Management of trauma in Canada Trauma, writes Strasberg in this issue of the Journal (page 597), is the "different disease". It is also the allembracing disease. It may affect anyone of either sex, whether old or young; it may occur any time anywhere; and it may damage any body organ or system. Trauma is a hazard of living and it has dimensions of tragedy that can touch each of us. It is tragic because it is sudden and unexpected, and because all too often it is the young who are cut down (trauma kills more people up to the age of 37 years than does any other mortal factor1). It is tragic, too, because to a varying degree trauma is preventable. To underline the importance of trauma, and particularly the importance of good management, Strasberg and his colleagues at the Toronto Western Hospital have prepared a group of papers on certain facets of the management of trauma. It is clear that each problem calls for competent treatment by an experienced surgeon; the papers as a set make it equally clear how important a team approach is to the management of the injured patient - even how desirable might be the services of a specialist known as a traumatologist. Some authorities do hold that traumatology is a much needed specialty; as Gill1 has said, "The day of the traumatologist is upon us whether or not we welcome it." Gill1 has also said that one of every eight general hospital beds is occupied by a patient who is being treated as a result of trauma, and this similarly lends support to the role of the traumatologist, as does the frequency of multiple, violent injuries that so many victims of trauma sustain. Moreover there is no doubt that the development of traumatology has led to remarkable advances in the management of trauma; as just one example, the mortality among some 7000 patients seen annually at the trauma unit at Chicago's Cook County Hospital of less than 2% 2
is eloquent testimony to the standard of trauma care that can be provided by special units. Such an approach to the management of trauma is perhaps typical of the best of American medicine, but it is a moot question whether geographic, demographic, economic and sociocultural considerations would justify this approach in Canada. Not that trauma is anything less than a huge problem in Canada - after all, in 1974 more than 12 000 persons died in this country as a result of trauma,3 and more than 50% of them died as a consequence of motor vehicle accidents. And quite apart from the cost in terms of human suffering and disability the cost in economic terms is appalling: extrapolation from United States data (the results of trauma, including hospitalization, rehabilitation and manpower loss, cost the US approximately 40 billion dollars each year1) suggests that the annual cost to Canada as a consequence of trauma must be of the order of 4 billion dollars. Even so, it is doubtful whether the density of population in relation to Canadian geography, and the lifestyle and social behaviour patterns of Canadians, are such that a highly structured and specialized (and expensive) approach to trauma care is yet desirable in Canada. This view is by no means inconsistent with the recognition that trauma, because it truly is the different disease in many respects, requires an appropriate and aggressive approach by Canadians. It is precisely because trauma is a unique problem with its own dimensions and peculiarities that Canadians should debate the best approach in Canada. At the same time it is worth remembering a remarkable observation: while major advances in our understanding and management of the other two major killers, cancer and heart disease, require new knowledge, with trauma a reduction in mortality of 20 to 50% would result from, instead,
regrouping, reorganizing and redeploying existing public and medical facilities to better effect.1 The approach to be developed in Canada must therefore be appropriate to the situation in Canada. This will not necessarily be easy, as one small example suggests. Consider the competent performance of tracheostomy and thoracotomy in the emergency setting. Most Canadian physicians have few opportunities to accumulate experience in these skills, because few Canadian physicians frequently see cases of trauma requiring such treatment. In a large American city two or three thoracotomies may be the rule in a hospital each week for knife and gunshot wounds to the heart, and as many as 80 to 90% of patients with such injuries survive if they are alive on reaching hospital - whereas even in the largest Canadian cities the much lower frequency of emergency thoracotomy means that this type of experience is lacking in Canada. And the corollary is important: lives may be lost in Canada because of lack of the experience that is required to initiate the aggressive therapy that may be needed in cases of major and life-threatening trauma. The problem is something of a paradox: in Canada the smaller amount of carnage than that occurring in the US means that Canadian physicians acquire less extensive experience on which to build a basis for the effective management of trauma patients. (The beneficial protection of automobile seat belts is similarly paradoxical: today the relative lack of serious head and chest trauma may mean that residents in even first-class training programs see less instructive material than was the case before seat belts were more generally used.) What solutions can be offered to the problem of effective trauma care in Canada in view of this paradox? First, the magnitude of the problem of trauma can and must be reduced
