Influence of Injury Pattern on Incidence and Severity of Posttraumatic Inflammatory Complications in Severely Injured Patients

Abstract Background: Severe trauma causes systemic inflammatory response syndrome (SIRS) which may lead to multiple organ dysfunction syndrome (MODS) or multiple organ failure (MOF). The aim of this study was to evaluate the influence of the injury pattern on the incidence and severity of SIRS, sepsis, MODS, and mortality. Methods: A total of 1,273 patients with an injury severity score (ISS) of ≥ 9 points and survival of more than 3 days were included in this retrospective study. Outcome parameters were various grades of SIRS, sepsis, MODS, and mortality. Results: Severe non-infectious SIRS occurred in 23%, sepsis in 14%, and severe MODS in 14% of the patients. Serious (abbreviated injury scale (AIS) ≥ 3 points) head injury and the ISS represented the most potent risk factors for severe SIRS. As estimated by multivariate logistic regression analysis, the presence of severe extremity and pelvic injuries, the ISS, and the male gender were found to be independent risk factors for sepsis. Severe injuries of the abdomen were associated with an increased risk for sepsis in the univariate analysis. Severe injuries to the head or abdomen, the ISS, and the male gender represented independent risk factors for the development of severe MODS. Regarding the late (> 3 days after trauma) hospital mortality, severe head injury, the ISS, and the patient’s age were independent risk factors. Conclusions: Head injury predominantly determines the incidence of non-infectious systemic inflammation, MOF, and late hospital mortality of patients with severe trauma. Skeletal or abdominal injuries represent relevant risk factors for septic complications. Thus, the incidence of posttraumatic, life-threatening inflammatory complications is related with certain injury patterns in addition to the gender and the severity of trauma.     

Long-term Outcome after Lower Extremity Injuries in Severely Injured Patients

Abstract Background: Extremity injuries, often caused by road accidents, are an increasing problem worldwide. The aims of this study were (1) to describe the characteristics of lower extremity injuries (LEI) in polytrauma patients, (2) to describe long-term outcomes, and (3) to assess the relationship between the various domains of the International Classification of Functioning, Disability and Health (ICF model). Materials and Methods: A prospective cohort study was conducted from 1999 through 2000. All (n = 507) consecutive severely injured patients (ISSH≥16) over the age of 16 years were included. Results: One-hundred and eighty six (139 men, 47 women) had suffered LEI; mean age was 37 years, mean ISS 25. At follow-up, a mean permanent impairment of 14% was found according to the criteria of the American Medical Association. In terms of the Glasgow Outcome Scale, 28% of patients recovered incompletely. Half of the patients reported limitations in activities of daily living and mobility and 60% were unable to walk more than 3 km. The overall Sickness Impact Profile-136 score showed mild/moderate disability. Scores on six subscales of the Short Form-36 were significantly below the normative data. Regression analyses showed low beta and R-square values, indicating poor association between impairment and other outcome measurements. Conclusions: The impact of LEI on mobility, activities and participation level of polytrauma patients is considerable. Instruments measuring function do not agree well with those measuring activities or participation. Instruments measuring impairment do not agree well with long-term outcomes relating to activities and participation.     

Nonoperative Management of Tracheobronchial Injuries in Severely Injured Patients

Purpose A rupture of the airway due to blunt chest trauma is rare, and treatment can prove challenging. Many surgeons suggest operative management for these kinds of injuries. Nonoperative therapy is reported only in exceptional cases. But there is still a lack of evidence from which to recommend surgical repair of these injuries as the first choice procedure.Methods We retrospectively analyzed the records of 92 multiple injured patients admitted to our trauma department between July 2002 and July 2003 for the incidence and management of tracheobronchial rupture (TBR).Results Five (5.4%) of 92 patients suffered from tracheobronchial injuries. The mean injury severity score was 38. There were three male and two female patients, with a mean age of 23 years. All patients had lesions <2 cm in size and were treated nonoperatively. One patient died from multiorgan failure, but the others recovered from TBR uneventfully. One patient developed acute pneumonia as a result of respirator therapy, but none of the patients had mediastinitis or tracheal stenosis within 3 months after injury.Conclusion We believe that surgical treatment is not mandatory in patients with small to moderate ruptures, and such aggressive treatment may even have adverse effects, especially in patients with multiple injuries.     

