Federal Scientific Clinical Center of Miners’ Health Protection, 

Leninsk-Kuznetsky, Russia

 

Trauma is a leading cause of mortality in individuals younger 40, and it creates significant social economic influence on society. This situation does not have significant tendencies towards decreasing. According to the data from WHO, 5.8 million people die from severe injuries each year, and the number of disabled persons exceeds this number more than three times [23, 27].

Treatment for such patients presents significant difficulties both in organization (different medical assistance for victims: at the accident site, during transport, diagnostics and treatment in the level I-II trauma centers, rehabilitation et al.) and necessity for rapid and adequate choice of medical diagnostic tactics in patients with multiple injuries, with each individual injury or combinations of injuries resulting in critical state and life threat [1, 2, 3, 4, 5]. It requires coordinated efforts from multiple specialists who simultaneously perform estimation, diagnostics and surgical treatment. Solution of ambitious and specific organizational, financial, medicodiagnostic and scientific research targets is impossible without timely and comprehensive information which can be realized with only the appropriate registry [6].

The increased attention to the problems of medical assistance for polytrauma favored development of the working groups almost in all countries of the world, which implement the modern achievements of continuous research work at the levels of national regulatory bodies in healthcare [12, 16, 25]. During Xth congress of traumatologists and orthopedists of Russia the problem of polytrauma was discussed and the decision was made that increasing efficiency in medical assistance, decreasing mortality, disability, reducing duration of treatment, social adaptation and increasing justice in financial provision for medical aid for patients with polytrauma it is necessary:

1)      to create the research group (association, academy or society) for issues of polytrauma;

2)      creation of uniform terminology and classification of polytrauma;

3)      development of the uniform registry for polytrauma with consideration of the international experience;

4)      adaptation of the international classification of diseases to estimation of financing, and treatment of patients with polytrauma to the system of obligatory medical insurance in Russian Federation.          

With  this publication we offer practical direction to solving the issues about terminology and registry of polytrauma with consideration of the international (the literature review for the interval of 60 years with searching available definitions of polytrauma, criterions for injury severity, severity of state, diagnostics, treatment, epidemiology, statistics, without limitations in terms of languages of publications) and our experience (treatment for 2,112 patients with polytrauma within 15 years).

As we know, the definition “polytrauma” was firstly introduced 50 years ago. The descriptive definitions were used, for example, at least two severe injuries (the head, chest or abdominal cavity) one of which is an injury to a limb [24], two or more significant injuries, one of which is potentially life threatening [11]. Isolated states (life threatening) were reviewed separately; the term barytrauma was made [19].

At the present time it is acknowledged that estimation of severity of trauma should consider severity of an injury and state of the patient. Severity of an injury is sufficiently stable value allowing estimation of the morphologic component of affection of the patient’s body. Severity of state is the value testifying the general response of the body to an injury in view of functional changes in vital systems [6]. This value is unstable and is characterized with fast changes during the process of effective treatment or at the background of complications of traumatic disease. Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) are among the simplest tools for effective estimation of severity of state in patients.           

Significance of reliable estimation of severity of state in patients with polytrauma can be multivariable. It can make the basis for scientific, social economic, quality control and educational tasks. Probably, for solving the specific tasks it is necessary to modify the existing recommendations. There are more than 50 scales for such purpose. Nevertheless, Injury Severity Score (ISS) [10] is the basis for most estimations of state in patients with polytrauma. It is recommended by the Committee of Trauma of American College of Surgeons and other trauma societies of different countries. Large-scale researches of outcomes of major injuries confirmed reliability of ISS and allowed developing the specific objective parameters for assessing polytrauma such as hemodynamics, metabolism and coagulation potential [14]. The estimation system based on the physiologic changes included description of the lethal triad for differentiating between stable, non-stable and terminal states. It resulted in detalization of ideas about polytrauma and appearance of additional terminology for description of subgroups of patients, for example, “border-line’ patients with polytrauma [20, 21].           