CMA JOURNAL/MARCH 19, 1977/VOL. 116 583
by the vigorous popularization and enforcement of preventive measures, whether they are the wearing of automobile seat belts, the wearing of safety glasses and helmets in industry, or the use of safe and well designed ladders in and around the home. Prevention must remain a paramount consideration. A second consideration is encouragement of research into not only prevention but also the epidemiology and causation of trauma. Third, information concerning all aspects of trauma must be effectively disseminated from centres where research is conducted and experience is considerable to practitioners who may be called on to give primary care in cases of trauma. Fourth, physicians particularly must be trained in the fundamental aspects of trauma and emergency care so that hospital emergency rooms can be staffed by personnel well prepared to give competent trauma care. And fifth, medical services - whether ambulance or
helicopter, emergency room or operating room, or city or country location - must be efficient, well equipped and coordinated in order to deliver the appropriate level of care. From the practical viewpoint, once a patient has sustained trauma correct management is essential. It is therefore to be hoped that the present group of papers on trauma supplemented by others (the first being that by Waddell on page 653) to be published, will facilitate discussion of trauma - a disease, regrettably, that has been labelled "the worst treated disease in modern society".4 DAVID A.E. SHEPHARD
References 1. GILL W: Multiple trauma: the wind of change. J R Coil Surg Edinb 20: 151, 1975 2. LOWE RI, BAKER RJ: Organization and function of trauma care units. / Trauma 13: 285, 1973 3. Statistics Canada: Causes of Death, Provinces by Sex and Canada by Sex and Age, cat no 84-203, 1974 4. MULLEN iT: The magnitude of the p:oblem of trauma. / Trauma 14: 1070, 1974
Correct use of aerosol inhalers Most medical equipment is technically sophisticated and efficient - as long as it is used correctly. In many instances such equipment is used in hospital by hospital personnel, and supervision and maintenance facilities are readily available. Often, however, medical equipment is used at home by patients, who may not fully understand how to use it and who do not have access to advice or maintenance; then, if the equipment has a therapeutic purpose, inefficient use may lead to ineffective therapy; for example, full therapeutic benefits are often denied the patient when aerosol inhalers are not used correctly. A recent survey of 100 physicians showed that 50% agreed that the total effectiveness of aerosols is reduced because patients do not administer them correctly. This finding is similar to those of two studies of patient use of aerosol inhalers - one study from France and the other from Scotland. The French study was of 20 asthmatic patients who apparently knew how to use aerosol canisters delivering bronchodilator drugs; only 5, however, used them effectively.1 The Scottish study revealed that 45 (14%) of 321 asthmatic patients were inefficient in using their canisters, and the authors of this study concluded that because "even after initial tuition some patients cannot use an inhaler correctly. .. regular checks of inhalation technique are therefore necessary".2 Aerosol inhalers are effective in directing small quantities of a therapeutic
agent for direct topical action into the lungs, and it is important that patients understand how to use inhalers correctly. For domestic use instructions can and should be given clearly both by the physician who prescribes an inhaler and by the pharmacist from whom the patient purchases it. Use of aerosol inhalers requires more skill on the part of the patient than does any other aspect of drug administration; it is therefore important that physicians as well as pharmacists themselves know how aerosol inhalers work. Essentially an aerosol inhaler is a propellant-powered nebulizer whose contents, which are under pressure of a liquefied or compressed gas, are released through the action of a valve. All aerosols have five features in common: a medicament, a propellant, a container, a metering valve, and an applicator (or actuator). The mechanical and functional aspects of aerosol inhalers are worth brief consideration. The medicament used in an inhaler is either in solution or suspension. A solution provides the advantage of uniform distribution, but most drugs are not soluble in chlorofluorohydrocarbons and so suspensions are more commonly used. These are more difficult to formulate, but they have the advantages of correct particle size (and so accurate control of drug in the spray) and inhalation of the required amount of active ingredient, but only a small amount of propellant. Any propellant used must be nontoxic, nonflammable, chemically inert
