Версия для печати Dats A.V., Dats L.S., Khmelnitskiy, I.V.

THE STRUCTURE OF DEFECTS OF MEDICAL ASSISTANCE IN POLYTRAUMA

Irkutsk State Medical Academy of Postgraduate Education – Branch of Russian Medical Academy of Continuous Professional Education, 

Irkutsk, Russia

A severe injury is one of the main problems of public healthcare. Annually, more than 5 million people die as result of polytrauma. The predicted value is about 8 million and more in 2020 [1-4].
Uncontrolled posttraumatic hemorrhage, which is caused by vascular damage, loss coagulopathy, hypothermia, consumption coagulopathy and rarefraction coagulopathy in infusion therapy, is a leading cause of potentially preventable deaths in patients with polytrauma [5].
According to V.V. Agadzhanyan and coauthors [6], the diagnostic defects were identified in 52.9 % of deceased patients with polytrauma, including 1.9 % with thanatological significant patterns. Moreover, the highest amount of errors (80.2 %) was related to the objective causes (extremely severe condition, need for resuscitation and surgical measures, short stay in hospital) and insufficient physicians’ experience.
According to the study by Maksimov A.V., based on the analysis of forensic medicine reports, the defects in rendering medical care for polytrauma did not prevent the lethal outcome by means of hypodiagnostics of the dominating injury in 18.8 % and its complications in 12 %, underestimation of severity of a complication in 10.7 % and inadequate treatment in 2.3 % [7]. The severity of the injuries often conceals the defects in diagnostics and treatment, resulting in objective estimation of realized medical care.
The analysis of the case records of the victims of road traffic accidents showed that 90.5 % of the defects in medical care for polytrauma were associated with diagnostics and treatment and also were related to subjective nature [8]. During forensic expertise, the identification of defects in diagnostics and treatment does not exclude them from the range of causal factors of unfavorable result of medical care.
Insufficient efficiency of results of medical and diagnostic process and, as result, decreasing quality of medical care were caused by lacks in organization and material-technical supply, absence of clear protocols for inhospital care for patients with shock-producing injury, imperfect regulatory documents describing the order of arrangement and realization of forensic expert activity [9].
The defects in arrangement of medical care present the serious healthcare problem and constitute a threat to safety of patients with polytrauma. Therefore, the problem of defects in rendering medical care for polytrauma is one of the most actual ones.

MATERIALS AND METHODS

The study was retrospective and consisted in the examination of the case records of 64 deceased patients with polytrauma who were admitted to the ICUs of 24 regional and city hospitals (level 2 and 3 trauma centers) of Irkutsk region in 2010-2016. The age of the patients was from 17 to 84. The case records were provided by the Territorial fund of obligatory medical insurance for residents of Irkutsk region. The study included only the diseases, which expertise results were approved by the representatives of the hospital administration.
At the moment of admission, the severity of traumatic injuries was estimated with Injury Severity Score (ISS). ISS was 25-40. The main injuries were identified: traumatic brain injury in 24 %, concurrent injuries in 24 %, skeletal injury in 21 %, thoracic injury in 16 %, abdominal injury in 12 %, spinal cord injury in 3 %.
The study protocol was approved by the ethical committee of Irkutsk State Medical Academy of Postgraduate Education (the session #1, January 14, 2010).
The medical care quality expertise was carried out according to the Order by Russian Health Ministry, November 12, 2012, No.901n, “About confirmation of the Order of arrangement of traumatological and orthopedic medical care for the population” [10], the Order by Russian Health Ministry, November 15, 2012 No. 919n, “About confirmation of the Order of arrangement of anesthesiology and critical care services for adult population” [11], the Order by Russian Health Ministry, July 7, 2015, No.422an, “About confirmation of criteria for estimating quality of medical care” [12], the project of clinical recommendations (the treatment protocol) for arrangement of medical care for multiple and associated injury (polytrauma) [13], the European guidance “Management of bleeding and coagulopathy following major trauma” (4th edition, 2016) [5].
Non-compliance of the above-mentioned national and international guidelines for examination, diagnostics, prevention and treatment of patients with polytrauma, as well as non-compliance of the instructions for prescription of medical drugs, were estimated by us as a defect in medical care arrangement.

