Despite numerous technological advances in clinical trauma specialities including surgery, the mortality from major trauma is still a challenge. Ho...
Despite numerous technological advances in clinical trauma specialities including surgery, the mortality from major trauma is still a challenge. However, the trauma management landscape has changed a lot. In this blog article, I will discuss some of the global trends and changes in trauma management.
Trauma management may differ depending on country, hospital and the level of the trauma centre. This is based on types of resources available and the number of patients admitted yearly. In general, the number of endovascular possibilities has increased over the last few decades due to technological developments. Standard open surgeries are replaced by minimally invasive techniques, which minimises the added operating physical trauma to the patient, reduce infection rates and recovery time as well as shortens the hospital stay. Also, the essential role of trauma teams has evolved to be more specialised.
Multi-detector computed tomography (MDCT) has revolutionised the diagnosis and treatment of trauma patients by allowing multiple injuries to be identified in a single, rapid study. One of the largest changes is the location of the CT scanner. In all trauma hospitals today, the scanner is appropriately situated within, or in close proximity to the emergency department, allowing a “whole body” scan of severely injured trauma patients within a very short time from their arrival in the hospital. Previously, emergency teams had to move the patients and transport them to the CT scanner, situated “somewhere” within the radiology department. The more patients are moved and the longer distance they need to be transported, the larger the risk of severe complications or even death. The CT scanner conveniently situated within the emergency department simplifies the process for the team, allowing urgent communications and decisions to be made.
Twenty years ago, trauma teams often consisted of one anaesthetist, one surgeon, and the associated nurses. Today, various clinical specialists are involved including radiologists, neurosurgeons, orthopaedic surgeons, plastic surgeons, vascular surgeons, anaesthesiologists, and experts on transfusion/blood bank, just to mention a few. Consequently, this puts higher demands on the communication and collaboration between specialists and team members. It is essential that every member understands the treatment pathway, each other’s role and communicates efficiently. The widely used Triage method is a tool for the priority of patients' treatment based on the severity of their condition. Already, when the trauma patient is in a helicopter or ambulance, the paramedics can communicate with the emergency team to decide which specialists are needed upon arrival to the hospital.
The collaboration between trauma disciplines has evolved dramatically over the last few decades. Interventional radiologists are being called to the emergency departments more frequently than previously. There is a shift in how interventional radiologists are being viewed when fully integrated into the emergency teams. This is also a consequence of the endovascular tools available to occlude arterial vessels (i.e. embolize) and thus prevent further bleeding. The location of the CT scanner within emergency departments, the close collaboration between emergency team members, i.e clinical specialists and paramedics, must be emphasised in this context. Additionally, the introduction of well-equipped hybrid operating rooms enables the performance of so-called hybrid procedures, endovascular and open surgery simultaneously.
As the number of endovascular possibilities increases and standard open surgeries are replaced by minimally invasive techniques, new possibilities also for training on endovascular procedures exists, with simulation training on top of the agenda. Emergency teams act under stress and need to make quick decisions. A simulated environment allows for emergency teams to train on endovascular procedures to prepare for stressful situations, enhance communication skills and discuss patient safety. Simulation gives the opportunity to perform entire procedures with the same devices, in the same order, as during a real patient procedure. Simulation training also provides the possibility for various specialists to train on the procedures - not only interventional radiologists but also vascular surgeons and trauma surgeons and many more.
Trauma CT angiography is essential. The anatomical structures marked on the trauma CT may be merged as a 3D image fusion in the hybrid suite by combining the intra-procedure endovascular cone-beam CT performed as an overlay and guidance on live fluoroscopy. Trauma surgeons will continue to be more specialised, and endovascular specialists will continue to be a crucial bridge of an early and accurate diagnosis. In future, several other specialists will interpret images and be familiar with the endovascular entourage. Diagnosis and treatment are destined to be outsourced to paramedics and clinicians in the field. It may be that the greatest impact is therefore still to come in saving lives as a result of trauma.
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