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Trauma surgery audit 2016
1) This document summarizes trauma census data and surgical procedures from the Division of Trauma Surgery and Critical Care at AIIMS for the year 2016. 2) There was a 2.6% increase in emergency department attendance in 2016 with 71% of patients triaged as green, 23% as yellow, and 6% as red. 3) A total of 1960 patients were admitted under trauma surgery with 73% from the ED and 27% follow up cases. 4) The most common modes of injury were road traffic accidents (52.8%), falls (17.4%), and assaults (13.8%). 5) A total of 1948 surgical procedures were performed, with the most common being for extremities (794), abdomen
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Trauma surgery audit 2016
- 1. Division of TraumaSurgery and Critical Care JPN Apex Trauma Center All India Institute of Medical Sciences TRAUMA CENSUS 2016
- 2. ED ATTENDANCE 2016(n=66,891) 46998, 71% 15677, 23% 3926, 6% Triage Green Yellow Red
- 3. FIVE YEAR EDDATA Year 2012 2013 2014 2015 2016 Total 53050 55171 55734 64913 66,891 2.6% INCREASE IN ED ATTENDANCE 38964 35316 40928 49677 46998 10950 17066 11729 11612 15677 3136 2789 3077 3624 3926 0 10000 20000 30000 40000 50000 60000 70000 2012 2013 2014 2015 2016 RED YELLOW GREEN
- 4. EMERGENCY DEPARTMENT RED AREADETAILS (N= 3906) SPECIALITY TOTAL NO ADMITTED RE-TRIAGED TO YELLOW ADMITTED/ TRANSFER OUT/ DISCHARGED SURGERY 1465 1408 57 18/8/31 NEURO- SURGERY 1530 1309 221 16/134/71 ORTHO 911 206 705 350/342/13
- 5. ED INTERVENTIONS (N=19,078) ProcedureNo. Suturing 18532 ICD Insertion 492 Tracheostomy 1 Cricothyroidotomy 0 SPC (Percutaneous) 17 CT Angiography 36
- 6. ADMISSION UNDER TRAUMASURGERY (N=1960) 1426, 73% 534, 27% A ED FUC
- 7. YEARLY SURGERY ADMISSIONS YEAR2012 2013 2014 2015 2016 SURGERY ADMISSIONS 1299 1625 1789 1879 1960 918 1348 1284 1386 1426 381 275 505 493 534 2012 2013 2014 2015 2016 ED FOLLOW UP 4% increase in annual surgery admissions
- 8. DEMOGRAPHIC PROFILE (N=1426) 1217, 85% 209,15% M/F Male Female 1152, 81% 150, 10% 124, 9% Adult ( >18yrs) Adolescent (12-18) Pediatric (<12yrs)
- 9. Demographic Profile (n-1426) Trendover 3 years Numbers of Admissions(n-1426) 55 189 476 312 170 43 33 6 87 246 491 296 136 79 37 14 106 240 536 265 130 101 39 9 less than 10 11-20 yrs 21-30 yrs 31-40 yrs 41-50 yrs 51-60 yrs 61-70 yrs more than 70 2014 2015 2016
- 10. MODE OF INJURY(N-1426) 52.8% 17.4% 13.8% 9.9% 4.4% 1.6% 0 100 200 300 400 500 600 700 800 Distribution Distribution
- 11. 719 174 170 193 1018 835 210 185 97 40 19753 248 197 142 64 22 0 100 200 300 400 500 600 700 800 900 RTA FFH ASSAULT UNINTENTIONAL RAILWAY TRACK INJURY SELF INFLICTED 2014 2015 2016 Mode of Injury (n-1426) Trend over 3 years