584 CMA JOURNAL/MARCH 19, 1977/VOL. 116
The modifier of digestive behaviour Indications: Sub-acute gastritis, chronic gastritis, gastnc sequellae of surgical procedures such as vagotomy and pyloroplasty. Under these conditions, when gastric emptying is delayed, Maxeran may relieve such symptoms as nausea, vomiting, epigastnc distress, bloating, etc. Small bowel intubation- Maxeran may facilitate and accelerate small bowel intubation. Side-effects: Drowsiness and, more rarely, insomnia, fatigue, headaches, dizziness and bowel disturbances have been reported. Parkinsonism and other estra-pyramidal syndromes have been reported infrequently. An increase in the frequency and seventy of seizures has been reported in conjunction with the administration of Maseran to epileptic patients. Precautions: Drugs with atropine-like action should not be used simultaneously with Maseran since they have a tendency to antagonize effect of this drug on gastrointestinal motility. Maxeran should not be used in conjunction with potent ganglioplegic or neuroleptic drugs since potentialion of effects might occur. Maxeran should not be used in patients with epilepsy and estrapyramidal syndromes, unless its espected benefits outweigh the risk of aggravating these symptoms. In view of the risk 01 extrapyramidal manifestations, metoclopramide should not be used in children unless a clear indication has been established. The recommended dosage of Maseran should not be esceeded since a further increase in dosage will not produce a corresponding increase in the clinical response. The dosage recommended for children should not be esceeded. Contraindications: Maseran should not be administered to patients in combination with MAO inhibitors, tricyclic antidepressants, sympathomimetics and foods with high tyramine content, since safety of such an association has not yet been established. As a safety measure, a twoweek period should elapse between using Maseran and administration of any of these drugs. The safety of use of Maseran in pregnancy has not been established. Therefore Maseran should not be used in pregnant women, unless in the opinion of the physician the espected benefits to the patient outweigh the potential risks to the fetus. Dosage and administration: For delayed gastric emptying Adults Tablets: .2 to 1 tablet (5 - 10 mg) three or four times a day before meals. Liquid: 5- lOin) (5-10mg) three or four times a day before meals. Injectable: When parenteral administration is required, 1 ampoule (10 mg) IM. or IV. (slowly) to be repeated 2 or 3 times a day if necessary. Children: (5 to 14 years): Liquid: 2.5 to 5 ml (2.5-5 mg) three times a day before meals. For small bowel intubation: Adults: One ampoule (10 mg) IV. - 15 minutes before intubation. Other routes (oral or IM.) may be used but with a greater period of latency. Children: (Sf0 14 years): 2.5 to 5 ml (2.5 - 5 mg) Availability: Tablets: Each white scored compressed tablet contains 10 mg of Metoclopramide hydrochloride. Bottles of 50 & 500 tablets. Liquid:
Each ml contains 1 mg of Metoclopramide hydrochloride. Available in bottles of 110 ml and 450 ml.
Injectable:
Each 2 ml ampoule contains 10 mg of Metoclopramide hydrochloride in a clear colourless solution. Keep away from light and heat. Available in boxes of 5 and 50 ampoules. Product monograph available upon
c.oc.c.o@ request.
PHARMACEUTIQUES LTEE PHARMACEUTICALS LTD
Laval, Que.
Canada.
is eloquent testimony to the standard of trauma care that can be provided by special units. Such an approach to the management of trauma is perhaps typical of the best of American medicine, but it is a moot question whether geographic, demographic, economic and sociocultural considerations would justify this approach in Canada. Not that trauma is anything less than a huge problem in Canada - after all, in 1974 more than 12 000 persons died in this country as a result of trauma,3 and more than 50% of them died as a consequence of motor vehicle accidents. And quite apart from the cost in terms of human suffering and disability the cost in economic terms is appalling: extrapolation from United States data (the results of trauma, including hospitalization, rehabilitation and manpower loss, cost the US approximately 40 billion dollars each year1) suggests that the annual cost to Canada as a consequence of trauma must be of the order of 4 billion dollars. Even so, it is doubtful whether the density of population in relation to Canadian geography, and the lifestyle and social behaviour patterns of Canadians, are such that a highly structured and specialized (and expensive) approach to trauma care is yet desirable in Canada. This view is by no means inconsistent with the recognition that trauma, because it truly is the different disease in many respects, requires an appropriate and aggressive approach by Canadians. It is precisely because trauma is a unique problem with its own dimensions and peculiarities that Canadians should debate the best approach in Canada. At the same time it is worth remembering a remarkable observation: while major advances in our understanding and management of the other two major killers, cancer and heart disease, require new knowledge, with trauma a reduction in mortality of 20 to 50% would result from, instead,