Comparative Update on Documentation of Trauma in Seven National Registries

Abstract Introduction: The role of trauma documentation systems for trauma research has continuously increased since the first trauma registries were developed in the late 1980s. Data acquisition and processing improved highly, partly because modern computer and network technologies offer new approaches. International comparison is important for the learning process and the investigation of differences in the mechanisms of injury, rescue systems and treatment protocols. We demonstrate keypoints of the learning curve thus supporting a further spreading of trauma registries. Methods: Seven exemplary trauma registries from the United States, Canada, Victoria (Australia), United Kingdom, France, Germany and the new European Trauma Audit and Research Network registry were analyzed according to their development until the current status. Special investigations were conducted for data acquisition, inclusion criteria and the volume and characteristics of patient data. Results: We found a clear overall beneficial influence of the documentation systems on the respective trauma system. Data acquisition displayed a wide range of difference from paper forms being entered into a centralized database by hand to direct entry of the data into the database by a local user via an Internet platform. Some systems copy computerized patient data from local hospital systems. Two registries are available in two languages. One has the option to add further languages as demanded. Datasets are comparable in terms of general data and a compulsory trauma diagnosis. Still, the details of the documented period of care and the inclusion criteria differ considerably. Discussion: We describe the important role of several trauma registries within a trauma care system. Although the success is hard to measure, related publications, continuous growth, the official use for quality control and the demand to participate by other countries stress their wide spread acceptance (secondary internationalization). These advantages make trauma registries a valuable tool in many countries.     

Evaluation of Systemic Inflammatory Response Syndrome (SIRS) Score as a Predictor of Mortality in Trauma Patients

Abstract Background: Systemic Inflammatory Response Syndrome (SIRS) score has been widely used for mortality risk assessment, out come and cost containment, it provides an excellent indication of the risk of mortality for trauma patients, but its validity is not assessed well in literature. In this study, we validate this score by measurement of its discrimination and calibration in a large population of trauma patients. Methods: Two large trauma centers in central part of Iran participated in the study. From December 2001 to May 2004; centers collected the information required for SIRS on all trauma patients at the time of admission. The performance of SIRS model was evaluated by assessing the discrimination (area under the receiver operator characteristic plot) and calibration (by calculating the expected and observed number of survivors and deaths in deciles of risk). Results: 4,300 patients were selected for analysis. Male patients comprised 90.4% of study population SIRS was present in 33% of patients at admission. Mortality rate was 9% (n = 387). It was 2.8% in negative SIRS patients and 9.7% in positive SIRS patient. The area under the Roc plot was 0.90 (0.89–0.91). The fit in groups of patients with different risks of death was 7.32. Conclusion: In summary the SIRS model is simple enough for it to be wildly used in trauma, it requires the collection of only four variables at the time of admission and it has good predictive power.     

Clinical and pathophysiological significance of severe neurotrauma in polytraumatized patients

Introduction: Traumatic brain injury (TBI) is present in up to two-thirds of multiply injured patients. The degree of TBI influenced the mortality and morbidity of multiple trauma significantly. Results: Important prognostic predictors are: injury severity score (ISS); Glasgow coma score [(GCS), motor score]; pupil size and reactivity; coma grade and duration; age; morphological primary brain lesion; and pathophysiological changes leading to secondary brain damage. The time course of brain edema, raised intracranial pressure and, especially, pathophysiology of disturbed cerebral blood flow and metabolism characterizes early and late periods of ischemic vulnerability. Conclusion: These should be taken into consideration when planning operative procedures in multiple-trauma patients. Avoidance of secondary ischemic brain damage by reducing the number of systemic insults (hypovolemia, hypotension, hypoxia) will improve prognosis of critically ill polytraumatized patients with head injury. Received: 25 May 1998     

