The significance of time in the outcome

The significance of time in the outcome

Injuries can happen at lightning speed. Time point 0 (time 0) is defined as literally the seconds prior to the event, when the patient is at their normal baseline. All subsequent events, including the acute physiological response to injury , the body’s internal mechanisms to maintain homeostasis (to compensate for the sequelae of trauma), the healing processes and the actions instigated by health professionals, are associated with a ‘timeline’. This ‘timeline principle’ is crucial to a deeper understanding of how to prioritise assessment, investigation and treatment in what may be a rapidly evolving situation following injury . There is an optimal time window during which an intervention can have a radically positive e ff ect on treatment outcome. Based on this timeline, interventions may be grossly categorised as emergent (life-saving), acute (restoring and maintaining physiological and physical stability) and delayed or semielective (focusing on the treatment of post-fracture fixation complications [non-union, infection and malunion from the orthopaedic trauma point of view]). In the immediate aftermath of a major trauma, the physiological crisis continues to evolve, the risk of death is increased and less appropriate and prompt interventions are carried out. Potentially rapidly ev olving situations, such as airway obstruction, tension haemothorax and haemopericardium, if left untreated, will inevitably have catastrophic consequences and therefore should be given priority in terms of the initial medical response to an injured patient. Thus, the seriousness and the immediate impact of a specific clinical condition should dictate its prioritisation, leading to a systematic approach (‘what kills first should be managed first’) ( Figure 26.2 ). - The Advanced Trauma Life Support (ATLS) system delineates an order of priorities defined by ABCD; that is, airway , breathing, circulation and disability (neurology). This hierarchy of priorities is based on the ‘time dependence’ prin - ciple. In other words, the time taken to manage an individual problem is the sum of the time taken to identify it and to execute e ff ective treatment ( Figure 26.3 ). In such settings, time is crit - ical, so the normal history and physical in vestigations are not performed during the ATLS primary survey , but the primary focus is on detecting and identifying individual problems, rank - ing them in order of priority and dealing with them e ff ectiv ely and e ffi ciently in their appropriate timeframes. The clinician should take into consideration the mechanism of injury and initial clinical findings then promptly request and carry out specific investigations, f or e xample computed tomography (CT) scans. This is to allow rapid and precise iden - tification of injuries that may benefit from early therapeutic intervention and that otherwise might be clinically challenging as the initial signs may be subtle or non-specific. This pro - active approach is critical, as the e valuation and diagnosis of an important injury may be di ffi cult before the full-blown and potentially life-threatening presentation of that injury . A typical example would be an RT A victim with a scalp laceration and a reduced Glasgow Coma Scale (GCS) score of 13/15; such a dr op in the GCS could be explained by head

Airway obstruction Intra-abdominal bleeding External haematoma Ischaemic limb 0 Time Figure 26.2 Estimated time from incident to death or irretrievable damage for various conditions. Overall timeline for generic injury Death Assessment time Response time 0 Time Figure 26.3 Diagrammatic representation of the relationship between assessment and response times. In this example, there is time to assess and respond effectively before death.

