Injury Management should be included as "Must Know"

1.  Professor (Dr.) Ranabir Pal: Situational analysis of trauma
(Epidemiology)
 Professor Amit Agrawal: Prehospital care of injury victims
 Dr Harsh Deora: Trauma Care at Hospital Levels
 Dr Amrita Ghosh: Injury Biomarkers
 Dr Raman Kumar: Primary Injury Care
Injury Management should be included as
"Must Know"

2.  Spectrum: Domestic, Peri-domestic and Occupational
 Estimated 1.5 to 2 million persons injured and 1 million
succumb to death every year in India
 In India one in every 6 cases of trauma die while in the US
the same figure is 1 in 200
 Injury is the leading cause of morbidity, mortality, disability
and socioeconomic losses (Public, Private, OOP)
 Road traffic injuries are the leading cause (60%) of TBIs
followed by falls (20%-25%) and violence (10%)
Burden of the problem
G. Gururaj. Epidemiology of traumatic brain injuries: Indian scenario, Neurological Research,2002;24:1, 2428.

3. Situational analysis
 0.5% of head injury cases transported by ambulance in New
Delhi*
 No first aid was administered in 65% of cases *
 7% of TBI cases arrive at a hospital within ‘‘Golden hour’’ **
 80% of trauma patients in India cannot get access to medical
care within the first hour ***
 50% of cases: no pre-hospital care or treatment offered by
qualified personnel when ambulance used to transport victim to
hospital****
* Colohan AR, Alves WM, et al. Head injury mortality in two centres with different emergency medical services and intensive care. J Neurosurg
1989;71(2):202-7
* * Pandian JD, et al. Factors delaying admission to a hospital-based stroke unit in India. J Stroke Cerebrovasc Dis. 2006;15(3):81-87.
* * * Fitzgerald M, Dewan Y,,et al. India and the management of road crashes: towards a national trauma system. Indian J Surg. 2006;
68(4):226-32
* * * * Ramanujam P, Aschkenasy M. Identifying the need for prehospital and emergency care in the developing world: case study in Chennai,
India. J A ssoc Physicians India. 2007;55:491-495.

4.  Emergency and pre-hospital care services are
fragmented
 Ambulance system ineffective due to poor infrastructure
 Lack of trained pre-hospital personnel
 Lack of support to access to services
 Pre-hospital care (c.f. ≠ First Aid):
Not accessible throughout the country
Unknown concept to Citizens and Family Physicians
EMS in India
*Sharma, M., & Brandler, E. (2014). Emergency Medical Services in India: The
Present and Future. Prehospital and Disaster Medicine, 29(3), 307-310.

5.  Do we have data that how many injury patients are being
treated by our colleagues across the country every year!
 What’s about those patients who did not require and/ or
turn up any hospital care!
 What’s the exact incidence of injuries as majority of
victims do not require in-hospital care/or do not reach to
hospital or do not have access to the hospital or treated
elsewhere!
What’s the real picture!
Sharma M, Brandler ES. Emergency medical services in India: the present and
future. Prehosp Disaster Med. 2014 Jun;29(3):307-10. doi:
10.1017/S1049023X14000296. Epub 2014 Apr 10. PubMed PMID: 24721137.

6. What is needed?
 Information on incident injury figures (c.f. cancer)
 Injuries require basic pre-hospital care + management
 Injuries require advanced pre-hospital care
 Injuries those do not require hospital care but requires
specialist attention
 Injuries that require in-hospital care
 First Contact Physician to be competent to classify

7. Proposal
 *There is an increasing injury burden demanding future
doctors to be well-trained and competent in trauma care
 *Responsibility of medical institutions to strengthen
healthcare set-ups and ‘Competency based’ teaching-
learning to rectify current deficiency for quality of injury care
 **Capacity building at all levels must go with Infrastructure
development, Indian road crash registry, Research and
Community education to halt trauma pandemic
*Pal R, Agarwal A, Galwankar S, Swaroop M, et al. The 2014 Academic College of
Emergency Experts in India’s INDO-US Joint Working Group (JWG) White Paper
on “Developing Trauma Sciences and Injury Care in India”. Int J Crit Illn Inj Sci
2014;4:114-30
**Pal R, Ghosh A, Kumar R, Galwanker S, Paul SK, Pal S, Sinha D, Jaiswal AK,
Moscote-Salazar LR, Agarwal A. Public Health Crisis of Road Traffic Accidents in
India: Risk factor assessment and recommendations on prevention on the behalf of