regrouping, reorganizing and redeploying existing public and medical facilities to better effect.1 The approach to be developed in Canada must therefore be appropriate to the situation in Canada. This will not necessarily be easy, as one small example suggests. Consider the competent performance of tracheostomy and thoracotomy in the emergency setting. Most Canadian physicians have few opportunities to accumulate experience in these skills, because few Canadian physicians frequently see cases of trauma requiring such treatment. In a large American city two or three thoracotomies may be the rule in a hospital each week for knife and gunshot wounds to the heart, and as many as 80 to 90% of patients with such injuries survive if they are alive on reaching hospital - whereas even in the largest Canadian cities the much lower frequency of emergency thoracotomy means that this type of experience is lacking in Canada. And the corollary is important: lives may be lost in Canada because of lack of the experience that is required to initiate the aggressive therapy that may be needed in cases of major and life-threatening trauma. The problem is something of a paradox: in Canada the smaller amount of carnage than that occurring in the US means that Canadian physicians acquire less extensive experience on which to build a basis for the effective management of trauma patients. (The beneficial protection of automobile seat belts is similarly paradoxical: today the relative lack of serious head and chest trauma may mean that residents in even first-class training programs see less instructive material than was the case before seat belts were more generally used.) What solutions can be offered to the problem of effective trauma care in Canada in view of this paradox? First, the magnitude of the problem of trauma can and must be reduced
CMA JOURNAL/MARCH 19, 1977/VOL. 116 583
by the vigorous popularization and enforcement of preventive measures, whether they are the wearing of automobile seat belts, the wearing of safety glasses and helmets in industry, or the use of safe and well designed ladders in and around the home. Prevention must remain a paramount consideration. A second consideration is encouragement of research into not only prevention but also the epidemiology and causation of trauma. Third, information concerning all aspects of trauma must be effectively disseminated from centres where research is conducted and experience is considerable to practitioners who may be called on to give primary care in cases of trauma. Fourth, physicians particularly must be trained in the fundamental aspects of trauma and emergency care so that hospital emergency rooms can be staffed by personnel well prepared to give competent trauma care. And fifth, medical services - whether ambulance or
helicopter, emergency room or operating room, or city or country location - must be efficient, well equipped and coordinated in order to deliver the appropriate level of care. From the practical viewpoint, once a patient has sustained trauma correct management is essential. It is therefore to be hoped that the present group of papers on trauma supplemented by others (the first being that by Waddell on page 653) to be published, will facilitate discussion of trauma - a disease, regrettably, that has been labelled "the worst treated disease in modern society".4 DAVID A.E. SHEPHARD
References 1. GILL W: Multiple trauma: the wind of change. J R Coil Surg Edinb 20: 151, 1975 2. LOWE RI, BAKER RJ: Organization and function of trauma care units. / Trauma 13: 285, 1973 3. Statistics Canada: Causes of Death, Provinces by Sex and Canada by Sex and Age, cat no 84-203, 1974 4. MULLEN iT: The magnitude of the p:oblem of trauma. / Trauma 14: 1070, 1974
Correct use of aerosol inhalers Most medical equipment is technically sophisticated and efficient - as long as it is used correctly. In many instances such equipment is used in hospital by hospital personnel, and supervision and maintenance facilities are readily available. Often, however, medical equipment is used at home by patients, who may not fully understand how to use it and who do not have access to advice or maintenance; then, if the equipment has a therapeutic purpose, inefficient use may lead to ineffective therapy; for example, full therapeutic benefits are often denied the patient when aerosol inhalers are not used correctly. A recent survey of 100 physicians showed that 50% agreed that the total effectiveness of aerosols is reduced because patients do not administer them correctly. This finding is similar to those of two studies of patient use of aerosol inhalers - one study from France and the other from Scotland. The French study was of 20 asthmatic patients who apparently knew how to use aerosol canisters delivering bronchodilator drugs; only 5, however, used them effectively.1 The Scottish study revealed that 45 (14%) of 321 asthmatic patients were inefficient in using their canisters, and the authors of this study concluded that because "even after initial tuition some patients cannot use an inhaler correctly. .. regular checks of inhalation technique are therefore necessary".2 Aerosol inhalers are effective in directing small quantities of a therapeutic