- 12. Modes of RTI(n- 753, 52.8% ) Mode of RTI No. % Pedestrian 161 21.3 Bicycle 22 2.9 Motorized 2 wheeler 311 41.3 Motorized 3 wheeler 49 6.5 4 wheeler 88 11.7 Heavy vehicle 43 5.7 Bullock cart 6 0.7 Unknown 73 9.6
- 13. Assault Cases (n=197,13.8% ) 39, 20% 108, 55% 50, 25% Cases Blunt assault Low velocity penetrating high velocity Penetrating
- 14. Anatomical Distribution ofInjuries (n= 2029) 97 101 409 680 452 182 108 0 100 200 300 400 500 600 700 800 Series 1
- 15. Head & Neck Maxillof acial Chest Abdome n & Pelvis Extremit ies Soft tissue Vascular 201697 101 409 680 452 182 108 2015 108 129 429 595 495 344 139 2014 119 129 444 492 475 205 136 97 101 409 680 452 182 108 108 129 429 595 495 344 139 119 129 444 492 475 205 136 0 100 200 300 400 500 600 700 800 AxisTitle Anatomical Distribution of Injuries(n=2029) Trend over 3 years
- 16. Abdominal Trauma (n=680) (33.5%of all Trauma, n= 2029) Organ Involved No. Solid Organ (Liver or Spleen) Single Organ 197 > 1 Organ 97 Hollow Viscus 103 Genitourinary 67 Pancreatico-duodenal 26 Others (Hemoperitoneum, Retroperitoneal hematoma) 191
- 17. Liver Trauma (n=139) (20.5% of all abdominal Trauma , n= 680 ) 90, 64.7 % 49, 35.2 % ISOLATED ASSOCIATED 16 38 24 33 28 0 5 10 15 20 25 30 35 40 GRADE 1 GRADE 2 GRADE 3 GRADE 4 GRADE 5
- 18. Liver Trauma Management(n=139) CECT OF LIVER TRAUMA Mortality : Total 16 ( 11.5%), Hemorrhagic Shock – 10 (62.5%); Septicemic shock 6 ( 37.5%) NOM w/o AE, 96, 69% NOM w/ AE, 14, 10% Operative w/ AE, 12, 9% Operative w/o AE, 17, 12% Mx
- 19. Splenic Trauma (n=116) (17.1% of Abdominal Trauma, n= 680) 68, 58.6% 48, 41.3% ISOLATED ASSOCIATED 17 28 23 34 14 0 5 10 15 20 25 30 35 40 GRADE 1 GRADE 2 GRADE 3 GRADE 4 GRADE 5
- 20. Splenic Trauma Management(n=116) CECT OF SPLENIC INJURY Non- Operative w/o AE, 62, 53% Non- operative with AE, 28, 24% Splenectom y, 24, 21% Splenorrap hy, 2, 2% Mortality : Total 2 ( 1.7%), Hemorrhagic Shock – 1 (50%); Septicemic shock 1 ( 50%) Failure of NOM - 0
- 21. Hollow Viscus Trauma(n=103) (15.1%of abdominal Trauma , n= 680) Hollow Viscus Procedure Nos. Esophagus: 3 (2.9)%) Cervical Oesophagostomy + FJ 3 Stomach: 15 (15.9%) Repair 15 Jejunum: 39 (39.4%) Repair 18 RA + FJ 21 Ileum: 23 (21.2%) Repair 8 RA 5 Ileostomy 10 Colon And Rectum: 23 (23.4%) Repair 6 RA 3 End Colostomy 12 Loop Colostomy 2
- 22. Pancreatico-duodenal Trauma(n=26) 3.8% ofall abdominal Trauma, n= 680 Procedure No. Spleen preserving Distal Pancreatectomy 5 Distal Pancreatectomy + Splenectomy 5 Repair of laceration 1 NOM 7 Isolated Pancreatic Trauma (n=18; 69.2%) Mortality : Total 1 (3.8%), Hemorrhagic Shock – 0; MODS – 1 ( 100%)