injury or by the presence of shock and hypoxia. Waiting for the development of overt clinical signs could be dangerous. Should there be any injury such as an extradural haematoma this can be diagnosed with a head CT prior to the presentation of clinical signs. Prompt surgical decompression will result in a reduced risk of morbidity and mortality . In this situation, if the time taken to make the diagnosis were prolonged, such that the clinical signs presented prior to treatment intervention, it may be too late to prevent the death of the patient ( Figure 26.4 This frequently encountered clinical case scenario demon strates the principle that we need to introduce a management response even before we have made the definitive diagnosis if we want to save the patient’s life. It is clear, theref ore, that the ‘timeline concept’ is critical in the safe management of trauma patients. Reducing the diagnosis time and response time of our interventions is dependent not only on clinical sta ff but also on the availability of resources. For the example above, a dedi cated trauma team and a CT scanner should be available 24/7. Recently , this 24/7 availability of the trauma team and the designation of regional hospitals to operate as Level I Trauma Centres, with the availability of all disciplines and appr equipment on site, has provided the necessary foundation for the development of a unified trauma care system in England. Indeed, the first reports published on its e ff ectiveness in saving lives have been very positive. The ‘timeline concept’ that has been discussed in the man agement of patients with multiple trauma can be applied to patients with isolated injuries. Again, the key issue – irrespec tive of the number of injuries – is to minimise delays in making the diagnosis and promptly initiate treatment. Suc h a global approach would save lives, reduce morbidity and make the healthcare system more e ffi cient in ter ms of resource utilisa tion, as well as cost-e ff ectiveness. The importance of time /uni25CF /uni25CF /uni25CF /uni25CF Most importantly , dealing with a patient in an acute set - ting is a dynamic situation, which may fluctuate unpredictably along the timeline. Therefore, any observation and analysis may evolve rapidly to an extent that interventions need to be modified according ly . Thus, ongoing patient evaluation is essential in order to identify and respond to every fluctuation noted in a timely fashion. The initial primary survey , applied according to the ATLS protocol in trauma patients, should be followed by secondary and tertiary clinical assessment, even after the acute phase of treatment has been completed suc - cessfully . Ongoing monitoring of vital organ activity , ordering of the necessary biochemical and radiological investigations and recording of all the findings in a single place can allow easier evaluation and identification of tr ends over time to facilitate prompt intervention. Such a strategy may reduce the risk of having undiagnosed injuries and delays in a patient’s treatment. Several studies have been published that report on missed injuries and make some recommendations on how to avoid these. The timeline following an injury is continuous, and the accumulated documentation may become voluminous, com - plex and confusing. It is helpful periodically to make the e ff ort ). to stand back and summarise the situation. In its recent trauma - guidelines, NICE refers to this and advises that a plain lan - guage summary of the situation directed at the patient’s family doctor, but intelligible and available to the patient or carers, should be produced within 24 hours.

Evolving assessment for extradural haematoma (a) Fracture Haematoma Subtle Clinically on on imaging clinical obvious imaging signs Components of response time (b) Refer Transfer Anaesthetise Decompress Overall timeline for extradural haematoma (c) 0 Time Figure 26.4 Diagrammatic representation of the relationship between assessment and response times for extradural haematoma: stages of assessment, (b) the components of the response and (c) the overall time from incident to death. It can be seen that relying on obvious clinical signs gives insuf /f_i cient time to respond effectively. A thorough understanding of the ‘timeline concept’ in trauma is critical Assessment should be completed within a set time The time to respond is limited The goal is for both assessment and response to take place in the time window prior to irreversible damage or death Death (a) the