“Damage Control” in Severely Injured Patients

Abstract The concept of “damage control” is established in the management of severely injured patients. This strategy saves life by deferring repair of anatomic lesions and focusing on restoring the physiology. The “lethal triad” hypothermia, coagulopathy, and acidosis are physiological criteria in the selection of injured patients for ”damage control”. Other criteria, such as scoring of injury severity or the time required to accomplish definitive repair, are also useful in determining the need for ”damage control”. The staged sequential procedures of ”damage control” include, after the selection of patients (stage 1), “damage control surgery” or “damage control orthopedics” (stage 2), resuscitation in the intensive care unit (stage 3), “second–look” operations or scheduled definitive surgery (stage 4), and the secondary reconstructive surgery (stage 5). The concept of ”damage control” was carried out in a third of 622 severely injured patients in our division. Although level I evidence is lacking, the incidence of posttraumatic complications and the mortality rate were reduced. However, better understanding of the significance and kinetics of physiological parameters including inflammatory mediators could help to optimize the “damage control” concept concerning the selection of patients and the time points of staged sequential surgery.     

多发伤中胸腰椎骨折误诊漏诊原因分析

目的　分析多发伤病例胸腰椎骨折的误诊漏诊原因。方法　通过对 1 4 7例多发伤合并胸腰椎骨折临床资料的回顾性分析 ,研究误诊漏诊的原因。结果　 2 8例胸腰椎骨折被误诊漏诊 ,占 1 9%。原因包括病情危重、读片失误和病情较稳定但未行X线检查。结论　对于多发伤患者应进行详细全面的脊柱物理检查 ,有阳性发现时应行X线检查 ,对于所有胸腰椎骨折或怀疑有胸腰椎骨折患者均应行CT扫描检查     

Predictors of Death in Trauma Patients who are Alive on Arrival at Hospital

Abstract Objective: To determine which factors predict death occurring in trauma patients who are alive on arrival at hospital Design Prospective cohort study Method Data were collected from 507 trauma patients with multiple injuries, with a Hospital Trauma Index–Injury Severity Score of 16 or more, who were initially delivered by the Emergency Medical Services to the Emergency Department of the University Medical Centre Utrecht (UMCU) during the period 1999–2000. Results: Univariate analysis showed that every year of age increase resulted in a 2% greater risk of death. If the patient had been intubated at the scene of the accident, this risk was increased 4.3-fold. Every point of increase in the Triage Revised Trauma Score (T-RTS) reduced the risk of death by 30%. A similar (but inverse) tendency was found for the HTI–ISS score, with every point of increase resulting in a 5% greater risk of death. There was a clear relationship between the base excess (BE) and hemoglobin (Hb) levels and the risk of death, the latter being increased by 8% for each mmol/l drop in BE, and reduced by 22% for each mmol/l increase in Hb. The risk of death occurring was 2.6 times higher in cases with isolated neurotrauma. These associations hardly changed in the multivariate analysis; only the relation with having been intubated at the scene disappeared. Conclusion: The risk of severely injured accident patients dying after arriving in hospital is mainly determined by the T-RTS, age, presence of isolated neurological damage, BE and Hb level. Skull/brain damage and hemorrhage appear to be the most important causes of death in the first 24 h after the accident. The time interval between the accident and arrival at the hospital does not appear to affect the risk of death. An erratum to this article is available at .     

Erratum to Predictors of Death in Trauma Patients who are Alive on Arrival at Hospital

