Evaluating aspects of the trauma care spectrum : Pre-hospital triage and prediction based on in-hospital findings

Abstract

One of the most important components in the organization of trauma care is pre-hospital triage: getting the right patient, in the right time, to the right hospital. The quality of the triage process for patients after a high energy trauma was evaluated in this thesis (chapter 2). Results showed an overall undertriage and overtriage rate of respectively 10.9% and 39.5%. Whereas medically speaking undertriage is the more important one of the two triage parameters, overtriage leads to an unnecessary burden for the recourses of a level one trauma center. Despite the fact that the less severely injured patients represent a large proportion of the total number of trauma patients, studies investigating the outcome of these patients in our trauma system are lacking. In Chapter 3 we compared the trauma care for the elderly patient with a hip fracture at the level one and two trauma center. The organization and facilities at the level two trauma center are designed for high-volume and less complex care. Results showed patients at the level two center received earlier surgical treatment, had shorter admission duration and less non-surgical related complications. Literature supports these findings showing an explicit positive effect of institutional volume at geriatric rehabilitation units with regard to complications and mortality. Clavicle fractures account for approximately 5% of all fractures. Most studies evaluating treatment of clavicle fractures exclude polytrauma patients. In Chapter 4 we analyzed the incidence of a clavicle fracture in polytrauma patients and which accompanying injuries most frequently occurred. These “ expected” injuries should be taken into account in an early stage of traumacare. The main findings were that 10% of all polytrauma patients had a clavicle fracture, with in 83% additional head and neck injuries and a rate of 77% additional thoracic injuries. In Chapter 5 we compared polytrauma patients with to the polytrauma patient without a clavicle fracture, in order to investigate if a clavicle fracture was associated with concomitant thoracic injury. Results showed that patients with a clavicle fracture had a higher mean ISS, additional thoracic injuries were more prevalent and had a higher rate of thoracic injury with an AIS ≥ 3. Although extensive research for the optimal treatment of clavicle fractures has been performed, comparative studies between monotrauma and polytrauma patients are lacking. In Chapter 6 we compared distribution and treatment in monotrauma and polytrauma patients with a clavicle fracture. Results showed that monotrauma patients had a higher incidence of displaced midshaft clavicle fractures(DMCF) compared to polytrauma patients. Also monotrauma patients with DMCF were treated operatively more frequently. Not all injuries in polytrauma patients are diagnosed during primary and secondary survey. Therefore a tertiary survey was introduced. In Chapter 7 all extremity injuries in polytrauma patients were analyzed. Delayed diagnosed injuries(DDI) were found in 12% of the polytrauma patients. High energy trauma, abdominal injury and extremity injury found during initial assessment were independent risk factors for DDI in polytrauma patients. In this study, the clavicle fracture was the most frequently diagnosed extremity injury in polytrauma patients.