8. Pre-hospital care
 The concept of pre-hospital trauma care has emerged after
the experiences of injuries sustained by Soldiers in Wars
 Focuses on caring for seriously ill or injured patients before
they reach hospital, and during emergency transfer to
hospital or between hospitals
 To improve patient outcome and reduce time at the scene
Blackwell TH. Pre-hospital care. Emerg Med Clin North Am.
1993 Feb;11(1):1-14.

9.  Depends of effective and emergency medical network of
communication
 At the site of trauma, complete, careful, and professional
examination
 Airway
 Breathing
 Circulation
 Disability
 Exposure
 Neck (cervical spine) stabilization
Pre-hospital care
Guidelines for the prehospital management of traumatic brain injury, 2nd edition. Prehosp Emerg
Care. 2008;12(Suppl 1):S1–52. doi10.1080/10903120701732052.

10.  Triage
 Initial and proper diagnosis
 Rapidly transport patients to the right hospital where the
definite management will be provided
 Professional and efficient medical care during
transportation, continuous evaluation, maintain good
oxygenation, I-V fluids
Transportation
Franschman G, Peerdeman SM, Andriessen TM, Greuters S, Toor AE, Vos PE, et al. Effect of secondary
prehospital risk factors on outcome in severe traumatic brain injury in the context of fast access to trauma
care. J Trauma. 2011;71:826–32.

11.  Documenting the incidence and categorization of injuries
(ranging form minor to major)
 A protocol driven approach to categorize injury
management
 Defining role and responsibilities of caregivers and cut offs
to decide when to transfer and where?
What is needed?

12. Proposal
 The basics of pre-hospital care (minor to major injuries) is
essential to the practice of medicine
 There is a need to expand and extend the scope of the pre-
hospital care
 A well-structured teaching-learning module to simulate
near-real life exposure
 Acute trauma training (ATT) and broad trauma training
(BTT) protocols
Vyas D, Hollis M, Abraham R, Rustagi N, Chandra S, Malhotra A, Rajpurohit V,
Purohit H, Pal R. Prehospital care training in a rapidly developing economy: a
multi-institutional study. J Surg Res. 2016 Jun 1;203(1):22-7.

13. DISCLOSURES
 Data is accurate as of 31/07/2019
 No financial disclosures and conflicts of interest
 Sources:
1. Ministry of Health and Family welfare
2. Uthkarsh PS, Gururaj G, Reddy SS, Ranjana S M.
Assessment and Availability of Trauma Care Services in a
District Hospital of South India; A Field Observational
Study. Bulletin of Emergency and Trauma. 2016;4(2):93-100
3. Creative Commmons (Licence 3.0)

14. Despite the fatal injury
Within the next 90 minutes:
•Dallas Parkland Hospital – had received the case-15min
•Despite gaping head wound- resuscitation was done-30min
•He was declared dead after the same- 60min
•Texas Gov. John Conally had a chest wound which was
operated – 60min
•90min- Lyndon B Johnson was sworn in as the new President
on board the Air-Force one.

15. Levels of trauma care
UNITED STATES (DIFFERENT FOR ADULTS AND CHILDREN)
Level I Trauma Centers:
•24-hour in-house coverage by general surgeons, and prompt availability of
care in specialties such as orthopedic surgery, neurosurgery, anesthesiology,
emergency medicine, radiology, internal medicine, plastic surgery, oral and
maxillofacial, pediatric and critical care.
•Referral resource for communities in nearby regions.
•Provides leadership in prevention, public education to surrounding
communities.
•Provides continuing education of the trauma team members.
•Incorporates a comprehensive quality assessment program.
•Operates an organized teaching and research effort to help direct new
innovations in trauma care.
•Program for substance abuse screening and patient intervention.
•Meets minimum requirement for annual volume of severely injured
patients.