Abstract Objective: To determine which factors predict death occurring in trauma patients who are alive on arrival at hospital Design Prospective cohort study Method Data were collected from 507 trauma patients with multiple injuries, with a Hospital Trauma Index–Injury Severity Score of 16 or more, who were initially delivered by the Emergency Medical Services to the Emergency Department of the University Medical Centre Utrecht (UMCU) during the period 1999–2000. Results: Univariate analysis showed that every year of age increase resulted in a 2% greater risk of death. If the patient had been intubated at the scene of the accident, this risk was increased 4.3-fold. Every point of increase in the Triage Revised Trauma Score (T-RTS) reduced the risk of death by 30%. A similar (but inverse) tendency was found for the HTI–ISS score, with every point of increase resulting in a 5% greater risk of death. There was a clear relationship between the base excess (BE) and hemoglobin (Hb) levels and the risk of death, the latter being increased by 8% for each mmol/l drop in BE, and reduced by 22% for each mmol/l increase in Hb. The risk of death occurring was 2.6 times higher in cases with isolated neurotrauma. These associations hardly changed in the multivariate analysis; only the relation with having been intubated at the scene disappeared. Conclusion: The risk of severely injured accident patients dying after arriving in hospital is mainly determined by the T-RTS, age, presence of isolated neurological damage, BE and Hb level. Skull/brain damage and hemorrhage appear to be the most important causes of death in the first 24 h after the accident. The time interval between the accident and arrival at the hospital does not appear to affect the risk of death. There was an error in the author's affiliation. Please note the correct institution of Hermann R. Holtslag: Rehabilitation Medicine University Medical Center Utrecht Utrecht The Netherlands The original article can be found online at     

Circulating Inflammatory and Metabolic Parameters to Predict Organ Failure after Muliple Trauma

Background: Patients encountering severe trauma are at high risk of sequential organ complications. We studied the value of circulating inflammatory mediators and metabolic parameters to evaluate their predictive value with respect to the development of multiple organ failure (MOF). Patients and Methods: In 77 traumatized patients with a mean Injury Severity Score (ISS) of 28.8±1.1 points, C-reactive protein (CRP), polymorphonuclear (PMN) elastase, lactate, interleukin-6 (IL-6), IL-8, and soluble tumor necrosis factor receptors 1 and 2 (TNF-R1 and TNF-R2) were determined for a period of 11 days following multiple trauma. Results: Weak and moderate correlations were found between mean plasma concentrations of all parameters and mean MOF scores calculated from the whole observation period [range: lactate (r=0.31, p < 0.01) to TNF-R1 (r=0.53, p < 0.001)]. Daily TNF-R1 and lactate concentrations of the 1st week moderately correlated with mean MOF scores of the 2nd week (p < 0.01). ISS weakly correlated with all parameters exept lactate [range: IL-8 (r=0.27, p < 0.05) and PMN elastase (r=0.46, p < 0.001)]. Prediction of MOF could not be improved by inclusion of several or all investigated mediators into multiple regression models. Conclusion: Only early plasma TNF-R1 and blood lactate concentrations showed a moderate association with the development of late posttraumatic organ failure. Thus, the predictive role of inflammatory mediators with respect to the manifestation of organ dysfunction after severe trauma seems limited. Received: October 23, 2002; revision accepted: November 12, 2002 Correspondence Address Johannes Frank, MD, Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe University Medical School, 60590 Frankfurt/Main, Germany, Phone (+49/69) 6301-5069, Fax -6439, e-mail: j.frank@trauma.uni-frankfurt.de     

Rehabilitation of the multiple injured patient with spinal cord injury: A systematic review of the literature

IntroductionPatients with multiple injuries including spinal cord injury (SCI) have low survivability. Little is known for the effect of SCI in their rehabilitation process.PurposeTo define differences in characteristics and outcomes during the rehabilitation of multiple injured patients with SCI compared to other polytrauma patients.Materials and methodsElectronic libraries provided 425 relevant articles. Applying the criteria, 6 articles were eligible for inclusion in this review.ResultsThe extracted data show that multiple injured patients with SCI have an increased length of stay (LOS) in rehabilitation. Initial functional levels, as also one- and two-years follow-up are also decreased. Similar results were found comparing SCI patients with or without multiple injuries: SCI patients with multiple injuries have an increased LOS and decreased functional levels compared with SCI patients. Finally, there was nota relevance between the circumstances of the injuries, like acts of terror, and the expected rehabilitation outcome.ConclusionDue to the rarity of eligible articles and the lack of homogenous accessing tools, a meta-analysis was not possible. There is a lack of a universal evaluation strategy or tool, for the severity of the multiple injured patients aiming at the rehabilitation outcome prognosis. Multiple-injured patients with SCI have longer rehabilitation LOS and functional outcomes compared to other polytrauma patients.Prospective studies are needed for evaluation of the differences according to the severity and the complexity of the injuries and the rehabilitation outcome depending on different rehabilitation methods and strategies.     