The significance of time in the outcome

Injuries can happen at lightning speed. Time point 0 (time 0) is defined as literally the seconds prior to the event, when the patient is at their normal baseline. All subsequent events, including the acute physiological response to injury , the body’s internal mechanisms to maintain homeostasis (to compensate for the sequelae of trauma), the healing processes and the actions instigated by health professionals, are associated with a ‘timeline’. This ‘timeline principle’ is crucial to a deeper understanding of how to prioritise assessment, investigation and treatment in what may be a rapidly evolving situation following injury . There is an optimal time window during which an intervention can have a radically positive e ff ect on treatment outcome. Based on this timeline, interventions may be grossly categorised as emergent (life-saving), acute (restoring and maintaining physiological and physical stability) and delayed or semielective (focusing on the treatment of post-fracture fixation complications [non-union, infection and malunion from the orthopaedic trauma point of view]). In the immediate aftermath of a major trauma, the physiological crisis continues to evolve, the risk of death is increased and less appropriate and prompt interventions are carried out. Potentially rapidly ev olving situations, such as airway obstruction, tension haemothorax and haemopericardium, if left untreated, will inevitably have catastrophic consequences and therefore should be given priority in terms of the initial medical response to an injured patient. Thus, the seriousness and the immediate impact of a specific clinical condition should dictate its prioritisation, leading to a systematic approach (‘what kills first should be managed first’) ( Figure 26.2 ). - The Advanced Trauma Life Support (ATLS) system delineates an order of priorities defined by ABCD; that is, airway , breathing, circulation and disability (neurology). This hierarchy of priorities is based on the ‘time dependence’ prin - ciple. In other words, the time taken to manage an individual problem is the sum of the time taken to identify it and to execute e ff ective treatment ( Figure 26.3 ). In such settings, time is crit - ical, so the normal history and physical in vestigations are not performed during the ATLS primary survey , but the primary focus is on detecting and identifying individual problems, rank - ing them in order of priority and dealing with them e ff ectiv ely and e ffi ciently in their appropriate timeframes. The clinician should take into consideration the mechanism of injury and initial clinical findings then promptly request and carry out specific investigations, f or e xample computed tomography (CT) scans. This is to allow rapid and precise iden - tification of injuries that may benefit from early therapeutic intervention and that otherwise might be clinically challenging as the initial signs may be subtle or non-specific. This pro - active approach is critical, as the e valuation and diagnosis of an important injury may be di ffi cult before the full-blown and potentially life-threatening presentation of that injury . A typical example would be an RT A victim with a scalp laceration and a reduced Glasgow Coma Scale (GCS) score of 13/15; such a dr op in the GCS could be explained by head

Airway obstruction Intra-abdominal bleeding External haematoma Ischaemic limb 0 Time Figure 26.2 Estimated time from incident to death or irretrievable damage for various conditions. Overall timeline for generic injury Death Assessment time Response time 0 Time Figure 26.3 Diagrammatic representation of the relationship between assessment and response times. In this example, there is time to assess and respond effectively before death.

injury or by the presence of shock and hypoxia. Waiting for the development of overt clinical signs could be dangerous. Should there be any injury such as an extradural haematoma this can be diagnosed with a head CT prior to the presentation of clinical signs. Prompt surgical decompression will result in a reduced risk of morbidity and mortality . In this situation, if the time taken to make the diagnosis were prolonged, such that the clinical signs presented prior to treatment intervention, it may be too late to prevent the death of the patient ( Figure 26.4 This frequently encountered clinical case scenario demon strates the principle that we need to introduce a management response even before we have made the definitive diagnosis if we want to save the patient’s life. It is clear, theref ore, that the ‘timeline concept’ is critical in the safe management of trauma patients. Reducing the diagnosis time and response time of our interventions is dependent not only on clinical sta ff but also on the availability of resources. For the example above, a dedi cated trauma team and a CT scanner should be available 24/7. Recently , this 24/7 availability of the trauma team and the designation of regional hospitals to operate as Level I Trauma Centres, with the availability of all disciplines and appr equipment on site, has provided the necessary foundation for the development of a unified trauma care system in England. Indeed, the first reports published on its e ff ectiveness in saving lives have been very positive. The ‘timeline concept’ that has been discussed in the man agement of patients with multiple trauma can be applied to patients with isolated injuries. Again, the key issue – irrespec tive of the number of injuries – is to minimise delays in making the diagnosis and promptly initiate treatment. Suc h a global approach would save lives, reduce morbidity and make the healthcare system more e ffi cient in ter ms of resource utilisa tion, as well as cost-e ff ectiveness. The importance of time /uni25CF /uni25CF /uni25CF /uni25CF Most importantly , dealing with a patient in an acute set - ting is a dynamic situation, which may fluctuate unpredictably along the timeline. Therefore, any observation and analysis may evolve rapidly to an extent that interventions need to be modified according ly . Thus, ongoing patient evaluation is essential in order to identify and respond to every fluctuation noted in a timely fashion. The initial primary survey , applied according to the ATLS protocol in trauma patients, should be followed by secondary and tertiary clinical assessment, even after the acute phase of treatment has been completed suc - cessfully . Ongoing monitoring of vital organ activity , ordering of the necessary biochemical and radiological investigations and recording of all the findings in a single place can allow easier evaluation and identification of tr ends over time to facilitate prompt intervention. Such a strategy may reduce the risk of having undiagnosed injuries and delays in a patient’s treatment. Several studies have been published that report on missed injuries and make some recommendations on how to avoid these. The timeline following an injury is continuous, and the accumulated documentation may become voluminous, com - plex and confusing. It is helpful periodically to make the e ff ort ). to stand back and summarise the situation. In its recent trauma - guidelines, NICE refers to this and advises that a plain lan - guage summary of the situation directed at the patient’s family doctor, but intelligible and available to the patient or carers, should be produced within 24 hours.

