EVALUATION OF PROVIDING PREHOSPITAL MEDICAL CARE FOR VICTIMS WITH POLYTRAUMA IN ROAD TRAFFIC ACCIDENTS IN THE ARCTIC ZONE OF THE RUSSIAN FEDERATION Baranov A.V., Klyuchevskiy V.V., Menshikova L.I., Barachevskiy Yu.E., Petchin I.V.
Arkhangelsk Regional Clinical Hospital,
Northern State Medical University, Arkhangelsk, Russia
Yaroslavl State Medical University, Yaroslavl, Russia
Currently, the Russian and foreign authors note the increasing number of road traffic accidents (RTA) and worsening severity of traffic injuries (TI) by means of predominance of polytrauma after high energy injuries [1-4]. Appropriate arrangement of medical care and its timeliness are the main factors influencing on treatment outcomes in patients with severe multiple and associated injury [5, 6]. The volume of medical care for patients with polytrauma includes the obligatory treatment of shock by means of appropriate transport immobilization, adequate anti-shock infusion therapy and full-featured analgesia. The absence of one of these items worsens the patient’s condition and significantly impairs the prognosis of survival [7, 8]. Therefore, the research of polytrauma as a part of TI is the important scientific direction, without a uniform solution and with need for further studies and improvement.
Objective – to assess the capacity and quality of prehospital medical care for victims with polytrauma in road traffic accidents in the Arctic zone of Arkhangelsk region.
MATERIALS AND METHODS
The study materials were the sample of 518 medical records (the form 003/u) of the RTA victims who were urgently admitted to the multi-profile hospitals of Severodvinsk from January 1, 2012 to December 31, 2016. The case histories were selected according to the criteria of retrospective continuous documental observation (the medical records of the RTA victims who received the hospital treatment during the study period were selected).
The inclusion criteria:
1. Male or female.
2. Age of 18 and older.
3. The persons who suffered in RTA in Severodvinsk, Arkhangelsk region, on the road segment FAD M-8 Kholmogory in the area of responsibility of the Severodvinsk emergency medical care station, who received the hospital management.
4. Injuries in 2012-2016.
The sings and the characteristics selected for analysis:
1. The place of RTA (a city, suburban roads).
2. Injury type (single, multiple, associated).
3. ISS.
4. Clinical diagnosis.
5. Time of arrival of the emergency medical team to the accident place.
6. Time of admission of a patient to admission departments of the Severodvinsk hospitals.
7. The volume of medical care at the prehospital stage.
The mean values were calculated for the quantitative sings: the median (the first and third quartiles) and simple arithmetical mean (mean-square deviation). Kolmogorov-Smirnov test was used for estimation of normalcy of distribution of the quantitative signs. Mann-Whitney’s test was used for comparison of two values in conditions of non-conformance of the data to the parameters of normal distribution.
The analysis of the categorical signs was conducted with construction of the contingency tables, calculation of chi-square test and Fisher’s exact test (for four-fold tables). The analysis was conducted with SPSS 22. The criterion of statistical significance was the probability of variable error < 5 % (p < 0.05).
ISS (Injury Severity Score; S. Baker et al., 1974) was used for estimation of severity of associated injuries. This scale considers the anatomic and topographic injuries and division of the human body into 6 segments.
An injury to each segment was conducted with 5-point scale. The points of 3 maximally injured segments were squared and summed. The final digital value was the estimation. The value of 41 points was critical and supposed the arrangement of urgent interventions.
The study corresponds to the ethical standards of Helsinki declare. The study protocol was approved by the biomedical ethical board of Northern State Medical University, Arkhangelsk, the protocol No.08/11-17, November 29, 2017.
RESULTS AND DISCUSSION
According to the order by the president of the Russian Federation, Severodvinsk city has been included into the Arctic region of Russia [9].
