Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma

A genomic storm in critically injured humans

Critical injury in humans induces a genomic storm with simultaneous changes in expression of innate and adaptive immunity genes.

Human survival from injury requires an appropriate inflammatory and immune response. We describe the circulating leukocyte transcriptome after severe trauma and burn injury, as well as in healthy subjects receiving low-dose bacterial endotoxin, and show that these severe stresses produce a global reprioritization affecting >80% of the cellular functions and pathways, a truly unexpected “genomic storm.” In severe blunt trauma, the early leukocyte genomic response is consistent with simultaneously increased expression of genes involved in the systemic inflammatory, innate immune, and compensatory antiinflammatory responses, as well as in the suppression of genes involved in adaptive immunity. Furthermore, complications like nosocomial infections and organ failure are not associated with any genomic evidence of a second hit and differ only in the magnitude and duration of this genomic reprioritization. The similarities in gene expression patterns between different injuries reveal an apparently fundamental human response to severe inflammatory stress, with genomic signatures that are surprisingly far more common than different. Based on these transcriptional data, we propose a new paradigm for the human immunological response to severe injury.

Imbalance between macrophage migration inhibitory factor and cortisol induces multiple organ dysfunction in patients with blunt trauma

Migration inhibitory factor (MIF) is associated with multiple organ dysfunction syndrome (MODS) in patients with systemic inflammatory response syndrome (SIRS). Our purposes were to determine the serum MIF, cortisol, and tumor narcosis factor-α (TNF-α) and to investigate the influences of the balance between the levels of MIF and cortisol in patients with blunt trauma. The cortisol levels were identical between the patients with and without MODS. However, the MIF and TNF-α levels in the patients with MODS were statistically higher than those of the patients without MODS. The cortisol/MIF ratios in the patients with MODS were statistically higher than those of the patients without MODS. The results show that MIF and TNF-α play an important role together in posttraumatic inflammatory response. An excessive serum MIF elevation overrides the anti-inflammatory effects of cortisol and leads to persistent SIRS followed by MODS in blunt trauma patients.

Experimental trauma models: an update

Treatment of polytrauma patients remains a medical as well as socioeconomic challenge. Although diagnostics and therapy improved during the last decades, multiple injuries are still the major cause of fatalities in patients below 45 years of age. Organ dysfunction and organ failure are major complications in patients with major injuries and contribute to mortality during the clinical course. Profound understanding of the systemic pathophysiological response is crucial for innovative therapeutic approaches. Therefore, experimental studies in various animal models are necessary. This review is aimed at providing detailed information of common trauma models in small as well as in large animals.

Experimentally approaching the ICU: monitoring outcome-based responses in the two-hit mouse model of posttraumatic sepsis

To simulate and monitor the evolution of posttraumatic sepsis in mice, we combined a two-hit model of trauma/hemorrhage (TH) followed by polymicrobial sepsis with repetitive blood sampling. Anesthetized mice underwent femur fracture/sublethal hemorrhage and cecal ligation and puncture (CLP) 48 h later. To monitor outcome-dependent changes in circulating cells/biomarkers, mice were sampled daily (facial vein) for 7 days and retrospectively divided into either dead (DIE) or surviving (SUR) by post-CLP day 7. Prior to CLP, AST was 3-fold higher in DIE, while all other post-TH changes were similar between groups. There was a significant post-CLP intergroup separation. In SUR, RBC and Hb were lower, platelets and neutrophils higher, and lymphocytes mixed compared to DIE. In DIE, all organ function markers except glucose (decrease) were few folds higher compared to SUR. In summary, the combination of daily monitoring with an adequate two-hit model simulates the ICU setting, allows insight into outcome-based responses, and can identify biomarkers indicative of death in the acute posttraumatic sepsis in mice.

Mortality decreases by implementing a level I trauma center in a Dutch hospital

BACKGROUND

Trauma centers are designed to improve survival and outcome of the injured patient. The implementation of these centers in the United States has shown to reduce the number of preventable deaths from serious injuries. This study compares outcomes of trauma patients during two separate time periods in a Dutch Level I trauma center, before and after obtaining the trauma center status.

