development in North America

The concepts of organized trauma care, many of which originated in military medicine, have been proven effective in the civilian sector. A formal trauma system includes all phases of care from prehospital through rehabilitation. Although trauma centers assume the leadership role, in a truly inclusive system, all healthcare providers (prehospital providers, community hospitals, and trauma centers) have a defined role in providing care to patients with trauma. As a result, patients receive treatment at the appropriate institution, resources are allocated appropriately, and the clinical outcome is optimized. Such a system ideally is suited to the unique needs of the mass casualty scenario.

Perioperative management of foot and ankle trauma

This review covers the perioperative management of trauma to the foot and ankle. The goal when treating these injuries is to return the patient to a sensate, plantigrade, painless, and functioning foot and ankle. Depending on the nature of the trauma, realistic outcomes should be established for the patient, family, and surgeon. The importance of early recognition and treatment of foot and ankle injuries has been established and is paramount for the overall recovery of traumatized patient.

Trauma systems

Trauma is one of the major causes of death and disability in modern society, particularly for the young. Organized trauma systems reduce mortality and morbidity from trauma. An effective trauma system addresses all aspects of trauma care, from prevention to rehabilitation. Well-developed trauma systems are currently available only to a minority of the world's population. Trauma systems in developed nations have much potential for improvement.