Reviewing RTA with medical consequences in Severodvinsk and in 12th kilometer of the federal road M-8 Kholmogory, we have registered 263 (50.8 %) patients with polytrauma, including 72 (13.9 %) patients with multiple injuries and 191 patients (36.9 %) with associated injuries.
There is a well-known notion of the golden hour as the critical time point of medical care for a patient, especially with severe, associated or combined injuries as result of RTA. The time parameter of arrival of the emergency medical team to the accident site in Severodvinsk and its suburban areas is presented in the table 1.
Table 1
Comparative estimation of time of arrival of emergency medical care team to a place of road traffic accident
| Arrival time of emergency medical care team |
Less than 20 minutes (1) |
21-40 minutes (2) |
41-60 minutes (3) |
More than 60 minutes (4) |
p value |
|
Severodvinsk
|
316 (85.2) |
42 (11.3) |
9 (2.4) |
4 (1.1) |
1-2 = 0.000 1-3 = 0.000 1-4 = 0.000 2-3 = 0.000 2-4 = 0.000 3-4 = 0.17 |
|
FAD M-8 and regional roads
|
17 (11.6) |
102 (69.4) |
20 (13.6) |
8 (5.4) |
1-2 = 0.000 1-3 = 0.6 1-4 = 0.0567 2-3 = 0.000 2-4 = 0.000 3-4 = 0.0165 |
|
Total |
333 (64.3) |
144 (27.8) |
29 (5.6) |
12 (2.3) |
1-2 = 0.000 1-3 = 0.000 1-4 = 0.000 2-3 = 0.000 2-4 = 0.000 3-4 = 0.006 |
The analysis of the time of arrival of the emergency medical team to the accident site has shown that the medical team arrived to the accident site within 20 minutes in most cases (85.2 %, p = 0.000), in 11.3 % - within 40 minutes, and only in 3.5 % the time was high.
For RTA on FAD M-8 or on the roads in the suburban regions of Severodvinsk, the time of arrival of the emergency medical team was less than 40 minutes almost in 70 % of the cases.
The general estimation of the time of arrival of the emergency medical team of the Severodvinsk emergency medical care service showed the time of arrival less than 40 minutes in 90 % of all cases, and only in 2.3 % it exceeded one hour that can be caused by remoteness of RTA, road congestion of FAD M-8 Kholmogory or bad road conditions in the period of unfavorable weather conditions in the Arctic region.
All RTA victims, especially with severe multiple and associated injury, require for fast realization of specialized medical care in the multi-profile hospital. The table 2 shows the characteristics of the patients in dependence of types of the injuries and arrival time in the multi-profile clinic.
Table 2
Comparative estimation of time of transportation of patients suffered in road traffic accidents to multi-profile hospital
|
Time of transportation to hospital |
Injury type |
Total
|
p value |
|
|
Multiple (1) |
Associated (2) |
|||
|
Less than 40 minutes |
54 (75.0 %) |
147 (77.0 %) |
201 (76.4 %) |
1-2 = 0.06 |
|
41-60 minutes |
8 (11.1 %) |
27 (14.1 %) |
35 (13.3 %) |
1-2 = 0.78 |
|
61-120 minutes |
7 (9.7 %) |
12 (6.3 %) |
19 (7.2 %) |
1-2 = 0.49 |
|
More than 120 minutes |
3 (4.2 %) |
5 (2.6 %) |
8 (3.0 %) |
1-2 = 0.6 |
The mean time of transfer of the patients from the accident site to the multi-profile hospital was 30 [20; 40] minutes. More than 75 % of the patients with multiple injuries and 77 % of the patients with associated injuries were transferred to the multi-profile hospital within 40 minutes. The time of transfer by the emergency medical team was less than 40 minutes in more than 90 % of the cases.
Therefore, more than 80 % of patients with polytrauma in the Arctic region of Arkhangelsk region received the medical care within 20 minutes after call to the emergency service, and more than 90 % of the patients were transferred to the multi-profile hospitals within 40 minutes after injury, less than 3 % - after 2 hours. It can be considered as a good result of work of the emergency medical team of Severodvinsk emergency medical care station.