RESULTS

The table 1 shows the analysis of the causes of lethal outcomes depending on the period of polytrauma.

 Table 1. The causes of lethal outcomes in various periods of polytrauma

Causes of lethal outcomes	Period of appearance of lethal outcomes
	Before 2 days	3-7 days	More than 7 days	Total
Hemorrhagic shock	20	-	-	20
Brain edema and disclocation in TBI	2	8	6	16
Ascendant spinal cord edema	1	1	-	2
Nosocomial pneumonia	-	-	5	5
Sepsis, septic shock	-	-	8	8
Fat embolia of pulmonary and cerebral vessels	2	-	-	2
Pulmonary embolia	-	-	3	3
Cardiac tamponade	1			1
Meningitis	-	-	1	1
Acute renal failure	-	-	4	4
CHF decompensation	-	-	2	2
ARDS	-	2		2
Total	26	11	29	66

26 (39.4 %) patients died within 2 days. Most deaths were caused by hemorrhagic shock (20 patients, 30.3 %). In the late period of polytrauma (more than 7 days), most cases of lethal outcomes (14, 21 %) were associated with infectious complications (sepsis, nosocomial pneumonia and meningitis).
The structure of the laboratory examination defects in the patients with polytrauma in the ICU is presented in the table 2.

Table 2. The structure of defects in laboratory examination of patients with polytrauma in the intensive care unit

Defects in examination	Rate of defects (%)*
Not examined:
Biochemical blood analysis	5 (7.6)
Coagulogram	10 (15.1)
Serum lactate	53 (80)
Plasma electrolytes	25 (37.9)
Arterial blood gases and base deficiency	65 (98.5 %)
Bloog group and Rh factor	12 (18.1 %)
Not examined over time:
General blood analysis	6 (9 %)
Coagulogram	5 (7.6 %)
Biochemical blood analysis	7 (10.6 %)

Note: * percentage is indicated in relation to the total amount of the patients with polytrauma (n = 66).

It was found that the most common defects in the examination were the absence of arterial blood gases examination (98.5 %), and serum lactate (80 %).
53 % of the cases were associated with the absence of primary clinical estimation of blood loss according to the changes in the main physiological values and response to initial intensive care for identification of coagulopathy risk and determination of the mode of infusion-transfusion therapy at the moment of admission to the ICU.
There was not any additional examination of the chest, the abdominal cavity and the pelvis, which present the main blood loss sources in trauma. The source of internal bleeding was not identified in 5 of 20 (25 %) patients with hemorrhagic shock.
The table 3 shows the structure of the defects and complications in the patients with polytrauma in the ICU.

Table 3. The structure of defects in diagnostics of injuries and complications in patients with polytrauma in the intensive care unit

Diagnostics defects	% (number of defects/total amount of patients for each nosological form)
Non-diagnosed complicatons:
Acute respiratory insufficiency	44 (20/45)
Hemorrhagic shock	20 (4/20)
DIC syndrome	57 (4/7)
Sepsis	75 (6/8)
Acute renal insufficiency	50 (2/4)
Nosocomial pneumonia	40 (2/5)
Pulmonary embolism	67 (2/3)
Acute respiratory distress syndrome	75 (3/4)
Fat embolia	50 (1/2)
Non-diagnosed injuries:
Liver rupture	40 (2/5)
Pelvic injury	20 (2/10)
TBI	6 (1/16)
Lung contusion	63 (5/8)
Massive hemothorax	50 (1/2)
Cardiac tamponade	50 (1/2)

Sepsis was not diagnosed in 6 of 8 patients (75 %), ARDS – in 3 of 4 patients (75 %), lung contusion – in 5 of 8 (62.5 %), ARF – in 20 of 45 (44 %).
The analysis of the ICU treatment of the patients with polytrauma identified the main groups of the defects: in correction of hypoxemia (the table 4), in intensive care of hemorrhagic shock (the table 5) and in non-compliance of the contraindications for prescription of medical drugs (the table 6).

