Acute Care

Avery Nathens, MD, PhD, MPH
Section Head

	HIPRC Overview Overview Injury Prevention at Work Acute Care Biomechanics Epidemiology Rehabilitation Collaborative Efforts

Developing new, more effective measures to resuscitate and treat injury victims

Prevention is the first line of defense against injury, but when measures go unheeded and life-threatening injuries occur, acute care specialists take over. Their work during the critical "golden hour" immediately following serious injury largely determines whether the victim survives. The Acute Care Section of the Harborview Injury Prevention and Research Center (HIPRC) strives to improve patient evaluation and treatment during this crucial stage, both to optimize the patient's chance of survival and maximize long-term recovery. This purview includes emergency medical care given at the injury site, during transport to the hospital and at the hospital. Of particular interest are pre-hospital care, acute emergency resuscitation, and interventions aimed at preventing long-term disability.

Reducing the impact of alcohol

Trauma physicians battle many obstacles to save the lives of seriously injured patients - blood loss, organ damage, oxygen deprivation, shock - and a less obvious yet equally formidable threat: alcohol. Alcohol-related injuries (including car crashes, drownings, falls, burns, assaults, murders and suicides) account for half of hospital admissions for trauma nationwide. The HIPRC Acute Care Section has devoted a large share of research to determine and mitigate alcohol's far-reaching influence.

Alcohol's causative role in injury is considerable, as shown by a HIPRC study of more than 3,500 adults admitted to Harborview Medical Center from March 1989 to February 1991. One-half had been drinking alcohol; the average level of consumption was nearly twice the legal limit for intoxication. More than half of assault victims were intoxicated at admission, as were more than one-third of patients with self-inflicted wounds. Three-fourths of acutely intoxicated patients had evidence of chronic alcoholism.

HIPRC research also revealed alcohol's damaging effect on the treatment of trauma patients. Alcohol intoxication interferes in the initial evaluation and management because it affects the actions of some drugs, mimics the symptoms of serious injury and causes a strong physical reaction when withdrawn from addicted users. This requires physicians to order more, expensive tests to get reliable examination results, increasing the use of invasive diagnostic and therapeutic procedures. To counteract this problem, HIPRC researchers recommend that all trauma centers screen the blood alcohol concentration of patients. Learning this information early in the interpretation of clinical findings may reduce the use of such procedures and ultimately save time, money and lives.

The researchers found that in general, trauma patients who were acutely intoxicated had no increased risk of complications, with the exception of patients with acute brain injury, whose intoxication increased their likelihood of undergoing several expensive, risky and invasive procedures. In contrast, chronic alcoholics were twice as likely to develop major complications, particularly pneumonia, were at higher risk for respiratory failure, and were more likely to need subsequent surgery.

Although HIPRC research found no connection between any level of alcohol consumption and death, a follow-up of trauma patients who were intoxicated at the time of admission showed they were two-and-a-half times more likely to be readmitted for later trauma than patients sober at admission.

These collective findings led the HIPRC to take a strong public stand on the treatment of trauma patients with alcohol-related injuries. Harborview is the first trauma center in the world to make alcohol intervention a routine part of trauma care, and the HIPRC urges other centers to follow this example.

"It's time for trauma centers to move beyond simply treating the injury," says Dr. Gregory Jurkovich, chief of trauma and director of Emergency Room Surgical Services at Harborview Medical Center. "Alcoholism is the most common chronic illness found in trauma patients, yet about half of trauma centers in this country do not even routinely test the blood alcohol content of their patients. We need to screen patients for alcoholism and refer them to appropriate treatment programs. In the current debate on the quality of health care and its costs, this makes human and financial sense."

In 1993, the HIPRC received a grant from the National Institute on Alcohol Abuse and Alcoholism to find the best way to enroll intoxicated trauma victims in alcohol treatment programs and to examine the impact of counseling on their relapse rates, long-term outcomes and ability to return to work.

Hypothermia in Trauma

Approximately four out of 10 trauma patients face not only the threat of their injuries, but also the danger of hypothermia from shock. Loss of body heat to below 35 degrees Celsius is a critical problem in the first few hours after severe injury, and can be difficult to treat with standard re-warming techniques. Blankets, environmental heat, and warmed, inhaled gases can take as long as four hours to raise a patient's core body temperature to a safe level, but HIPRC acute care specialists developed an alternative method that takes only 36 minutes to reverse the condition and any associated problems, including impaired heart function and reduced blood clotting. The new technique, continuous arteriovenous re-warming, improved the survival rates of patients with moderately severe injuries, significantly reducing their blood and fluid requirements, incidence of organ failure and lengths of stay in intensive care. Initially Harborview was the only site using the procedure, but government approval in October 1995 extended its availability nationwide.

In addition to developing this improved re-warming technique, research on hypothermia has produced important guidelines for treating hemorrhage in trauma patients. HIPRC investigators demonstrated that hospitals' standard test to assess blood-clotting ability underestimates clotting abnormalities in hypothermic patients, that hypothermia thus can be an undiagnosed source of clotting abnormalities, and that it exacerbates any existing clotting problems. Trauma specialists typically treat the severe bleeding that results by replacing the patient's platelets and clotting factors, but hypothermia was found to impair the functioning of these agents, suggesting that rewarming is a more effective treatment strategy.

Emergency medical services research

Harborview is internationally recognized for its development of an integrated system of emergency response, treatment and research vital to the successful recovery of trauma patients. Trauma patients in rural areas have a higher death rate than those in urban centers, but the reasons why are not clearly understood. To elucidate this problem the HIPRC compared the response times of Advanced Life Support transport teams in rural areas to those in urban centers. Although longer gaps in time exist in rural areas between when a motor-vehicle crash occurs and the arrival of emergency aid, this is due to delays in notifying authorities, often because crashes in remote areas go undiscovered. Researchers determined that the emergency medical system in rural locales is sound but improvement is needed to compensate for these notification delays.

The value of emergency techniques also comes under HIPRC scrutiny. Emergency resuscitative thoracotomy, a surgical technique to access an airway through the chest wall, is used liberally in the field and in hospital emergency departments. However, a HIPRC evaluation showed it to be ineffective, expensive and risky for some patients, exposing medical personnel to lethal infection. Researchers defined a limited range of circumstances in which the technique can be justifiably used, setting a policy that maximizes patient survival while reducing inappropriate expense and personnel risk.

Future directions

The Acute Care Section will continue these useful evaluations to improve patients' immediate survival and long-term recoveries, Jurkovich said, along with efforts in trauma system development. He also expects to expand research on the immune system to better understand and manipulate the body's response to acute injury, particularly to prevent and treat the exaggerated inflammatory response that causes multiple organ failure and death.

A model system of statewide trauma care

Guided by the trauma experts at Harborview Medical Center, the only Level I trauma center in a four-state region, Washington state has played a leading role nationally in developing a statewide trauma system to efficiently triage patients to optimal emergency care. Developed in collaboration with the Harborview Injury Prevention and Research Center (HIPRC), Harborview's highly acclaimed trauma registry serves as an important model for this program. The registry, a database comprised of information on 22,000 patients seen in Harborview's emergency department, enables statistical analyses of injuries based on gender, age, race, cost, severity, cause, hospital length of stay, and many other factors.

"All major trauma should have a data set, so that injury can be tracked by distribution, need, injury patterns, legislation, education, resource development and targets for prevention," says Dr. Ronald Maier, Harborview surgeon in chief. "The level of medical care in Washington has always been high. What was lacking was an organized plan to integrate that expertise. Now, thanks to the statewide trauma plan, we distribute patients to the hospital that will maximize their recovery."

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