Most popular modern definitions are still based on the main concept: combination of injuries resulting in a life-threatening state [1, 7, 8, 13, 14]. Unfortunately, the approach is characterized with absence of objective quantitative values and presents only evidence of 4th level.  

During the last years the European Society of Traumatologists had multiple discussions of these issues, tried to improve the existing terminology of polytrauma and define specific parameters with potential for maximally unlimited usage for definition of this nosology [13]. The results were presented by the experts at the 13th International Conference Dedicated to Polytrauma (Aachen, Germany) on November, 30 – December, 1, 2012.

Inside the researched population the following distribution of mortality level in association with frequency of injured body regions was found: 11.8 % – at least two injuries in 2 regions, AIS ≥ 3; 28.3 % – in 3 regions; 37.4 % – in 4 regions; 58.0 % – in 5 regions. This conclusion was made after correlation of the data by the international experts and our results after the retrospective analysis of 2,112 case histories. But these results did not allow putting some clarity into the terminological discordance of the term polytrauma. There was an open question about severity of state. The multicentral study by Pape Hans-Christoph, Lefering Rolf, Butcher Nerida et al. [22] gives more concise review of this question (table 1).

Table 1
Demographic data of the patients who entered the study with Injury Severity Score ≥ 16

The data in the table 1 shows that 5 main physiologic parameters influence on increasing mortality and risk of mortality. The conducted univariate analysis of mortality found the cut-off value for 5 parameters: age ≥ 70 – 38.0 %; acidosis – 38.8 %; coagulopathy – 48.3 %; Glasgow Coma Scale ≤ 8 – 38.3 %; hypotension – 35.3 %.         

The addition of the physiologic variables to the main part of estimating system for trauma (table 2) results in consistent increase in predicted mortality. These findings correspond to earlier studies [21].

Table 2

Predominance of five pathologic states (additional parameters associating with increasing rate of lethal outcomes) (according to Pape H-C, Lefering R, Butcher N. et al., 2014

 

Moreover, for ISS > 15 the mortality of 18.7 % was noted regardless of 5 additional parameters. After addition of any additional parameter the reliable data block predicted increase in possible lethal outcome to 35-38 % (the clinical relevant value).    

 This type of research did not include parameters allowing estimation of activity of systemic inflammatory response to an injury. However, as the experts note, none of inflammatory indicators (IL-6 or other) for estimating the degree of inflammatory responses was available in the large European data bases. It was unlikely that any marker among the above-mentioned ones was available for the universal usage in the immediate future. The experts made a decision not to review these indicators at the present time, the rather that the parameters which were used in this study successfully predicted possible results.       

Therefore, the following parameters were accepted for objectification of polytrauma definition:  

-          ISS > 15,

-          AIS≥ 3 at least in 2 regions of the body,

-          At least 1 of 5 standardized pathologic states: hypotension (systolic pressure ≤ 90 mm Hg), changes in consciousness level (GCS ≤ 8), acidosis (base deficit ≤ -6.0), coagulopathy (partial thromboplastin time ≥ 40 sec. or international normalized ratio ≥ 1.4) and the age > 70.

Without doubt, none of the parameters is the discovery. The Russian and international literature includes multiple publications with discussions regarding these issues at various times, but it did not result in the consensus in relation to the term polytrauma. We believe that in relation to the basis for the term polytrauma it is appropriate to accept the offer from the international experts at the 13th International Conference Dedicated to Polytrauma (Aachen, Germany) with Berlin amendments; moreover, for the past 10 years the greatest proportion of the Russian publications uses ISS > 16 as characterization for examined groups of patients.

Having at least the main instrument (what is polytrauma) one can continue detailed discussion of the following practical construction of polytrauma registries.      

Registries. What’s the business?

In the modern world the registries appeared far long time ago. The national centers were developed in the European countries: in Germany in 1993, little later in Sweden, Belgium, the Netherlands, England, USA, Canada, Japan et al. In Russian Federation the attempts relating to development of registries are in view of guidelines of different levels, algorithms for different situations, but they have recommendatory characteristics; it is unknown how they are used in practice, and how efficient; no feedback. Absence of the modern information results in absence of the uniform “language” during discussions of polytrauma issues.          

