THE DEPENDENCE OF THE INCIDENCE OF INFECTIOUS COMPLICATIONS FROM THE TIME OF MEDICAL CARE FOR THORACOABDOMINAL INJURIES
City Clinical Hospital No.9,
Izhevsk State Medical Academy, Izhevsk, Russia
Urbanization and war conflicts, rapid industrial development and increasing amount of technogenic disasters promote the increasing rates of injuries [1]. Approximately 1/5 of all associated injuries, which amount is increasing continuously, demonstrate the thoracoabdominal pattern [2-5]. Such injuries are characterized by significant severity of patients’ condition, high amount of complications and substantial mortality. Knowledge of time intervals, when patients with associated (including thoracolumbar) injuries usually address to medical facilities, allows timely and most efficiently arranging the medical and preventive measures [6, 7].
The objective of the study – to identify the relationship between the incidence of infectious complications and time of treatment for patients with thoracoabdominal injuries at the prehospital stage and in the emergency department.
MATERIALS AND METHODS
The retrospective analysis included 233 medical cases of the inhospital patients with associated thoracic and abdominal injuries and diaphragm injury. The patients were treated in the specialized hospital of Izhevsk (City Clinical Hospital No.9, the Udmurtia First Republican Hospital) during the period from January 1, 2009 to March 31, 2016. The exclusion criteria were the age < 18, presence of severe traumatic brain and skeletal injuries, pregnancy, concurrent pathology in the decompensation stage. The mean age was 35.7 ± 9.9. ISS was 21.2 ± 7.0. The condition severity was estimated with RAPS. The probability of survival was 90.5 ± 7.0 %. The infectious complications, which developed after 48 hours in the hospital, were identified in 66 (28.3 %) patients. Besides the medical cards of the inhospital patients, the data from the accompanying emergency sheets (time of call to an emergency aid station, time of transfer to a specialized hospital) were used.
The time intervals of realization of medical care for the patients with thoracoabdominal injuries from time of injury to time of surgical treatment (time of referral to medical care, duration of prehospital care and transportation, duration of medical care in the admission unit) and influence of this time on development of infectious complications were analyzed. The prehospital medical care included infusion therapy, analgesia, application of sterile dressing. The maneuver brigades of emergency medical care transferred the patients to the hospital. The diagnostic and anti-shock measures (infusion therapy, analgesia) were realized in the admission unit.
The statistical analysis was conducted with Microsoft Office Excel 2007 and the automatic calculators from www.medcalc.org. The mean values, the error in the mean, χ2 test, the correlation coefficient, Kolmogorov-Smirnov's test and odds ratio were calculated. All basic bioethical principles were adhered during the study.
RESULTS AND DISCUSSION
The thoracoabdominal injury is 3.5-7.2 % of the total amount in patients with mechanic injuries and up to 21.5 % from the amount of patients with the associated injury. The wounds as the most common cause of thoracoabdominal injuries were identified in 217 (93 %) patients, the closed injuries were in only 16 (7 %) patients. A knife was a main cause of the wounds – 181 (83.2 %) patients.
There were 192 (82.4 %) men and 41 (17.6 %) women. The women received their thoracoabdominal injuries mainly in daytime and in the early evening hours (12 (54.5 %) patients), the men – at night time (74 (63.8 %) patients) (χ2 = 2.6678; ð = 0.2). According to the seasons of the year, the ratio between the men and the women was approximately similar (χ2 = 1.0428; ð = 0.7). According to the months, the amount of the women with the thoracoabdominal injuries was uniform (2-4 patients per month), but the men were injured mostly in February and seldom in December. Regardless of gender, the maximal amount of the patients with the thoracoabdominal injuries was registered between 8:00 p.m. and 23:59 p.m. (49 (35.5 %) patients) and in February (23 (12.8 %)), the minimal amount – between 4:00 a.m. and 7:59 a.m. (8 (5.8 %) patients) and in December (10 (5.6 %)).
The patients with severe injuries were admitted to the specialized hospital between 4:00 a.m. and 7:59 a.m. (ISS = 24.55 ± 6.7) in June, and mostly in other summer months. The patients with less severe injuries were admitted in March between 8:00 a.m. and 12:00 a.m. (ISS = 14.63 ± 6.2).
The infectious complications were identified in 66 (28.3 %) of the patients. In most cases one patient had several infectious complications. Their general amount was 103 (1.6 case per 1 patient): pneumonia – 38 (36.9 %) cases, purulent postsurgical wounds – 13 (12.6 %), pleural empyema and pleuritis – 11 (10.7 %), purulent criminal wounds – 9 (8.7 %), pancreonecrosis and peritonitis – 7 (6.8 %) cases, subdiaphragmatic abscess – 6 (5.8 %), retroperitoneal cellular phlegmon – 3 (2.9 %), ulcerative necrotic perforative enterocolitis – 2 (1.9 %), omentitis, soft tissue phlegmon, gangrenous cholecystitis, osteomyelitis, large intestine necrosis, keratitis, small pelvis abscess – 1 (1.0 %).