agent for direct topical action into the lungs, and it is important that patients understand how to use inhalers correctly. For domestic use instructions can and should be given clearly both by the physician who prescribes an inhaler and by the pharmacist from whom the patient purchases it. Use of aerosol inhalers requires more skill on the part of the patient than does any other aspect of drug administration; it is therefore important that physicians as well as pharmacists themselves know how aerosol inhalers work. Essentially an aerosol inhaler is a propellant-powered nebulizer whose contents, which are under pressure of a liquefied or compressed gas, are released through the action of a valve. All aerosols have five features in common: a medicament, a propellant, a container, a metering valve, and an applicator (or actuator). The mechanical and functional aspects of aerosol inhalers are worth brief consideration. The medicament used in an inhaler is either in solution or suspension. A solution provides the advantage of uniform distribution, but most drugs are not soluble in chlorofluorohydrocarbons and so suspensions are more commonly used. These are more difficult to formulate, but they have the advantages of correct particle size (and so accurate control of drug in the spray) and inhalation of the required amount of active ingredient, but only a small amount of propellant. Any propellant used must be nontoxic, nonflammable, chemically inert
584 CMA JOURNAL/MARCH 19, 1977/VOL. 116
The modifier of digestive behaviour Indications: Sub-acute gastritis, chronic gastritis, gastnc sequellae of surgical procedures such as vagotomy and pyloroplasty. Under these conditions, when gastric emptying is delayed, Maxeran may relieve such symptoms as nausea, vomiting, epigastnc distress, bloating, etc. Small bowel intubation- Maxeran may facilitate and accelerate small bowel intubation. Side-effects: Drowsiness and, more rarely, insomnia, fatigue, headaches, dizziness and bowel disturbances have been reported. Parkinsonism and other estra-pyramidal syndromes have been reported infrequently. An increase in the frequency and seventy of seizures has been reported in conjunction with the administration of Maseran to epileptic patients. Precautions: Drugs with atropine-like action should not be used simultaneously with Maseran since they have a tendency to antagonize effect of this drug on gastrointestinal motility. Maxeran should not be used in conjunction with potent ganglioplegic or neuroleptic drugs since potentialion of effects might occur. Maxeran should not be used in patients with epilepsy and estrapyramidal syndromes, unless its espected benefits outweigh the risk of aggravating these symptoms. In view of the risk 01 extrapyramidal manifestations, metoclopramide should not be used in children unless a clear indication has been established. The recommended dosage of Maseran should not be esceeded since a further increase in dosage will not produce a corresponding increase in the clinical response. The dosage recommended for children should not be esceeded. Contraindications: Maseran should not be administered to patients in combination with MAO inhibitors, tricyclic antidepressants, sympathomimetics and foods with high tyramine content, since safety of such an association has not yet been established. As a safety measure, a twoweek period should elapse between using Maseran and administration of any of these drugs. The safety of use of Maseran in pregnancy has not been established. Therefore Maseran should not be used in pregnant women, unless in the opinion of the physician the espected benefits to the patient outweigh the potential risks to the fetus. Dosage and administration: For delayed gastric emptying Adults Tablets: .2 to 1 tablet (5 - 10 mg) three or four times a day before meals. Liquid: 5- lOin) (5-10mg) three or four times a day before meals. Injectable: When parenteral administration is required, 1 ampoule (10 mg) IM. or IV. (slowly) to be repeated 2 or 3 times a day if necessary. Children: (5 to 14 years): Liquid: 2.5 to 5 ml (2.5-5 mg) three times a day before meals. For small bowel intubation: Adults: One ampoule (10 mg) IV. - 15 minutes before intubation. Other routes (oral or IM.) may be used but with a greater period of latency. Children: (Sf0 14 years): 2.5 to 5 ml (2.5 - 5 mg) Availability: Tablets: Each white scored compressed tablet contains 10 mg of Metoclopramide hydrochloride. Bottles of 50 & 500 tablets. Liquid:
Each ml contains 1 mg of Metoclopramide hydrochloride. Available in bottles of 110 ml and 450 ml.
Injectable:
Each 2 ml ampoule contains 10 mg of Metoclopramide hydrochloride in a clear colourless solution. Keep away from light and heat. Available in boxes of 5 and 50 ampoules. Product monograph available upon
c.oc.c.o@ request.
PHARMACEUTIQUES LTEE PHARMACEUTICALS LTD
Laval, Que.
Canada.