- 23. Procedure No. Drain Placementfor Duodenal Hematoma 1 Repair + RD + FJ 3 NOM 2 Pyloric Exclusion + GJ + RD + Repair (2nd part of Duodenal Injury) 2 Pancreatico-duodenal Trauma(n=26) Pancreatic Associated with Duodenal Trauma (8; 30.7%)
- 24. Genitourinary trauma (n=67) (9.8of Abdominal trauma (n=680) Management KIDNEY (41, 61.9%) Operative: • Nephrectomy • Repair 4 3 NOM 34 URETER (4, 6.3%) Repair DJ Stenting 1 3
- 25. Genitourinary trauma(n=67) Management BLADDER (11, 17.4%) ExtraperitonealNOM WITH PUC 5 Intraperitoneal Repair with SPC 4 Repair with PUC 2 URETHRA (5, 7.9%) SPC 5 TESTES (1, 1.5%) Repair 1 PENILE TRAUMA (3, 4.7%) Repair 3 VAGINAL TRAUMA 2 Repair 2
- 26. Laparoscopic & EndoscopicProcedures (n=51) Procedure No. Diagnostic Laparoscopy 38 Lap Diaphragmatic Repair 4 PEG 4 Lap Cholecystectomy 3 Percutaneous endoscopic Necrosectomy 2
- 27. Thoracic Trauma (n=409) 314, 81% 73, 19% B WithICD Without ICD 387, 95% 22, 5% A Non-Operative Operative Mortality : Total 15 (3.66%), Hemorrhagic Shock – 4 (27.5%); Septicemic shock 11 ( 66.5%)
- 28. Thoracic Injury (n=409) OperativeCases, n=22; 5.5% Intra-op picture of Thoracotomy Major Indications No. Massive Hemothorax 6 Cardiac Trauma 4 VATS 3 Bronchopleural fistula 3 Subclavian artery injury 2 Lung hernia repair 1 Resuscitative Thoracotomy 3
- 29.
- 30. Upper Limb, n=66,68.04% Peripheral Vascular Trauma (n=97) 7 29 10 14 6 0 5 10 15 20 25 30 35 AXILLARY BRACHIAL RADIAL ULNAR RADIAL+ULNAR
- 31. Lower Limb (n=31,30.92%) Peripheral Vascular Trauma (n=97) 11 20 0 2 4 6 8 10 12 14 16 18 20 FEMORAL POPLITEAL
- 32. Vascular Trauma Management(n=97) Average Critical Ischemic time (Hrs) INTERPOSITION GRAFT EEAwith EMBOLECTOM Y EMBOLECT OMY only Outcome RSVG Synthetic Limb salvage Ampu tation AXILLARY (7) 8Hrs 1 - 6 0 6 1 BRACHIAL (29) 7.5hrs 8 - 18 3 29 0 RADIAL (12) 6Hrs - - 12 0 12 0 ULNAR (18) 6Hrs - - 18 0 18 0 FEMORAL (11) 9Hrs 2 1 7 1 10 1 POPLITEAL (20) 6.5Hrs 10 - 4 6 17 3
- 33. Vascular Trauma Management(n=97) EtEAnastomosis : 65 cases, 66.2% Reverse Saphenous Graft : 21 cases, 22.4% Embolectomy: 10 cases, 9.4% PTFE Graft (Femoral artery): 1 case, 1.3% Primary Amputation: 0 Amputation (after vascular intervention): 5 cases, 5.7%
- 34. Central Vascular Injury(n=11) VESSELINVOLVED NO. MANAGEMENT Subclavian Artery 02 04 Inter-position grafting Non op ( Concomitant Brachial Plexus Injury - Viable non-functional limb) Inferior Vena Cava 01 Primary Repair Descending Thoracic Aorta 02 Stent grafting External Carotid Artery 01 Repair Common carotid artery 1 REPAIR