The prehospital algorithm of emergency actions for patients with severe multiple and associated injuries includes the primary estimation of patients’ condition, arrangement of sufficient volume of medical care and fast transfer to the nearest hospital for appropriate specialized treatment.
Our analysis of the prehospital medical procedures for patients with RTA-associated polytrauma showed the following: use of analgetics (92.8 %), infusion of anti-shock agents (65.4 %), transport immobilization (90.9 %) and transfer to the clinics of Severodvinsk or, in serious cases, to the level 1 trauma center – Arkhangelsk Regional Clinical Hospital. Most patients received these procedures to a greater or lesser degree (p < 0.001) (the table 3).
Table 3
Comparative estimation of volume of prehospital medical care for patients suffered in road traffic accidents
|
Type of medical care |
Injury type |
Total
|
p value |
|
|
Multiple (1) |
Associated (2) |
|||
|
No care |
8 (11.1 %) |
5 (2.6 %) |
13 (4.9 %) |
1-2 = 0.0045 |
|
Analgesia |
63 (87.5 %) |
181 (94.8 %) |
244 (92.8 %) |
1-2 = 0.0411 |
|
Immobilization |
62 (86.1 %) |
177 (92.7 %) |
239 (90.9 %) |
1-2 = 0.09 |
|
Intravenous infusion |
21 (29.2 %) |
151 (79.1 %) |
172 (65.4 %) |
1-2 = 0.0501 |
The RTA victims with multiple injuries received the analgesia in 87.5 % of the cases, immobilization – in 86.1 %, intravenous infusion – in 29.2 %.
The patients with associated injury received the immobilization of injuries in 94.8 % of the cases, analgesia – in 94.8 %, intravenous infusion – in 79.1 %.
The high percentage of critically ill patients with polytrauma, who did not receive adequate anti-shock therapy with intravenous infusions at the prehospital stage, indicates that the emergency medical team underestimates the severity of injuries in RTA. Since multiple and associated injuries in persons who suffer in RTA are accompanied by massive bleeding, injuries to internal organs, and hemorrhagic and traumatic shock, we think that the prehospital stages should include appropriate analgesia, immobilization and intravenous infusion for all patients with assumption of these injuries, with aim of early correction of shock of various origin.
CONCLUSION
1. More than 80 % of all patients received the medical care at the RTA place within the time not exceeding 20 minutes after a call to the emergency medical service, and more than 90 % of the patients were transferred to the multi-profile hospitals of Severodvinsk within 40 minutes after trauma.
2. At the prehospital stage, the medical care was realized for most (p < 0.001) patients with polytrauma. It included analgetics (92.8 %), infusion of anti-shock agents (65.4 %), transport immobilization (90.9 %) and transfer to the medical facilities of Severodvinsk or Arkhangelsk.
3. It was found that the significant proportion of patients with polytrauma had not received adequate anti-shock therapy (with multiple injuries – 29.2 %, with associated injuries – 79.1 %) with intravenous infusion. It supposes that the emergency medical team underestimates the severity of injuries in RTA.
For minimization of the medical and sanitary consequences of RTA, we have determined the main directions, which can reduce the prehospital mortality:
1. Increasing the professional competence in persons who perform the first medical care with all necessary components: anti-shock measures, adequate analgesia, transport immobilization, and special preparation of medical team to medical care for patients with polytrauma. Realization of such preparation should include traumatologist-orthopedists, specialists of disaster medicine centers and departments of medical educational institutions.
2. Creation of conditions for fast arrival of emergency medical teams and urgent response teams to the RTA place for realization of medical care through interaction with rescue services, road police and Ministry of Emergency Situations.
3. Optimization of prehospital medical care standards for RTA victims with development of step-by-step algorithm of medical care for patients with polytrauma at the prehospital stage of medical evacuation for a particular area, with consideration of its climatic features.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of clear or potential interests relating to publication of the article.