221 (94.8 %) patients were initially admitted to the specialized hospitals. Among them, 220 (99.5 %) patients were transferred by emergency cars (one patient independently got to an emergency medical station and then was transported to City Clinical Hospital No.9), 1 (0.5 %) patient was transported by a passing car. Initially, 12 (5.2 %) patients addressed to other city or republican hospitals. From there they were transferred to City Clinical Hospital No.9. In the cases of primary addressing to the specialized hospital, the time from an injury to realization of specialized medical care was 48 (40-61 minutes). The rate of infectious complications was 59 (26.7 %) for the above-mentioned cases. For addressing to other medical facilities, the time from an injury to transfer to the specialized hospital was 156 (24-1,668) hours. The delay in admission to the specialized medical facility was characterized by the increasing number of infectious complications: 7 (58.3 %) cases (χ2 = 5.6111; ð = 0.05).
The signs of alcohol intoxication were found in 174 (74.7 %) patients with thoracoabdominal injuries. Patients with alcohol intoxication are mostly admitted during evening and night hours (151 (64.8 %) patients) as compared to day time (83 (35.2 %) patients), (ƛýìï = 1.94; ð = 0.01). Patients without signs of alcohol intoxication had higher chances of infectious complications (OR = 2.92 (1.57-5.45), p = 0.001).
The main amount of the patients called to an emergency station 60 minutes after a thoracoabdominal injury (68 (66.7 %) patients). 26 (25.5 %) patients called to an emergency aid station within 6-12 hours after an accident. The lowest amount of the patients (8 (7.8 %)) required for medical care later that 12 hours after an accident. The time from an injury to call to an emergency aid station did not depend on ISS, but was important for the rate of infectious complications: during addressing within 60 minutes, the rate of infectious complications was 8 (11.8 %) patients, after 12 hours – 3 (42.9 %) (χ2 = 6.47; ð = 0.05).
The duration of transportation was within the limits of “the golden hour” in most cases: 17 (8.7 %) patients were transferred within 30 minutes, 129 (65.8 %) – within 31-60 minutes, 50 (25.5 %) patients – more than 61 minutes. Meanwhile, the shortest time of transfer was registered between 12:00 p.m. and 4:00 p.m. and between 4:00 a.m. and 8:00 a.m. (45.4 and 48.2 minutes correspondingly), the longest time – 65.3 minutes – between 8:00 a.m. and 12:00 p.m. The relationship between the injury severity and duration of transportation was not found (r = 0.08). The rate of infectious complications demonstrated the insignificant differences in dependence on duration of transportation to the hospital (χ2 = 2.71; ð = 0.3). When transportation lasted for more than 61 minutes, the mortality was 2 (4 %) patients. The probability of the unfavorable outcome was higher in the patients who were admitted to the hospital within less than 30 minutes (3 (17.6 %) patients) (χ2 = 4.099, ð = 0.2). A tendency to increasing risk of death can be associated with higher severity of condition: the first group demonstrated the probable survival rate of 84.1 %, the second group – 90.9 % according to RAPS (ƛýìï = 0.65, ð = 0.8).
The mean time from arrival to the admission department to the surgical treatment demonstrated the significant differences at different time of the day. The shortest period was at night time from 8:00 p.m. to 4:00 a.m. (46-47 minutes), the longest one – at day time (from 12:00 p.m. to 4:00 p.m., 945 minutes). There was not any relationship between the time before the surgical treatment and the injury severity (r = -0.1). For the cases of infectious complications, the time interval was 38 (20-65) minutes, in absent complications – 41.5 (25-70) minutes. There were no differences between the time from the moment of admission and the surgical treatment in dependence on development of infectious complications (ƛýìï = 0.76, ð = 0.61).
CONCLUSION
The patients with thoracoabdominal injuries are more often admitted to specialized hospitals within the interval from 8:00 p.m. to 11:59 p.m. (49 (35.5 %) persons) and in February (23 (12.8 %) patients). In most cases (68 (66.7 %) persons), patients call to an emergency aid station within one hour after an accident and they are transported to a specialized hospital within “the golden hour”. The study showed that the rate of infectious complications did not depend on the time from the moment of an injury to arrangement of specialized medical care: for addressing within 60 minutes, the rate of infectious complications was 8 (11.8 %) patients, after 12 hours – 3 (42.9 %).