Table 4. The structure of defects which appeared during correction of hypoxemia in patients with polytrauma in ICU

Treatment defects	Rate of defects, total (%)*
No tracheal intubation in airways obstructions: coma, injury to lower jaw bone and neck	2 (4.4)
No prescription of oxygen in hypoxemia	3 (6.7)
No ALV in persistent hypoxemia at the background of maximal delivery of oxygen	4 (8,8)
Late initiation of ALV (at stage of hypoxic heart arrest)	2 (4.4)
Incompliance of ALV parameters with low respiratory volume (6 ml/kg) in patients with ARDS or risk of its development	3 (6.7)

Note: * – percentage is indicated in relation to total amount of patients with hypoxemia (n = 45).

Table 5. Структура дефектов интенсивной терапии геморрагического шока у пациентов с политравмой

Intensive care defects	Rate of defects, total (%)*
Insufficient volume of introduced packed red blood cells 250-500.0 in hemorrhagic shock (targeted level of hemoglobin = 70-90 g/l is not achieved)	4 (20)
No transfusion of packed red blood cells in hemorrhagic shock	2 (10)
No transfusion of plasma in bleeding and more than 1.5-fold increasing prothrombin time and APTT	2 (10)
No introduction of cryoprecipitate and/or plasma at plasma level of fibrinogen < 1.5-2 g/l	2 (10)
No introduction of platelets in thrombocytopenia lower than 50×109/l	3 (15)
No introduction of platelets in thrombocytopenia lower than 100×109/l	2 (10)
Prescription of vasopressors without designation of dose in µg	3 (15)
Introduction of vasopressors for patients without TBI at the background of continuous bleeding in systolic arterial pressure > 90mm Hg	3 (15)

Note: * – percentage is indicated in relation to total amount of patients with hemorrhagic shock (n = 20).

In 18% of the cases, the defects in the treatment were determined by inadequate intensive care of hypoxemia relating to airway management, oxygen prescription and ALV.
In 30 % of the cases, the defects in the treatment were determined by inadequate intensive care of hemorrhagic shock as result of insufficient volume or non-use of packed red blood cells.
Prescription of non-prescribed medical agents was identified in 30 % of the cases.

Table 6. The structure of defects as result of incompliance of contraindications in drugs prescription

Treatment defects	Amount of defects
Introduction of potassium in oligo-, anuria	3
Introduction of b-adrenoblockers at background of arterial hypotony	2
Introduction of NSAIDs in non-corrected hypovolemia and/or ongoing bleeding	6
Introduction of curantyl in ongoing bleeding	2
Introduction of trental in ongoing bleeding	1
Introduction of aspirine in ongoing bleeding	2
Introduction of heparine in ongoing bleeding	1
Planned introduction of lasix in TBI	5
Planned introduction of mannitol in TBI	4
Introducton of 5% glucose in acute period of TBI	6
Introduction of tranexam in subarachnoidal bleeding	1
Introduction of prednisolone in TBI	3

