Trauma Center Rigshospitalet Copenhagen University Hospital Anne Marie Sørensen, Senior Consultant, MD, Ph.D (anaesthesiology)

TraumaCenter Rigshospitalet

Trauma Center, Copenhagen University Hospital, Rigshospitalet Rigshospitalet Uptake area 2.4 mio. cizens

800.000 cizens 1.6 mio. cizens Rigshospitalet – Trauma Center

§ Highly specialized hospital § Specialists 24/7 (almost….) § Specially trained nurses and other health care personnel § Special focus on severely injured § Educaon, quality improvement and research § Traumadatabase (TARN) Rigshospitalet Trauma Center Cooperaon between a variety of departments

§ Anestesiology § Blood bank § Burn unit § Pediatric surgery § Diagnosc radiology and IR § Gynecologi & obstetrics § Intensive care therapy in total 68 beds: § Muldisciplinary, neuro- og thoracic/cardiac § Vascular surgery § Thoracic/cardiac surgery § Abdominal/liver surgery Rigshospitalet Trauma Center Cooperaon between a variety of departments

§ Neurosurgery § Ortopedic surgery incl pelvis-, spine- & hand § Oto-rhino-laryngology § Plasc § Psychiatry § Pediatric § Dental, oral, maxillo-facial surgeon § Hyperbaric oxygen pressure chamber (decompression) § Urology Trauma Centre acvies

§ Trauma team acvaon (1.100/year) § Trauma paents requring haemostac resuscitaon in 2013: 127 – 13 Damage Control Surgery in the Traume Bay § Medical severe emergencies (450/year) § Burn paents (250/year) § Highly specialised emergency department (12.000/year) § Only selected paents (physician triaged) § Medullary cancer paents § CT scan & operang room 24/7 § Cardiac arrest team – Rigshospitalet § Disaster management

Trauma Triage

§ Physiology § Children, consciousness, circulaon, breathing § Anatomical § Traumac brain injury, penetrang, severe fracture/amputaon, burns § Mechanism of injury § Traffic, fall from heights, violence, drowning/hypothermia

Physician on the Mobile Emergency Care Unit, HEMS or ambulances acvates trauma team

TraumaCenter Rigshospitalet Systemac lifesaving procedures

§ ABCDE (ATLS) § Inial assessment § Treat most severe injuries first § Ad hoc consultaon from all speciales § Closed loop communicaon

TraumaCenter Rigshospitalet The Trauma Team 24/7

§ Teamleader Consultant Anesthesiologist § Ortopedic surgeon Consultant § Anesthesiologist Intern/fellow/registrar § Ortopedic surgeon Intern/fellow/registrar § Abdominal surgeon Consultant (FAST) § Anesthec nurse § 3 trauma nurses § Secretary § 2 orderlies § 2 technicians in Radiology § Radiologist Consultant (on call) § 2 bioanalysts TraumaCenter Rigshospitalet

Systemac lifesaving procedures § Airway § Breathing § Circulaon (i.v. lines, a-kanulla, resuscitaon – haemostac resuscitaon) § Priority § FAST § X-ray thorax § X-ray Pelvis § CT-scan To opmize inial resuscitaon and treatment of the severely injured paent New trauma Bay – October 2013

The new trauma and resuscitaon area

• >260 m2 (> 2691²) • 5 bays • 2 with CT scanner and operang table in the Trauma Bay • Angio Suite coming soon - seperately

Trauma Center, Copenhagen University Hospital, Rigshospitalet Trauma Center, Copenhagen University Hospital, Rigshospitalet Trauma Center, Copenhagen University Hospital, Rigshospitalet Trauma Center, Copenhagen University Hospital, Rigshospitalet Angio Suite (coming soon)

Rigshospitalets TraumeCenter

In total 1098

Paents with ISS >15 250 paents Non Survivors 18

Queson: Would they be alive if IR was present? 2013 Non survivors TraumaTeam Acvaon In total 18 N= 1098 Burn injuries 4

Hypothermia 1

Brain injuries 4

Stabbing (PEA at arrival) 3

Mulble injuries 2 (PEA at place of accident) Intervenon Radiology – a possibility?

Motorbike L4 fracture Laesion of v. cava -> retroperitoneal haematoma Awake (3 hour) Not surviving operaon 30% of trauma2013 patient Gun shot – neck Intubated prehospital. Massive transfusion. DamageinvolvingThoracotomia, sternotomia: bleeding from all Controlhepar are Surgery coiled vessels in regio subclavia Mulble injuries – Intubated prehospital. Massive transfusion. 13 patientes fall from height Thorax, extremies. Pelvisfracture – pelvis sling. Explorave laparotomia (DCS): retroperitoneal haematoma Car vs. Pedestrian Awake (GCS 11). Massive transfusion. Pelvic fracture type C. C-clamp. Explorave laparotomia (DCS) : retroperitoneal haematoma

Furture

Intervenon Radiologists in the TraumaTeam? 24/7? On Call? How can we teach ALL surgeons and anaesthesiologists to incorporate IR in treatment of Traumapaents? Radiologists (IR)as an integrated part of the TraumaTeam ? Research & Quality Improvement Are we the best?

ACIT3: 2010-11: 182 trauma paents in Copenhagen

A B 40% 100% 5 90% 35% (2-10) 5 5 80% 30% 5 (3-9) (2-10) (2-9) 70% 25% 5 60% 5 20% (4-9) 5 50% 5 (4-9) (4-9) (4-8) 2 40% 15% 3 2 (2-4) 3 30% (2-3) (2-4) (2-4) 10% 20% 5% RBC 10% RBC 0% FFP 0% FFP 2h PC 2h PC 6h 6h 12h 12h 24h 24h Haemorrhagic mortality < 15% in severely injured trauma patients Johansson PI, Sørensen A et al. Transfusion 2013 Johansson et al. Submitted. 2012 The ”package soluon” - Transfusion packages Haemostac Resuscitaon

Stored thawed AB RhD negave plasma immediately available for transfusion.

Acute Transfusion Package (ATP) 5 RBC, 5 FFP; 2 Platelet Concentrates (rao ~ 1 : 1 : 1) Results in – Haematocrit ~ 30% – Coagulaon factor concentraon >30% – Platelet count of 80 109/L – Normal TEG®

The packages are to be used unl haemostasis Focus on Temperature, Acidose, Avoid diluon Johansson, Stensballe et al. Transfusion 2007 Consultaon/Verificaon

§ Consultaon/Verificaon Programs for Hospitals § Site visit on 9-11 July 2012 § Verificaon visit § Trauma System Assessment § 4 experts from ACS

From the Execuve Summary § The review team and the Verificaon Review Commiee evaluated the degree to which the Rigshopitalet trauma program met the general principles and funconal intent of these criteria within the context of the Danish system § Using this approach, Rigshospitalet was found to be funconing at a level consistent with that of a Level I center Trauma Center, Copenhagen University Hospital, Rigshospitalet Trauma Center, Copenhagen University Hospital, Rigshospitalet Trauma Center, Copenhagen University Hospital, Rigshospitalet