www.elsevier.es/medintensiva
TRAUMA
AND
CRITICAL
CARE
UPDATE
Challenges
in
care
of
trauma
patient
in
Spain.
The
need
for
implementation
of
scientific
evidence
including
secondary
prevention
夽
E.
Fernández
Mondéjar
a,d,∗,
F.J.
Álvarez
b,
J.C.
González
Luque
caServiciodeCuidadosCríticosyUrgencias,HospitalUniversitarioVirgendelasNieves,Granada,Spain bFarmacología,FacultaddeMedicina,UniversidaddeValladolid,Valladolid,Spain
cUnidaddeCoordinacióndelaInvestigación,DirecciónGeneraldeTráfico,Madrid,Spain dInstitutodeInvestigaciónBiosanitariaibs.GRANADA,Granada,Spain
KEYWORDS
Traumapatients; Scientificevidence; Secondary
prevention; Motivational intervention
Abstract Themortalityoftraumapatientshasimprovedsignificantlyinrecentdecadesdue toacombinationoffactors:medicalcare,educationalcampaignsandstructuralchanges. Gen-eralizationofbothout-ofhospitalemergencemedicalservicesandthehospitalcareinspecific centersfortraumatizedhasundoubtedlycontributedtothisdecline,butotherfactorssuchas periodiccampaignstopreventworkplaceandtrafficaccidents,aswellasimprovementsinthe roadnetworkhaveplayedakeyrole.
Thechallengenowistocontainmortality,forwhichisessentialananalysisofthesituation todetectpotentialareasofimprovement.
Theapplicationofdiagnosticortherapeuticactionswithscientific evidenceisassociated withlowermortality,butasinotherareasofmedicine,theapplicationofscientificevidence intraumapatients isbarely50%.Moreover, nearly90%oftraumadeathsoccurinthecrash siteorduringthefirst72hofhospitalization,thevastmajorityasaresultofinjuries incom-patiblewithlife.Inthesecircumstancesitisclearthatpreventionisthemostcost-effective activity.Asmedicalpractitioners,ourroleinprevention ismainlyfocusedonthesecondary prevention toavoid recidivism,for whichitisnecessarytoidentifythepossibleriskfactors (frequentlyalcohol,illegaldrugs,psychotropicmedication,etc.)andimplementabrief moti-vationalintervention.Thisactivitycanreducerecidivismbynearly50%.InSpain,theactivity in thisfield isnegligible; therefore, measures shouldbe implemented for dissemination of secondarypreventionintrauma.
©2014ElsevierEspaña,S.L.U.andSEMICYUC.Allrightsreserved.
夽
Please citethisarticle as:Fernández MondéjarE, ÁlvarezFJ, González Luque JC. Retosasistenciales enla atención alpaciente traumatizadoenEspa˜na.Lanecesidaddeimplementacióndelaevidenciacientíficaincluyendolaprevenciónsecundaria.MedIntensiva. 2014;38:386---390.
∗Correspondingauthor.
PALABRASCLAVE
Traumatismos; Evidenciacientífica; Prevención
secundaria; Intervención motivacional
RetosasistencialesenlaatenciónalpacientetraumatizadoenEspa˜na.Lanecesidad deimplementacióndelaevidenciacientíficaincluyendolaprevenciónsecundaria
Resumen Lamortalidaddelospacientestraumatizadoshadescendidosignificativamenteen lasúltimasdécadascomoconsecuenciadeunacombinacióndefactorestantoasistencialescomo estructuralesyeducacionales.Lageneralizacióndelosserviciosdeemergencias extrahospita-lariosylaasistenciahospitalariaencentrosespecíficosparatraumatizadoshacontribuidosin dudaaeste descenso,perootros factorescomo lascampa˜nasperiódicas deprevención de accidentesdetráficoylaborales,asícomo lasmejorasenlaredviariahanjugadounpapel fundamental.
Elretoactualconsisteenseguirdisminuyendolamortalidad,paralocualesfundamentalun análisisdelasituaciónquedetectelaspotencialesáreasdemejora.
La aplicación deactuaciones diagnósticas oterapéuticas con evidencia científicase aso-ciaconunamenormortalidadpero,comoenotrasparcelasdelamedicina,enlospacientes traumatizadoslaaplicacióndelaevidenciacientíficaapenasllegaal50%.Porotraparte,casi el90%delospacientesquefallecenportraumatismoslohacenenellugardelaccidenteoen lasprimeras72hdehospitalización,lainmensamayoríadelasvecescomoconsecuenciade lesionesincompatiblesconlavida.Enestascircunstanciaspareceevidentequelaprevención eslaactuaciónmáseficiente.Comomédicosasistenciales,nuestropapelenlaprevenciónse centrafundamentalmenteenlaprevenciónsecundariaparaevitarlareincidencia,paralocual esnecesarialaidentificacióndelosfactoresderiesgo(generalmentealcohol,drogasilegales, psicofármacos)yrealizarunaintervenciónmotivacionalbrevequepuedereducirla reinciden-ciacasiun50%.EnEspa˜na,laactividadenestecampoesprácticamentenula,porloquedeben implementarsemedidasparasuimplantación.
