During the study period, three thousand eight hundred and twenty-eight (3,828) patients were hospitalized in the ICU of the SO UH. Among them, one thousand and forty-six (1,046) were trauma patients (18.6%), including 195 with TT (5.1% of ICU hospitalizations and 18.6% of trauma patients). Eight patients whose records could not be found (2 patients) or missed critical information (6 patients) were missing, and the remaining 187 were included in the research.
The mean age was 38.1±13 years (range: 2-76 years), and the sex ratio was 6.8. One hundred and eighty-four patients (98.4%) were evacuated from the accident scene to the emergency department (primary transfer) and then transferred to ICU, while 3 (1.6%) were transferred from another hospital (secondary transfer). Epidemiological data are presented in Table 1.
On admission to the ICU, patients presented some vital distress. One hundred and seventeen patients (62.6%) had respiratory distress, 9 (4.8%) hemorrhagic shock, and 46 (24.6%) severe coma (Glasgow coma scale ≤ 8). The mean SPO2 was 87.1±55.9% (range: 25-99%). Respiratory disorders are displayed in Table 2.
Diagnostic imaging included chest X-ray, head CT scan, limbs X-ray, thoraco-abdominal CT scan and chest CT scan in respectively 185 patients (98.9%), 142 (75.9%), 68 (36.4%), 67 (35.8%) and 12 patients (6.4%). Blood group and D rhesus, blood count, uremia, serum creatinine and blood glucose tests were performed in all patients. C-reactive protein (CRP) and blood ionogram were performed in 180 (96.2%) and 174 patients (93.0%) respectively. The median hemoglobin concentration was 8.8 ± 3, 7 g. dl−1 (range: 3.3 to 12 g.dl−1).
Table 1
Epidemiological data of TT patients
|
Frequency (n)
|
Percentage (%)
|
Comorbidity
|
|
|
Hypertension
|
12
|
6.4
|
Diabetes
|
3
|
1.6
|
Asthma
|
2
|
1.1
|
Causes and mechanisms of TT
|
|
|
Road Traffic Accident (RTA)
|
163
|
87.2
|
Motorcycles colliding
|
63
|
33.7
|
Automobile-motorcycle colliding
|
51
|
27.3%
|
Automobile-obstacle colliding
|
20
|
10.7%
|
Motorcycle-obstacle colliding
|
20
|
10.7%
|
Automobile-pedestrian colliding
|
9
|
4.8
|
Assault
|
15
|
8.0
|
Struck by walls and heavy loads
|
5
|
2.7
|
Fall from a height
|
3
|
1.6
|
Impalement by an ox
|
1
|
0.5
|
Admission time* (hours)
|
|
|
[1 to 2]
|
115
|
61.5
|
]2 to 24]
|
69
|
36.9
|
>24 hours
|
3
|
1,6
|
Means of transport
|
|
|
National fire service’s vehicles
|
87
|
46.5
|
Motorcycles
|
77
|
41.2
|
Private vehicles
|
20
|
10.7
|
Ambulance
|
3
|
1.6
|
Total
|
187
|
100
|
*Duration from accident time to ICU admission |
Table 2
Respiratory disorders in TT patients
Characteristics
|
Frequency (n)
|
Percentage (%)
|
Middle hypoxia (SPO2 = 90-94%)
|
42
|
22.5
|
Moderate hypoxia (SPO2 = 85-89%)
|
78
|
41.7
|
Severe hypoxia ((SPO2 ˂ 85%)
|
28
|
15
|
Tachypnoea
|
108
|
57.8
|
Cyanosis
|
89
|
47.6
|
Chest indrawing
|
40
|
21.4
|
Emphysema
|
24
|
18.8
|
Thoracic asymmetry
|
16
|
8.6
|
Bradypnea
|
9
|
4.8
|
Paradoxical breathing
|
7
|
3.7
|
It was about isolated TT in 14 patients (7.5%) and polytrauma in 173 patients (92.5%). Closed TT accounted for 90.4% and penetrating TT for 9.6%. Associated injuries included: cranioencephalic injuries in 75.9%, abdominal contusion (50.8%), pelvic limb trauma (19.2%), thoracic limb trauma (17.1%), cervical spine trauma (7.0%), thoracic spine trauma (2.1%), and lumbosacral spine trauma (0.5%). The distribution of chest injuries is displayed in Table 3.
