Influence of trauma origin site on admission rates of patients submitted to emergency laparotomy

1 Hospital do Trabalhador, Service of General Surgery, Curitiba, PR, Brazil. Brunello Influence of trauma origin site on admission rates of patients submitted to emergency laparotomy. 2 Rev Col Bras Cir 45(5):e1970 public policies. Thus, this study aimed to evaluate the influence of the place of trauma occurrence on the trauma scores (ISS, RTS, TRISS) of patients submitted to emergency exploratory laparotomy in a trauma reference hospital center in the country.


INTRODUCTION
T he evolution of rescue systems and the possibility of initiating interventions at the trauma scene have led to a significant fall in early post-traumatic mortality rates, especially in those injuries directly associated with the development of early death 1 .Studies show that population density is a strong and independent predictor of a county's mortality rates 2,3 .The time elapsed between injury and definitive treatment is important and it is reasonable to assume that the time of transport to the hospital seems to be an independent predictor of mortality.Some authors affirm that there is greater mortality in patients living in rural areas 4 .However, these studies were mostly based on national databases, not containing anatomical and physiological data of the lesions, necessary to calculate the indices of trauma to assess the probability of survival.
One of the ways to assess the severity of trauma patients and to predict their prognoses is through the trauma scores.The main examples of trauma scores we used in the article were: Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and Injury Severity Score (ISS).All scores are used to estimate survival and risk of complications, being used in the preparation of care protocols [5][6][7] .
Knowledge of the patients' profile is of paramount importance for the improvement of the service provided, facilitating the direction of

Original Article
Influence of trauma origin site on admission rates of patients submitted to emergency laparotomy.

Influência do local de origem do trauma nos índices de admissão de pacientes submetidos à laparotomia de emergência.
Luis Fernando spagnuoLo BruneLLo, accBc-pr 1 ; ana Luísa Bettega, accBc-pr 1 ; phiLLipe geraLdo teixeira de aBreu reis, acBc-pr 1 ; FLávio danieL saavedra tomasich, tcBc-pr 1 ; iwan augusto coLLaço, tcBc-pr 1 ; camiLa roginski guetter, accBc-pr 1 ; thamyLe moda de santana rezende, accBc-pr 1 ; adonis nasr, tcBc-pr 1 Objective: to evaluate the influence of the site of trauma occurrence on the trauma scores of patients submitted to emergency laparotomy.Methods: this is a retrospective, observational, analytical study.We included 212 patients who underwent exploratory laparotomies in the period of January 2015 and December 2017.We obtained information about the accident site and vital data of the patients based on data collection through electronic and physical records.We analyzed the trauma indices of patients from Curitiba and its Metropolitan Region and the place where the patient was rescued (physical establishment or public road).Results: among the 212 patients studied, 184 (86.7%) were brought by the Prehospital Care Service from the city of Curitiba, and 28 (13.3%), from the Metropolitan Region of Curitiba.Twenty-five patients (17.6%) were rescued in physical establishments, while 117 (82.4%) were rescued on public roads.We observed higher values of Injurity Severity Scores (ISS) in patients coming from the Metropolitan Region than in those coming from Curitiba (29.78 vs 22.46, P=0.009), but higher values of Trauma and Injury Severity Scores (TRISS) in patients from Curitiba than the ones from the Metropolitan Region (90.62 vs 81.30, P=0.015).Patients rescued in public roads presented lower Revised Trauma Scores (RTS) (6.96 vs 7.65, P=0.024) and TRISS (86.42 vs 97.21; P=0.012).Conclusion: trauma victims from sites more distant from the referral center and rescued on public roads presented worse prognosis.