©2014ElsevierEspaña,S.L.U.ySEMICYUC.Todoslosderechosreservados.
Thecareofserioustraumapatientshasclearlyimproved in Spain over the last few decades. Protocolized inter-vention by the Emergency Services and hospital care in specific trauma centers are the two main elements con-tributingtotheimprovementsinpatientcare.Inaddition, othermeasuressuchasimprovementsintheroadnetwork, andworkplaceand trafficaccidentpreventioncampaigns, have had an important influence in reducing the mortal-ity rate due to trauma in this country. Achieving further significant reductions in such mortality constitutes a dif-ficult challenge and requires a careful analysis, with the directingofeffortstowardtheareaswiththegreatest defi-ciencies.
One-halfofalldeathsoccuratthecrashsiteduringthe firstfewminutes,andofthepatientsthatdieinhospital, the immensemajority (almost 90%) doso withinthe first 72hofadmissionasaresultofanatomicalorphysiological injuriesthatareincompatiblewithlife.1Deathsthatoccur
atalaterstageandwhichintheoryarepotentiallyavoidable occurasaresultofcomplicationssuchasmultiorganfailure, infections, acute respiratory distresssyndrome, etc., and accountforabout2---3%ofthetotalfatalities.2Considering
the above, it is reasonable to assumethat improvements in the management of specific injuries (head, thoracic, abdominal-pelvicandlimbinjuries)willhardlyimprovethe prognosisofthesepatients.
Although we still seek to reduce the mortality rates among polytraumatized patients, the margin for such improvement may be scarce. Probably the most efficient way to reduce avoidable deaths is to encourage applica-tionofthetreatment guidesbasedonscientificevidence.
Nevertheless,therearestudiesthatsuggestthe contrary---reportingastablemortalityratedespiteintenseeffortsto improvethe management oftrauma patients.3 This could
bebecausecertaincentersofexcellencemayhavereached suchalowmortalityratethatfurthersignificantreductions aretechnicallynotfeasible.
However,patientcareisnothomogeneous,andthereare centerswithagreatermarginforimprovementbecauseof lesseradherencetothescientificadvances.4,5Shafietal.,4
inamulticenterstudy,foundthata10%increasein compli-ance with scientific evidence resulted in a 14% decrease in mortality risk among the most serious trauma cases. There are no data in Spain onthe degree of compliance with scientific evidence. Nevertheless, on extrapolating data from trauma centers in the United States, it is seen that almost 50% of the recommended diagnostic or therapeutic measures are not adequately applied, and this percentage is even higher among the most seri-ous trauma cases.6 As in other areas of Medicine,7---10 it
is clear that application of the demonstrated scientific advancesis a pendingissuewithmuchroom for improve-ment.
avoided, the mortality rate could be lowered by 13%. In comparison,mortalitycouldbe reducedby over50% with anadequatepreventionsystem,particularlyinreferenceto secondaryprevention.1
ActivityinthisfieldispracticallynonexistentinSpain,11
despitethefactthatboththescientificevidenceand com-monsensepointtotheneedtoadoptsecondaryprevention protocols.It isnotorious thatdespite the importanceand potentialfor application ofsuch measures in Spain, little interest hasbeen shown onthe part of the publichealth institutionsandscientificsocieties.Toourknowledge,only the Spanish Society of Intensive Care Medicine, together with the Spanish National Plan on Drugs, have drafted a monographanalyzingthedifferentdimensionsofthe prob-lemandunderscoringtheneedforactivityinthisfield.12It
isthereforeclearthatwehaveimportantandurgentmargin forimprovementinthisarea.
Forsometimetherehasbeen theintention toreplace theconceptoftraumaticaccidentwithtraumaticdisease. Suchachangeisnotaminorissue,sinceitimpliesavariation inconceptualperception.Traumaticaccidentisassociated withanuncontrollablerandomorchancefactorinwhichbad luckplaysapreponderantrole.Incontrast,theideaof trau-maticdiseaseaimstoincludealltheclinicalaspectsofthe conceptofdisease,andinthissenserandomnessorchanceis replacedby associateddeterminants,withan identifiable causalfactor(energy). Inother words, thenewparadigm causes accidents toevolve from somethingunforeseeable (inwhichconcernonlyfocusesonprovidingadequate treat-ment of the injuries) to traumatic disease, in which we alsomustaddresstheunderlyingetiologyandplacespecial emphasisontheriskfactors.