Usually registries of polytrauma are nationwide and designed for increasing warranted availability and provision of high quality of medical assistance for patients with severe injuries. Two main tasks should be solved: warranty of quality of medical assistance in individual medical facilities and implementation of developed high tech, evidence-based methods for organization, diagnostics and treatment.   

The main tasks:

1.      Controlling the whole chain of medical process for the purpose of identification of the weak and strong aspects from perspective of attending physicians and patients in individual medical facilities.

2.      Formation of measures for solving the issues of rendering assistance for patients with severe injuries at different stages.

3.      Definition of the main criterions for estimating efficiency, quality of treatment and rehabilitation. 

4.      Provision of the basis for clinical and special studies to get timely answers to the most actual questions of epidemiology of severe trauma, diagnostics, treatment, economics, quality of life, prognosis, estimation, recommendations, estimation of equipment status in medical facilities and qualification of medical staff. 

 

There are many examples of necessity for solving these tasks.

Who and when makes diagnosis polytrauma? At prehospital stage? In hospital? Who is an attending physician among all specialists? At which stages? What are the main and obligatory criterions for quality of diagnostics and treatment and which are secondary? How necessary financing is calculated?   

It is certainly that adherence to the recommendations accepted by the concilium of the specialists can lead to significant decrease in mortality and disease incidence. However one cannot accept the registries of polytrauma as something inviolable; they should be tested in practice, and the results are discussed by the working group or are corrected if it is necessary.     

The efforts for increasing efficiency of the patient in medical facilities resulted in development and implementation of the range of testing operations in medicine. One of the most famous and successful things is the control list of measures (CLM) for provision of safety of surgical intervention implemented by WHO in 2010. The analysis of the data after its implementation showed decreasing mortality at the stages of intensive care from 1.5 % to 0.8 % and decreasing level of serious complications from 11 % to 7 % [15, 17].

The initial CLM included 18 items and was tested in 12 cities of the world [27] (table 3).

Table 3

CLM (check list of the measures) of injury treatment according to WHO (modified and adapted in St. Michael Hospital)

      

Despite of detailed discussion by the experts, the employees of the Hospital of Saint Michael (Canada) met with some difficulties during implementation [18] (table 4).

Table 4
The main obstacles to introduction of CLM for injury?

After completion of the experimental period (5-6 months) the version of the control list was modified on the basis of the information from the clients of the clinic. The use of this version became obligatory. The adapted version was positively accepted, and at the present time it is actively used in almost all department of traumatology resuscitation.    

This study has some disadvantages. The presence of observers which worked independently from the trauma team may result in overvaluation of degree of correspondence to the control list (Hawthorne effect). Moreover, the results of the clinical trial are not available yet. Therefore, we have not any measurements of the results to make certain of benefit. The study was conducted in the single center. Therefore, the observed problems may not extend into other trauma centers.     

The WHO control list for trauma was kindly accepted as the secondary measure for treating difficult trauma patients in most clinics of Canada and European society. It has the potential for improving quality of treatment and safety for the patient.     

In the end one should note that at the present time the international expert group developed the main definition of the term polytrauma. The criterions for objectification have been found. They are simple and available for all medical facilities treating severely injured patients. We are absolutely agreed with these offers and recommend them as the basis for implementation into the scientific practical activity of the Russian medicine.       

With these criterions the expert group (associations, academies or societies) for polytrauma problems can develop and implement the main national registries of polytrauma (for example, the recommendations from WHO). It is undoubtedly that for successful integration of the registries one should consider the concurrent problems of accommodation, acknowledgment, obligatory availability/transparency, possibilities for feedback in performers and developers etc. Such work requires active participation of employees in the trauma centers of all levels. For better understanding the potential positive moments from the Russian national registry of polytrauma the new studies and discussions are necessary. Realization of our desires is possible only with participation of the Ministry of Health of Russian Federation.