Acute Renal Failure in Polytraumatized Patients: Prediction of Outcome

Prediction of outcome of acute renal failure (ARF), particularly inpatients with multisystem organ failure (MSOF), is a very important issue and a very difficult task. In patients with ARF as a consequence of severe polytrauma, frequent complications (e.g., sepsis, respiratory insufficiency, DIC, hepatic insufficiency, etc.) contribute to a hyperbolic state, and in the case of synergistic action, they start the mechanism of MSOF. In 33 patients (1 female, 32 male, 38.61 ± 8.79 years) with severe polytrauma acquired in war combat, ARF developed requiring hemodialysis (HD) treatment. Seventeen out of 33 (51.4%) recovered renal function. In 12 out of 33 patients, MSOF occurred with less successful recovery results. The analysis of pathophysiologic mechanisms of MSOF appearance and ARF outcome has shown the importance of blast injuries, bowel injury, respiratory insufficiency requiring assisted ventilation, and sepsis. Although severe hemorrhage and shock are the common mechanism of ARF appearance in these patients, it seems that wounds by themselves can be of great importance, as abdominal wounds are more frequently associated with ARF and MSOF than in other types.     

Evaluation and management of haemorrhagic shock in polytrauma: Clinical practice guidelines

Haemorrhagic shock is the most common preventable cause of early mortality in polytrauma patients. Road traffic injuries are the most common cause for polytrauma and most commonly include orthopaedic injuries. Hence, orthopaedic trainees and junior orthopaedic surgeons need to be well aware of evaluation and management of haemorrhagic shock in the multiple injured patient. The present narrative review discusses evaluation and current principles in management of haemorrhagic shock in a polytrauma patient. A classification system for haemorrhagic shock based on ATLS guidelines has been described along with novel use of colour coding to facilitate better and effective use of the classification. A treatment algorithm has also been presented for quick reference. The emphasis is to avoid overloading with crystalloid fluids, replacing with blood and blood products (Balanced resuscitation), permissive hypotension, prevent and acutely treat lethal conditions such as hypothermia, acidosis and coagulopathy. The management of haemorrhagic shock in polytrauma patient is quite challenging and require a detailed knowledge of its management. An arbitrary and haphazard management of these patients may lead to severe complications. We have mentioned the broad principles of management of hypovolemic shock in a polytrauma patient.     

Pediatric trauma: experience of a combat support hospital in Iraq

Background/Purpose

The mission of the combat support hospital (CSH) is to evaluate and treat combatants injured during war operations. The 31st CSH in Balad and Baghdad, Iraq, during Operation Iraqi Freedom 2 also treated many injured civilians, including children. The purpose of this article is to report the experience of the 31st CSH treating pediatric trauma patients.

Methods

A retrospective review of a comprehensive patient database collected in theater was conducted.

Results

From January 1 to December 31, 2004, we treated 99 patients 17 years and younger. The average age of these patients was 10.6 years. Nine died of their wounds. The mean injury severity score was 11.6. Forty-one sustained gunshot wounds, 13 acquired fragment wounds (55% penetrating), and 22 were injured by improvised explosive devices (22%). Seventy-three patients required a total of 191 operations: 18 celiotomies, 8 craniotomies, 23 skeletal fixations, and 75 wound washout/debridements, among others. Predictors of mortality included admission Glasgow Coma Score less than 4 and admission pH less than 7.1.

Conclusions

The primary mission of the CSH in theater remains unchanged, but its role is evolving. With this study, we can begin to understand the needs of wounded children in urban conflict and help guide training and resource allocation in the future.     