- 35. Neck trauma (n=29) 9,31% 13, 45% 2, 7% 5, 17% A Blunt Low velocity penetrating High velocity penetrating Kite injuries
- 36. Neck trauma –Injurydistribution (n=29) 7 15 7 0 5 10 15 20 AeroDigestive Vascular Soft tissues Injuries 3 20 6 0 10 20 30 Zone I Zone II Zone III Neck Zones
- 37. Neck trauma –Management (n=29) Procedure No. Primary Tracheal Repair 05 Exploration with Hemostasis 12 Primary Repair of Larynx 02 NOM 10
- 38. Oral and MaxillofacialInjury (n=101) Mandible (n=63) 27 9 11 16 0 5 10 15 20 25 30 PARASYMPHYSIS ANGLE PARASYMPHYSISAND ANGLE PARASYMPHYSISAND CONDYLE DISTRIBUTION MANDIBLE INJURY
- 39. Oral and Maxillofacial(n=101) Others (n=38) Subdivision of Cases-Mid Face 7 10 9 12 0 2 4 6 8 10 12 14 Lefort1 Lefort2 Lefort3 ZMCwith panfacial
- 40. Soft Tissue ReconstructiveProcedures (n=862) 265, 30.6% 368, 42.4% 129, 15.3% 4, 0.4% 96, 11.1% STSG DEBRIDEMENT DEBRIDEMENT + STSG FTG FLAP
- 41.
- 42. Operative Procedures(n=1948) 1497, 76% 348,17% 132, 7% Distribution General Anesthesia Spinal anesthesia Local Anesthesia
- 43. OPERATIVE PROCEDURES (N=1948) Type No. EMERGENCY 765 PLANNED 1183 Region-wise No. ABDOMEN 324 THORAX 41 MAXILLO-FACIAL 101 VASCULAR 108 EXTREMITIES 794 HEAD &NECK 55 GENITO URINARY 31 PLASTIC AND SOFT TISSUE 494 Type of Anesthesia No. GA 1459 SA 343 LA+BRACHIAL 146
- 44. NUMBER OF SURGICALPROCEDURES THORAX THORACOTOMY 26 VATS 3 ABDOMEN SPLEEN SPLENECTOMY 29 SPLENORRHAPHY 2 LIVER PACKING 29 PACK REMOVAL 25 OESOPHAGUS OESOPHAGOSTOMY 3 REPAIR 0 STOMACH REPAIR 15 PEG 4 DUODENUM REPAIR 5 DUODENOSTOMY+FJ 5 JEJUNUM REPAIR 18 RA 21
- 45. ABDOMEN ILEUM REPAIR 8 ILEOSTOMY+REPAIR 10 COLON COLOSTOMY14 REPAIR 6 RA 3 PANCREAS RESECTION 10 GALL BLADDER CHOLECYSTECTOMY 2 CBD REPAIR 0 MESH LAPAROSTOMY 49 PELVIS PACKING AND INTERNAL ILIAC ART. LIGATION 14 GENITOURINARY KIDNEY RENORRHAPHY 3 NEPHRECTOMY 4 URETER REPAIR 1 STENTING 3
- 46. GENITOURINARY BLADDER REPAIR 6 SPC 4 URETHRAURETHROPLASTY 5 LAPROSCOPIC PROCEDURES DIAGNOSTIC LAPROSCOPY 38 EXTREMITY STUMP REVISION/ SECONDARY SUTURING 151 VASCULAR CENTRAL VASCULAR REPAIR 7 PERIPHERAL VASCULAR REPAIR 97 FACIAL BONES MANDIBLE ORIF WIRING 46 7 NECK TRACHEA TRACHEAL REPAIR 6 NECK EXPLORATION 20 PLASTIC AND SOFT TISSUE GRAFT + FLAP SURGERY 394 + 100 DEBRIDEMENT 528
- 47. Planned Abdominal Procedures ProcedureNos. Abdominoplasty 11 Colostomy Restoration 6 Ileostomy Restoration 1 Urethroplasty 5 Inlay Mesh Hernioplasty
- 48. INTERVENTIONAL RADIOLOGY (n=98) • Liver Angio-embolization – 26 • Splenic AE – 28 • Pelvic – 4 • Renal Artery – 2 • Maxillary Artery – 3 • PCN – 3 • PTBD – 2 • IVC filter – 2 • Misc. (PEG, Thrombin inj, Other arteries) - 19
- 49.