Table 3
Distribution of thoracic injuries
|
Frequency (n)
|
Percentage (%)
|
Lung contusion
|
67
|
35.8
|
Hemothorax
|
45
|
24.1
|
One rib fracture
|
25
|
13.4
|
Pneumothorax
|
21
|
11.2
|
Chest penetrating wound
|
18
|
9.6
|
Fracture of more than 1 rib
|
14
|
7.5
|
Flail chest
|
7
|
3.7
|
The ICU management varied according to injuries, vital distresses, resuscitation physician and the recommendations of the various specialists. The essential components of the treatment were: vascular filling (normal saline or ringer's lactate, for moderate hypotension and Gelofusine for severe hypotension or moderate blood loss), intravenous administration of vasopressors in case of shock (ephedrine, norepinephrine or rarely epinephrine), blood transfusion, and analgesia. The mean volume of vascular filling during the first 24 hours was 3500±790.6 ml (range: 1500 to 5500 ml). Patients were transfused 1 to 5 units of units of packed red cells (mean: 2.1± 0.8), and 1 to 3 units of fresh frozen plasma (mean: 1.2 ± 0.6). Pleural effusion was managed by decompression needle thoracostomy and/or pleural drainage. All patients received analgesic treatment, using various associations of paracetamol (1 g per 6 to 8 hours), nefopam (20 mg per 6 to 8 hours), tramadol (50 to 100 mg per 6 to 12 hours), ketoprofen (100 mg per 12 hours), and subcutaneous morphine-based analgesia or IV morphine titration. In children, the dosage of drugs was adjusted to weight. IV sedation with propofol, fentanyl, and diazepam was applied to ventilated patients. Non-ventilated patients could also be sedated with diazepam and IV or subcutaneous morphine. The means of resuscitation are presented in Table 4.
Table 4
ICU management and therapeutic interventions
|
Frequency (n)
|
Percentage (%)
|
Sedation
|
101
|
54
|
Hemodynamic resuscitation
|
|
|
Fluid resuscitation
|
41
|
21.9
|
Vasopressors
|
27
|
14.4
|
Blood transfusion
|
93
|
49.7
|
Respiratory resuscitation
|
|
|
Airway release
|
165
|
88.2
|
Oxygen delivery by mask
|
123
|
65.8
|
Tracheal intubation + mechanical ventilation
|
26
|
13.9
|
Tracheal intubation + Oxygen
|
13
|
6.9
|
Decompression needle thoracostomy
|
21
|
11.2
|
Pleural drainage
|
20
|
10.7
|
Respiratory physiotherapy
|
7
|
3.7
|
Tracheotomy + mechanical ventilation
|
2
|
1.1
|
Patients were receiving prophylactic (100%) or curative antibiotics (75.4%), and glucose serum when the oral route was not possible (92.5%). Nine patients (4.8%) were urgently operated for thoracic injuries before admission to the ICU, out of whom 4 cases of firearm chest wounds, 4 cases of thoracoabdominal stabbing wound, and a case of blowing wound of the thorax with costal flap. Forty-one patients (21.9%) underwent urgent surgery for concurrent injuries: 27 cases of open limbs fractures, 7 cases of extradural hematoma, 2 cases of cerebral-meningeal hemorrhage, 1 case of cervical disc herniation, 1 case of cervical vertebral dislocation fracture, 1 case of traumatic rupture of the spleen, 1 case of open fracture of facial bones and 1 case of the scrotal wound.
Evolvements
The average length of ICU stay was 12.7±6 days (range: 1-28 days). One hundred and three patients (55.8%) manifested at least one complication: wound infection and sepsis in 81 patients (43.3%), bronchopulmonary infection in 60 (32.1%), acute respiratory distress syndrome (ARDS) in 48 (25.7%), hemorrhagic shock in 31 (16.6%), septic shock in 28 (15%), and pulmonary embolism in 3 patients (1.6%). Fifteen patients (8.0%) sustained prolonged ventilation and could not be weaned from the ventilator, until they died. Overall, 84 patients (44.9%) died in the ICU, while 103 patients (55.1%) were transferred to the wards. The recorded causes of death were: septic shock in 26 cases (30.9%), hemorrhagic shock in 12 (14.3%), brain injuries in 31 (36.9%), and ARDS in 8 cases (9.5%). The causes could not be identified in 7 cases (8.3%).