Evolving assessment for extradural haematoma (a) Fracture Haematoma Subtle Clinically on on imaging clinical obvious imaging signs Components of response time (b) Refer Transfer Anaesthetise Decompress Overall timeline for extradural haematoma (c) 0 Time Figure 26.4 Diagrammatic representation of the relationship between assessment and response times for extradural haematoma: stages of assessment, (b) the components of the response and (c) the overall time from incident to death. It can be seen that relying on obvious clinical signs gives insuf /f_i cient time to respond effectively. A thorough understanding of the ‘timeline concept’ in trauma is critical Assessment should be completed within a set time The time to respond is limited The goal is for both assessment and response to take place in the time window prior to irreversible damage or death Death (a) the

The significance of time in the outcome

Injuries can happen at lightning speed. Time point 0 (time 0) is defined as literally the seconds prior to the event, when the patient is at their normal baseline. All subsequent events, including the acute physiological response to injury , the body’s internal mechanisms to maintain homeostasis (to compensate for the sequelae of trauma), the healing processes and the actions instigated by health professionals, are associated with a ‘timeline’. This ‘timeline principle’ is crucial to a deeper understanding of how to prioritise assessment, investigation and treatment in what may be a rapidly evolving situation following injury . There is an optimal time window during which an intervention can have a radically positive e ff ect on treatment outcome. Based on this timeline, interventions may be grossly categorised as emergent (life-saving), acute (restoring and maintaining physiological and physical stability) and delayed or semielective (focusing on the treatment of post-fracture fixation complications [non-union, infection and malunion from the orthopaedic trauma point of view]). In the immediate aftermath of a major trauma, the physiological crisis continues to evolve, the risk of death is increased and less appropriate and prompt interventions are carried out. Potentially rapidly ev olving situations, such as airway obstruction, tension haemothorax and haemopericardium, if left untreated, will inevitably have catastrophic consequences and therefore should be given priority in terms of the initial medical response to an injured patient. Thus, the seriousness and the immediate impact of a specific clinical condition should dictate its prioritisation, leading to a systematic approach (‘what kills first should be managed first’) ( Figure 26.2 ). - The Advanced Trauma Life Support (ATLS) system delineates an order of priorities defined by ABCD; that is, airway , breathing, circulation and disability (neurology). This hierarchy of priorities is based on the ‘time dependence’ prin - ciple. In other words, the time taken to manage an individual problem is the sum of the time taken to identify it and to execute e ff ective treatment ( Figure 26.3 ). In such settings, time is crit - ical, so the normal history and physical in vestigations are not performed during the ATLS primary survey , but the primary focus is on detecting and identifying individual problems, rank - ing them in order of priority and dealing with them e ff ectiv ely and e ffi ciently in their appropriate timeframes. The clinician should take into consideration the mechanism of injury and initial clinical findings then promptly request and carry out specific investigations, f or e xample computed tomography (CT) scans. This is to allow rapid and precise iden - tification of injuries that may benefit from early therapeutic intervention and that otherwise might be clinically challenging as the initial signs may be subtle or non-specific. This pro - active approach is critical, as the e valuation and diagnosis of an important injury may be di ffi cult before the full-blown and potentially life-threatening presentation of that injury . A typical example would be an RT A victim with a scalp laceration and a reduced Glasgow Coma Scale (GCS) score of 13/15; such a dr op in the GCS could be explained by head