16. Levels of trauma care
Level II Trauma Center:
24-hour immediate coverage by general
surgeons, as well as coverage by the
specialties of orthopedic surgery,
neurosurgery, anesthesiology,
emergency medicine, radiology and
critical care.
Tertiary care needs such as cardiac
surgery, hemodialysis and microvascular
surgery may be referred to a Level I
Trauma Center.
Provides trauma prevention and
continuing education programs for staff.
Incorporates a comprehensive quality
assessment program.
Level III Trauma Center:
•24-hour immediate coverage by
emergency medicine physicians and the
prompt availability of general surgeons
and anesthesiologists.
•Incorporates a comprehensive quality
assessment program
•Has developed transfer agreements for
patients requiring more comprehensive
care at a Level I or Level II Trauma Center.
•Provides back-up care for rural and
community hospitals.
•Offers continued education of the nursing
and allied health personnel or the trauma
team.
•Involved with prevention efforts and must
have an active outreach program for its
referring communities.

17. Levels of trauma care
Level IV Trauma Center:
Basic emergency department
facilities to implement ATLS
protocols and 24-hour laboratory
coverage. Available trauma nurse(s)
and physicians available upon patient
arrival.
May provide surgery and critical-
care services if available.
Has developed transfer agreements
for patients requiring more
comprehensive care at a Level I or
Level II Trauma Center.
Incorporates a comprehensive
quality assessment program
Involved with prevention efforts
and must have an active outreach
program for its referring
communities.
Level V Trauma Center:
•Basic emergency department
facilities to implement ATLS protocols
•Available trauma nurse(s) and
physicians available upon patient
arrival.
•After-hours activation protocols if
facility is not open 24-hours a day.
•May provide surgery and critical-care
services if available.
•Has developed transfer agreements
for patients requiring more
comprehensive care at a Level I
though III Trauma Centers.

18. INDIA 2019
 No accreditation program as of today
 2013- Ministry of Health and Family welfare developed a
scheme- Highway trauma care
 No trauma victim has to be transported for more than 50
kilometers and a designated trauma care facility is available
at every 100 Km.
 “Trauma Care Facility is a healthcare institution that has the
resources and capabilities necessary to provide trauma
services at a particular level to injured patients”

19. Levels of trauma care in India
DIVIDED INTO 4 LEVELS:

20. Trauma centers vs Emergency rooms
 As a matter of law, all hospitals are required to promptly
attend to all medical emergencies and hence must have
emergency services.
 As a matter of degree, emergency departments are designed
for a broad scope of minor to severe medical emergencies
while a trauma center has a focused scope of practice and
strict requirements for staffing, specialist availability and
response times to cater specifically to the critically injured.
THUS TRAUMA CENTER IS A SYSTEMS CONCEPT AND NOT A
INFRASTRUCTURE CONCEPT

21. Current concept of levels of trauma
care in India
 Level IV
• Appropriately equipped and manned mobile hospital / ambulances.
• Provided by MoRTH / NHAI / NRHM / State Govts., etc as the case maybe.
 Level III
• Initial evaluation and stabilization (surgically if appropriate) to the trauma
patient.
• Comprehensive medical and surgical inpatient services- who can be
maintained in a stable or improving condition without specialized care.
Emergency doctors and nurses are available round the clock.
• Physicians, surgeons, Orthopaedic surgeon and Anaesthetist would be
available round the clock to assess, resuscitate, stabilize and initiate
transfer as necessary to a higher-level Trauma Care Service
• Limited intensive care facility, diagnostic capability, blood bank and other
supportive services.
• District/ tehsil hospitals with a bed capacity of 100 to 200 beds would be
selected for level III care.

22. Current concept of levels of trauma
care in India
 Level II
 Definitive care for severe trauma patients.
 Emergency physicians, surgeons, Orthopaedicians and
Anaesthetists are in-house and available to the trauma patients
immediately on arrival.
 On-call facility for neurosurgeons, pediatricians. If neurosurgeons
are not available, general surgeons trained in neuro-surgery for a
period of 6 months in eminent institutions would be made available
24*7.
 Should be equipped with emergency department, intensive care
unit, blood bank, rehabilitation services, broad range of
comprehensive diagnostic capabilities, and supportive services.
 Existing medical college hospitals or hospitals with bed strength of
300 to 500 should be identified as Level II Trauma Center.