It should be remembered that in the year 2004, and for the first time in history, the World Health Organiza-tiondedicatedthe7thofApril tothepreventionoftraffic accidentsand thedevelopmentoftraffic safetyasa pub-lichealth activity.The messagechosencouldnotbemore clear:‘‘Trafficsafetyisnoaccident’’.13
Onexaminingtheriskfactors,itisseenthatone-halfof all injuries areassociated toalcohol anddrug abuse.14---17
The data of the European DRUID project show that driv-ingunder theeffects ofalcohol, illegal drugsand certain medicationsisparticularlycommoninItaly(15%)andSpain (14.8%),whiletheEuropeanaveragerateis4.4%.18 On
re-examiningthedataaccordingtotrafficdistributioninSpain andincludinginformationreferredtomotorcycles,the per-centageofpositivecasesforsuchsubstanceswasfoundto be16.9%.19
Theaggravatingfactorofrecidivismalsomustbeadded totheaboveconsiderations.Indeed,incasesoftrauma asso-ciatedto alcohol and drugs, the probabilityof recidivism doublesincomparisonwithtraumacasesnotrelatedtosuch substances.20,21
Reincidence of illegal behavior or involvementin acci-dents is a problem with enormous sociosanitary and economic implications, and in Spain this issue requires urgentattention.Inthehospitalsetting,secondary preven-tionmeasurescanreducerecidivismbyalmost50%,22,23with
anexcellentcost-effectivenessratio.24
Likeallnewmanagementactivities,theimplementation ofsecondarypreventionisnotwithoutdifficulties.However, ifwewanttomakeprogressinthefieldofprevention,the
only option is tocontrol thecause,and in one-halfof all casesthecauseisalcoholandillegaldrugs.
The first step is to identify the association between trauma and substance use based onthe determination of toxicagentsinbloodandurine,ortheapplicationof ques-tionnaires such as the AUDIT,25 followed in positive cases
by a structured motivational interview.26 The aim of this
interview is toofferpatients informationand make them aware of the link between substance use and injury, the risksinvolved,andtheneedtochangetheirbehaviorinthis respect.Traumapatientswhohaveconsumedalcohol,and particularlythosewhoconsumecannabisorcocaine,donot viewsuchhabitsasimplyinganincreasedriskofinjuries.27
Theapplicationofsuchaprotocolisassociatedtosignificant reductionsintheincidenceoffutureinjuries.22
Anyattempttomodify behavioris undoubtedlya com-plicated task,thoughconvalescenceafter injuryoffers an idealopportunitytotrytoachievesuchchanges,sinceunder thesecircumstancesthepatientsareawareoftheriskthey haveexperienced,andarethereforemoreopenand moti-vatedtochangetheirhabits.
A number of aspects must be analyzed, such as confi-dentiality implications28 andthe needfor specifictraining
inthisfieldinordertoguaranteeeffectivess,29thoughthe
difficulties can be overcome. The situation may be com-paredwiththatofasmokerwhosuffersaheartattack.It isinconceivableforsuchapatienttoleavehospitalwithout receivingexpressrecommendationstostopsmoking.Inthe caseoftraumavictims,wemustidentifyapossiblerelation toalcoholanddrugs,andiftheassociationisconfirmed,we mustprovidemotivationalcounselingascommentedabove. The efficacy of suchmeasures has been widely confirmed for alcohol, tothe pointwhere in the United Statesthey are now mandatoryin all level I trauma centers.30 Other
countrieshavealsoidentifiedanurgentneedfor interven-tioninthisfield31and,giventhemagnitudeoftheproblem,
areadoptingspecificpreventionplanstargetedtoconcrete populationsinwhichalcoholabuseisaparticularly impor-tantriskfactor.32
Focusingourmaineffortsonpreventiondoesnotmean thatweshouldnotalsoadvanceindiagnosticortherapeutic aspectsreferredtospecificinjuries.Nomatterhowsmall, suchadvancesofferhelpinthemanagementofourpatients, andthefundamentalconcernofthephysicianmustcontinue tobetheconcretepatientdealtwithineachmoment. Nev-ertheless,itmustberememberedthatknowledgeinitselfis notenough:itmustbeadequatelyapplied,andwecurrently have a broad rangeof resources at our disposal that are often notcorrectly used.Intraumaticdisease,asin other fieldsofMedicine,theimplementationofscientificevidence is a priority challenge.7---10 Evolution fromthe publication
ofadvancesorclinicalpracticeguidestotheirgeneralized application is certainly acomplexissue that canbe influ-encedbymanyfactors,33,34evenofacommercialnature,35
and requires an extensive analysiswhich falls beyondthe scopeofthisarticle.
Conclusion
scientific evidence is low in the most serious trauma patients,despitethefactthatitispreciselyinthesecases where such implementation is particularly useful. Conse-quently,ourmaineffortsshouldcenterontheadoptionof protocolswarrantedbyclinicalpracticeguidesbasedon sci-entificevidence.Ontheotherhand,majordeficienciesare seenintheapplicationofsecondarypreventionprotocolsin relation toalcohol anddrugs. There isscientific evidence that suchprotocols,targeted topeoplewhodrive, afford a decrease in recidivism of almost 50%. Their incorpora-tiontoourhealthcaresystemthereforemust beapriority concern.
Conflict
of
interest
Theauthorsdeclarethattheyhavenoconflictofinterest.
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