Brunello
Influence of trauma origin site on admission rates of patients submitted to emergency laparotomy.We described clinic and demographic characteristics with normal distribution using mean and standard deviation.We calculated We found higher ISS values in patients coming from the Metropolitan Region than in those coming from Curitiba (P=0.009).We observed greater values of TRISS in patients from Curitiba than in individuals from the Metropolitan Region (P=0.0155).There was no statistically significant difference between the RTS of the two localities (P=0.405)(Table 2).
There were 14.6% of deaths in patients from Curitiba and 25% in patients coming from the Metropolitan Region.Despite the trend towards higher mortality in the metropolitan region, it showed no significant difference (P=0.165).On the other hand, the time of transport from the place of trauma to the reference hospital was higher in the Metropolitan Region cases than in the Curitiba ones (P<0.001)(Table 3).
As for the trauma scene in which the patient was assisted for the first time after trauma, there was a predominance of rescues from public roads (182 patients, 85.8%), followed by care in Basic Health Units (BCU) or Emergency Care Units (ECU) (18 patients, 8.4%).There were no documented deaths in patients attended at their place of work or at home.Patients rescued in public roads presented lower values of RTS (P=0.034) and TRISS (P=0.023)than those rescued in a physical establishment.
We observed no statistically significant difference between the number of deaths and ISS among patients assisted in these trauma scenes (Table 4).

DISCUSSION
For this study, as predicted in the literature, the trauma indices were used to evaluate the possibility of survival of the polytraumatized patient and to quantify their physiological changes and anatomical lesions.The sample consisted of patients submitted to exploratory laparotomy, with the aim of directly evaluating the trauma indices with greater fidelity.Two of the three indices evaluated (TRISS and RTS) showed a positive association with the place of trauma where the ISS was higher in patients from the metropolitan region, indicating that they were more severely injured, and a higher TRISS in patients from the capital, representing a greater chance of survival for such patients 8 .We did not include patients admitted by direct search in this study, only those by referenced search, with prehospital care.In this way, the transportation time was calculated by the difference of the hours recorded in the Rescue Attendance Report (RAS) and the Emergency Bulletin issued by the hospital at the time of admission.Although there were differences between the time of transportation to the hospital of patients from the Metropolitan Region in relation to those coming from Curitiba (112min.vs 37min., P<0.001), the number of deaths among these locations did not present a significant difference (P=0.165).A cohort study of 19,167 patients 9 found that the time of transport to the referral hospital influences survival of trauma patients.However, the authors of the study found this association with a transport time of less than 20 minutes.The present study did not show differences between the mortality rate for transport times greater than 20 minutes.
Increased waiting for definitive treatment may influence the patient's neurological worsening, hemodynamic instability and, consequently, a higher risk of Cardiopulmonary arrest, among other conditions 10 .However, despite the fact that patients from the metropolitan region presented a more severe picture on arrival at the emergency room (minor TRISS), we did not find a relation between the place of occurrence of trauma and mortality.In addition, higher we observed ISS scores in patients from the metropolitan areas, indicating more severely injured patients.This may be due to the higher crime rate in the metropolitan area.
As for the trauma scene from which the victim was rescued, we observed a higher index of anatomical lesions (ISS) in patients rescued from

2
Rev Col Bras Cir 45(5):e1970 public policies.Thus, this study aimed to evaluate the influence of the place of trauma occurrence on the trauma scores (ISS, RTS, TRISS) of patients submitted to emergency exploratory laparotomy in a trauma reference hospital center in the country.and retrospective data collection.We included patients who underwent exploratory laparotomy from January 2015 to December 2017.The study scenario was the Emergency Room of the Hospital do Trabalhador (HT), which admits patients who arrive at the hospital by referenced search (SIATE/SAMU).We performed data collection retrospectively from the electronic medical records, and the authors developed a specific field record for this study, which included sociodemographic data, prehospital care records, clinical data, diagnosis, treatment (surgery), postoperative, survival and trauma indices.We excluded from the study the cases of patients with inaccessible records, lack of relevant information for the research, patients younger than 18 years of age, patients who were not rescued by the prehospital care and patients who were not submitted to exploratory laparotomy.We classified and analyzed the data collected in two different ways: the first corresponded to the trauma site (Curitiba or Metropolitan Region) and the second corresponded to the trauma scene (physical establishment or public road) in which the patient was found and assisted for the first time after trauma.By Metropolitan Region, we understood all the municipalities that, by conurbation, have become close to the Paraná's capital, Curitiba.We collected data retrospectively, between January 2017 and March 2018, compiled them using thema Google Docs® online form and them analyzed using the open online Socscistatistics® platform.

Table 2 .
Trauma indices according to the trauma location.

Table 3 .
Mortality rate and time of transport from the trauma location.