23. Current concept of levels of trauma
care in India
 Level I:
 Highest level of definitive and comprehensive care for patient with
complex injuries.
 Emergency physicians, nurses and surgeons would be in-house and
available to the trauma patient immediately on their arrival.
 The services of all major super specialties associated with trauma care
would be available 24*7.
 Situated at essentially at a distance of less than 750 to 800 kms apart;
these Level I Trauma Centers need not necessarily be along with the
Highways corridor.
 Tertiary care centers to which patients requiring highly specialized medical
care are referred.
 Due to high levels of skill, specialists and infrastructure required, Level I
Trauma Centers should be only in medical college hospitals.

24. Workflow of a trauma case

25. Proposal
 Family physicians form the first line of defense against this
epidemic of traumatic brain injury
 Its is important to identify what patient or what type of
injury requires what kind of care
 Levels of trauma care are not only important but ESSENTIAL
knowledge for any physician
 Post emergency care and rehabilitation is also very
important and thus needs to be the responsibility of every
doctor
“Either we stop this epidemic now or be its victim”

26. Biomarker molecules
 Early diagnosis + Prompt interventions → Better
prognosis of morbidity, mortality and disability
 Information on basal status, outcomes
 User-friendly +cost-effective + ↑sensitivity, ↑specificity
 Stratify severity +Predict prognosis
 Minimally invasive procedure to obtain
 Quick decision for imaging + Multidisciplinary referral
 Serum: Preferred Biofluid sample
 CSF: Best sample in mTBI
4/27/2021
Dr. Amrita Ghosh FMPC 2019 Need of Point-of-care Injury
biomarkers in Primary Health care
26

27. Point-of-care testing (POCT)
 Point-of-care testing (POCT) enables immediate pathology
results to be used for timely clinical action during the
patient presentation.
 Clinical benefits of POCT for acute trauma patients in
remote communities need evaluation
4/27/2021
Dr. Amrita Ghosh FMPC 2019 Need of Point-of-care Injury
biomarkers in Primary Health care
27

28. Injury biomarkers of TBI
 Ubiquitin Carboxy-terminal Hydrolase-L1 (UCH-L1)
 Glial fibrillary acidic protein (GFAP)
 Neuron-specific Enolase (NSE)
 Glial specific S100 Calcium-binding β protein (S100ß)
 τ proteins (TAU), Cleaved-Tau (C-Tau)
 Myelin Basic Protein (MBP)
 Matrix Metalloproteinase-2 (MMP-2)
 Creatine-kinase brain isoenzyme (CK-BB)
4/27/2021
28

29. Injury biomarkers: What next
 Alpha-II-spectrin breakdown products (SBDPs)
 Microtubule-Associated Protein 2 (MAP2)
 Neurofilament (NF)
 Interleukins (IL-8, 10)
 C-reactive Protein (CRP)
 microRNAs (miRNAs)
 Ferritin, Creatinine
4/27/2021
29

30. Proposal
 False positivity in serum obscure clinical acumen &
interventions in case of pre-existing comorbidities
 In holistic approach, need extensive research on
POCT biomarkers of trauma which are user-friendly in
daily medical practice to upgrade clinical practice
guidelines
 Lingering question : Whether any laboratory test
battery should be recommended as a “routine
protocol” across the entire spectrum of trauma
4/27/2021
Dr. Amrita Ghosh FMPC 2019 Need of Point-of-care Injury
biomarkers in Primary Health care
30

31. Update
 Translational research needed for simple yet user-
friendly with high sensitivity and specificity injury
biomarkers at the primary health care levels
 S100 β is one of the most studied biomarkers, but still
not much clinical utility is explored
 FDA-USA: Approved ALERT-TBI data that confirmed
high concentration in blood drawn 2-3 hours after
insult: UCHL-1 + GFAP biomarkers combined - for
routine clinical uses across USA
4/27/2021
Dr. Amrita Ghosh FMPC 2019 Need of Point-of-care Injury
biomarkers in Primary Health care
31