DISCUSSION

Our study includes the analysis of the defect in arrangement of medical care for the patients with traumatic injuries admitted to the ICU of the regional and city hospitals of Irkutsk region.
We have found that the most common defects in the examination are absent study of arterial blood gases and deficiency of the bases, which control the oxygenation, ventilation and perfusion of tissues, as well as absence of primary clinical estimation of blood loss volume according to the changes in the main physiological values, and according to response to primary intensive care that are necessary for identification of coagulopathy risk and hemorrhage control.
Considering the danger of hypoxemia or hyperoxia, hypercapnia or hypocapnia during ALV, it is necessary to control the breathing in compliance with the patient’s requirements, with dynamic control for most important parameters including arterial blood gases and airway pressure.
We have found that pulse oximetry was a single tool for controlling the breathing in all patients with polytrauma. One should remember about the technical limitations for pulse oximetry that influence on the accuracy of saturation assessment such as signal receipt disruption during transportation, external lighting from fluorescent sources, an inappropriately selected transducer, presence of anemia and abnormal forms of hemoglobin, vasoconstriction and poor tissue perfusion.
One should remember that pulse oximetry cannot estimate hyperoxia and the values of ventilation. According to a recent study, hyperoxia is associated with increasing mortality owing to increasing production of free radicals and intensifying hyperoxic vasoconstriction [14]. PaO₂ > 200-300 is considered as the level of hyperoxia that causes some complications [15]. Long term hyperoxia can cause the atelectasis and lung injury in polytrauma [5]. For minimizing the complications of hyperoxia during ALV it is necessary to control the oxygenation with consideration of arterial blood gases.
It is necessary to consider that pulse oximetry measures the oxygenation, but not ventilation. According to the data by E. Damiani et al. (2014), hyperventilation in ALV causes the increase in mortality after polytrauma [14]. The target carbon dioxide partial pressure (PaCO₂) should be 35-40 mm Hg.
Hyperventilation-associated hypocapnia leads to increasing vasoconstriction, decreasing cerebral perfusion and disordered perfusion in cerebral tissue. Cerebral lactic acidosis appears immediately after induction of hypocapnia in children and adults with TBI and hemorrhagic shock [15]. Even the moderate level of hypocapnia (PaCO₂ < 27 mm Hg) can worsen a primary cerebral injury by means of apoptosis. If hypovolemia is absolute or relative, then hypoventilation with positive pressure can decrease the venous return and cause the hypotonia and cardiovascular insufficiency [8].
The problem of measurement of arterial blood gases is associated with presence of appropriate equipment in ICU and professional level of a physician. According to the international and national clinical guidelines for assessment of hypoxemia, hypercapnia, acid-base balance in determination of indications and carrying out ALV for patients in ICU, it is necessary to examine the parameters of arterial blood gases [5, 11, 12, 15]; gas analyzers are included into the list of necessary equipment in ICU [15].
Posttraumatic bleeding is the main cause of death in patients with polytrauma. It can arise after vascular injury and dilution coagulopathy during infusion therapy. Therefore, to minimize the blood loss it is necessary to identify the bleeding source and make the surgical and coagulation control over it.
We have found that the bleeding source was not identified in 25 % of the patients with hemorrhagic shock because of absence of an additional examination of the chest, the abdomen and the pelvis, which present the main sources of posttraumatic blood loss. According to the European and Russian recommendations, the diagnostics of unidentified source of bleeding in hemorrhagic shock should include ultrasonography, CT and diagnostic peritoneal lavage for abdominal bleeding, radiography, ultrasonography, CT, pleural puncture for pleural bleeding, and radiography and CT for pelvic injury [5, 13].
We have found that 20 % of the patients with hemorrhagic shock did not receive any plasma transfusion, cryoprecipitate or platelets. In case of bleeding, plasma transfusion should be performed for more than 1.5-fold increasing prothrombin time and APTT. Cryoprecipitate is used if plasma fibrinogen is lower than 1.5-2 g/l. Platelets are transfused for thrombocytopenia < 50 in patients without TBI and < 100 in patients with TBI [5].
Further examinations are required for more detailed analysis of defects in medical care for polytrauma with division into the separate topics (for example, acute respiratory and renal failure, coagulopathy, sepsis and others) with development of recommendations for treatment.

CONCLUSION

The most common defects in examination of polytrauma are absence of examination of arterial blood gases, deficiency of bases and lactate, and absent initial clinical estimation of blood loss according to a response to initial intensive care.
The source of internal bleeding was not identified in 5 of 20 (25 %) patients with hemorrhagic shock owing to absent additional examination of the chest, the abdomen and the pelvis.
The treatment defects in 31 % of the cases were determined by inadequate removal of hypoxemia after airway management, prescription of oxygen and ALV, and in 55 % – with non-adequate intensive care of hemorrhagic shock owing to insufficient volume and absent introduction of packed red blood cells.

Information of financing and conflict of interests:
The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.

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