Airway obstruction Intra-abdominal bleeding External haematoma Ischaemic limb 0 Time Figure 26.2 Estimated time from incident to death or irretrievable damage for various conditions. Overall timeline for generic injury Death Assessment time Response time 0 Time Figure 26.3 Diagrammatic representation of the relationship between assessment and response times. In this example, there is time to assess and respond effectively before death.

injury or by the presence of shock and hypoxia. Waiting for the development of overt clinical signs could be dangerous. Should there be any injury such as an extradural haematoma this can be diagnosed with a head CT prior to the presentation of clinical signs. Prompt surgical decompression will result in a reduced risk of morbidity and mortality . In this situation, if the time taken to make the diagnosis were prolonged, such that the clinical signs presented prior to treatment intervention, it may be too late to prevent the death of the patient ( Figure 26.4 This frequently encountered clinical case scenario demon strates the principle that we need to introduce a management response even before we have made the definitive diagnosis if we want to save the patient’s life. It is clear, theref ore, that the ‘timeline concept’ is critical in the safe management of trauma patients. Reducing the diagnosis time and response time of our interventions is dependent not only on clinical sta ff but also on the availability of resources. For the example above, a dedi cated trauma team and a CT scanner should be available 24/7. Recently , this 24/7 availability of the trauma team and the designation of regional hospitals to operate as Level I Trauma Centres, with the availability of all disciplines and appr equipment on site, has provided the necessary foundation for the development of a unified trauma care system in England. Indeed, the first reports published on its e ff ectiveness in saving lives have been very positive. The ‘timeline concept’ that has been discussed in the man agement of patients with multiple trauma can be applied to patients with isolated injuries. Again, the key issue – irrespec tive of the number of injuries – is to minimise delays in making the diagnosis and promptly initiate treatment. Suc h a global approach would save lives, reduce morbidity and make the healthcare system more e ffi cient in ter ms of resource utilisa tion, as well as cost-e ff ectiveness. The importance of time /uni25CF /uni25CF /uni25CF /uni25CF Most importantly , dealing with a patient in an acute set - ting is a dynamic situation, which may fluctuate unpredictably along the timeline. Therefore, any observation and analysis may evolve rapidly to an extent that interventions need to be modified according ly . Thus, ongoing patient evaluation is essential in order to identify and respond to every fluctuation noted in a timely fashion. The initial primary survey , applied according to the ATLS protocol in trauma patients, should be followed by secondary and tertiary clinical assessment, even after the acute phase of treatment has been completed suc - cessfully . Ongoing monitoring of vital organ activity , ordering of the necessary biochemical and radiological investigations and recording of all the findings in a single place can allow easier evaluation and identification of tr ends over time to facilitate prompt intervention. Such a strategy may reduce the risk of having undiagnosed injuries and delays in a patient’s treatment. Several studies have been published that report on missed injuries and make some recommendations on how to avoid these. The timeline following an injury is continuous, and the accumulated documentation may become voluminous, com - plex and confusing. It is helpful periodically to make the e ff ort ). to stand back and summarise the situation. In its recent trauma - guidelines, NICE refers to this and advises that a plain lan - guage summary of the situation directed at the patient’s family doctor, but intelligible and available to the patient or carers, should be produced within 24 hours.

Evolving assessment for extradural haematoma (a) Fracture Haematoma Subtle Clinically on on imaging clinical obvious imaging signs Components of response time (b) Refer Transfer Anaesthetise Decompress Overall timeline for extradural haematoma (c) 0 Time Figure 26.4 Diagrammatic representation of the relationship between assessment and response times for extradural haematoma: stages of assessment, (b) the components of the response and (c) the overall time from incident to death. It can be seen that relying on obvious clinical signs gives insuf /f_i cient time to respond effectively. A thorough understanding of the ‘timeline concept’ in trauma is critical Assessment should be completed within a set time The time to respond is limited The goal is for both assessment and response to take place in the time window prior to irreversible damage or death Death (a) the