急性颈髓损伤并发MSOF的类型及原因分析

目的：通过探讨急性颈椎颈髓损伤并发多系统器官衰竭（ｍｕｌｔｉｐｌｅｓｙｓｔｅｍｏｒｇａｎｆａｉｌｕｒｅ，ＭＳＯＦ）发病因素及其类型，为防治伤后ＭＳＯＦ提供依据。方法：对我院１９８２年１月～１９９７年５月收治的３０３例急性外伤性颈椎颈髓损伤并发ＭＳＯＦ的３２例病人进行回顾性分析。结果：颈髓损伤并发ＭＳＯＦ的诱因为肺部感染，高热，水电解质平衡紊乱，低蛋白血症和术后继发性颈髓损害。ＭＳＯＦ的发生率为颈髓损伤病人１０．５６％，死亡２５例，死亡率为ＭＳＯＦ病人７８．１３％。结论：消除ＭＳＯＦ的诱因并对可能发生或已发生功能不全的器官进行有效的功能支持，才能降低颈髓损伤后ＭＳＯＦ的发生率、死亡率     

Diagnosis,Timing and Treatment of Cervical Spine Injuries in Polytraumatized Patients

Abstract Treatment of polytrauma patients has been discussed extensively during the past decades. Management in the prehospital phase, on admission, and in the early postoperative/ICU-period has to refer to injury severity, priority of injuries, and likelihood of development of multi organ failure. Cervical spine injuries are reported in 4–34% of polytrauma cases. Securing the cervical spine by a hard collar is one of the basic procedures in the prehospital phase. Different strategies of assessing the cervical spine are still discussed controversially. Since plain radiographs, CT-scan, MRI, and flexion/extension fluoroscopy still play a role in early diagnosis of cervical spine injury, we present an analysis of cervical spine injuries in our multiple trauma patients to elucidate our algorithm. We reviewed our data between January 2003 and December 2006 concerning epidemiology, diagnosis and treatment of cervical spine injury in polytrauma patients. Multislice-CT (MSCT) or Multidetector-CT was used as standard diagnostic procedures in the polytraumatized patient. In 97% of patients, CT-scanning showed to be a reliable tool in detecting injuries of the cervical spine. Only in two patients (3%), additional MRI lead to a change in treatment strategy. Of 66 polytraumatized patients with significant cervical spine injury, 25 (37.9%) received surgical treatment within 24 h. Sixteen patients (24.2%) were treated surgically after stabilization on ICU. There was a better outcome concerning length of hospitalization in the “day-onesurgery” group. We consider MSCT as standard approach towards diagnosis of cervical spine injury in polytrauma patients. MRI and flexion/extension fluoroscopy can give additional information in selected cases.     

Treatment and outcome of traumatic biliary injuries in children

Background/Purpose

Traumatic biliary tract injuries in children are rare but may result in significant morbidity. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome.

Methods

We conducted a retrospective review of patients with biliary tract injury using the trauma registry at our level 1 pediatric trauma center from 2002–2012.

Results

Twelve out of 13,582 trauma patients were identified, representing 0.09% of all trauma patients. All were secondary to blunt trauma. Mean age was 9.7 years [range 4–15], and mean Injury Severity Score was 31 ± 14, with overall survival of 92%. Biliary injuries included major ductal injury (6), minor ductal injury with biloma (4), gallbladder injury (2), and intrahepatic ductal injury (1). Major ductal injuries were managed by endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent (5) and Roux-en-Y hepaticojejunostomy (1). Associated gallbladder injury was managed by cholecystectomy. In addition, the associated biloma was managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). Two patients with ductal injuries developed late strictures after initial management with ERCP and stent placement. One of the two patients ultimately required a left hepatectomy, and the other has been managed conservatively without evidence of cholangitis. Two patients required placement of additional drains and prolonged antibiotics for superinfection following biloma drainage.

Conclusion

Biliary tract injuries are rare in children, and many are amenable to adjunctive therapy, including ERCP and biliary stent placement with or without placement of a peritoneal drain. Patients with a discrete ductal injury are at higher risk for stricture and require close follow up. Hepaticojejunostomy remains the definitive repair for large extrahepatic biliary tract injuries or transections.