- 50. • ICU ADMISSION– 588 • ICU MORTALITY – 108 ( 18.3%)
- 51.
- 52. ICU Interventions 191 205 186 56 146 147 0 50100 150 200 250 ICD CENTRAL LINE ARTERIAL LINE PCT FOB DIALYSIS
- 53. ICU MORTALITY (N=108) HAEMORRHAG ICSHOCK, 36, 33% SEPTIC SHOCK, 39, 36% MODS, 14, 13% HEAD INJURY, 6, 6% ARDS, 8, 7% OTHERS, 5, 5%
- 54. ANATOMICAL DISTRIBUTION OF MORTALITY( N-108) HEAD AND NECK, 13, 12% ABDOMEN AND PELVIS, 49, 45% THORAX, 23, 21% EXTREMITY, 19, 18% VASCULAR, 2, 2% SOFT TISSUE, 2, 2%
- 55. 3 Yearly MortalityComparison 34 44 3636 43 39 4 5 5 7 16 14 5 7 6 0 5 10 15 20 25 30 35 40 45 50 2014 2015 2016 HEMORRHAGIC SHOCK SEPSIS ARDS MODS HEAD INJURY
- 56. INJURY SEVERITY SCORE(ISS) 0 5 10 15 20 25 30 35 40 45 50 1 11 21 31 41 51 61 71 81 91 101
- 57. Cause of Deathin ISS 15 and < 15 (n=16) 2 8 3 1 1 1 0 1 2 3 4 5 6 7 8 9 OTHERS SS MODS ARDS HS HI
- 58. MULTIPLE CASUALTIES SI. NO MODE OF INJURY MECHANISMPLACE DATE VICTIMS BROUGHT TO ED 1 RTI Head on collision between 2 cars Meerut 03-01-16 6 2 Constructio n site Mud collapse Kidwai Nagar 11-01-16 12 3 RTI Truck overturn Suraj Kund 21-01-16 13 4 RTI Tempo hit by Truck Sarita Vihar 22-01-16 7 5 RTI Car hit with DTC bus BRT Corridor 23-02-16 5 6 RTI Bike and Rikshaw passengers hit by car Kalkaji 27-02-16 6
- 59. 7 Assault GroupAssault Fatehpur Beri 14-04-16 15 8 Constructio n site Collapse of wall Fatehpur Beri 20-04-16 5 9 RTI Head on collision between 2 cars Dwark Express 25-04-16 12 10 Assault Group Assault Malaviya Nagar 25-10-16 21 11 RTI Pedestrian hit by 4 wheeler Noida 25-11-16 5 12 RTI Bus Overturn Sarai Kale Khan 27-12-16 8
- 60.
- 61. • Total EDadmission – 1426 • Total ED mortality – 11 • Total OT mortality - 13 • Total ICU mortality – 108 • Total mortality Rate – 9.25%
- 62. Early and LateMortality(n=132) 0 10 20 30 40 50 60 70 <6hrs 6-24hrs 24-72HRS >72HRS 36 8 21 67
- 63. SUMMARY • Average EDattendance per day is 180 • Around 52 minor procedures done in ED per day. • Majority of trauma victims are young males( 20-40 years, 59%). • RTI is the most common mode of injury( 52.8%). • Two wheeler were involved in 45.65% of RTI cases. • Majority of thoracic, liver , spleen and renal injuries treated non operatively • Newer interventions like PEN utilized.
- 64.
- 65.
- 66. Infected Subclavian Stentwith septicemia
- 67. Thrasher Entrapment ofhair Scalp avulsion
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- 72.