METHODS

Prospectively, patient data were collected from an automated database in the years 1996 through 1998 (period 1) and 2003 through 2005 (period 2) in the University Medical Center in Utrecht. The patients included and analyzed were adult trauma victims admitted to our trauma center.

RESULTS

A total of 4,069 patients in total were included, 2,348 in period 1 and 1,721 in period 2. Mean age was 45.9 years and 48.1 years, respectively (p < 0.001). Men comprised 62% and 64%, respectively (not significant). After obtaining the trauma center status, more severely injured patients were admitted (mean Injury Severity Score was 9.6 in group 1 vs. 12.4 in group 2, p < 0.001). Adjusted for age and injury severity, the inhospital mortality was lower (odds ratio: 0.606, p < 0.05) in the second group. Adjusted for age, Injury Severity Score, and mortality, the hospital stay was shorter (p < 0.001) in the second group. Fewer patients were admitted to the intensive care unit (p < 0.001), but the length of stay appeared longer (p = 0.055) after trauma center designation.

CONCLUSION

This study implies that the implementation of a trauma center reduces mortality, shortens hospital stay, and decreases the number of intensive care unit admittances in Utrecht, the Netherlands.

Post injury multiple organ failure

The understanding of post injury multiple organ failure (MOF) has evolved considerably since it was first described more than 30 years ago. Improved trauma care has decreased the mortality of single organ injury, although these patients may go on to MOF. There has been significant investigation in both the basic science and clinical understanding of MOF. This research has altered management strategies thereby decreasing the incidence and mortality related to MOF. Despite this MOF remains the greatest contributor to late trauma death and morbidity. This review defines essential terminology, examines the historical perspective of MOF, describes common scoring systems, describes the changes in epidemiology, discusses the aetiology and pathophysiology, reviews current prevention, resuscitation and treatment strategies and provides future direction for research.

Early predictors of morbidity and mortality in trauma patients treated in the intensive care unit

BACKGROUND

We investigated the incidence and severity of post-injury morbidity and mortality in intensive care unit (ICU)-treated trauma patients. We also identified risk factors in the early phase after injury that predicted the later development of complications.

METHODS

A prospective observational cohort study design was used. One hundred and sixty-four adult patients admitted to the ICU for more than 24 h were included during a 21-month period. The incidence and severity of morbidity such as multiple organ failure (MOF), acute lung injury (ALI), severe sepsis and 30-day post-injury mortality were calculated and risk factors were analyzed with uni- and multivariable logistic regression analysis.

RESULTS

The median age was 40 years, the injury severity score was 24, the new injury severity score was 29, the acute physiology and chronic health evaluation II score was 15, sequential organ failure assessment maximum was 7 and ICU length of stay was 3.1 days. The incidences of post-injury MOF were 40.2%, ALI 25.6%, severe sepsis 31.1% and 30-day mortality 10.4%. The independent risk factors differed to some extent between the outcome parameters. Age, severity of injury, significant head injury and massive transfusion were independent risk factors for several outcome parameters. Positive blood alcohol was only a predictor of MOF, whereas prolonged rescue time only predicted death. Unexpectedly, injury severity was not an independent risk factor for mortality.

CONCLUSIONS

Although the incidence of morbidity was considerable, mortality was relatively low. Early post-injury risk factors that predicted later development of complications differed between morbidity and mortality.

Risk of symptomatic heterotopic ossification following plate osteosynthesis in multiple trauma patients: an analysis in a level-1 trauma centre

BACKGROUND

Symptomatic heterotopic ossification (HO) in multiple trauma patients may lead to follow up surgery, furthermore the long-term outcome can be restricted. Knowledge of the effect of surgical treatment on formation of symptomatic heterotopic ossification in polytrauma is sparse. Therefore, we test the effects of surgical treatment (plate osteosynthesis or intramedullary nailing) on the formation of heterotopic ossification in the multiple trauma patient.

METHODS

We retrospectively analysed prospectively documented data of blunt multiple trauma patients with long bone fractures which were treated at our level-1 trauma centre between 1997 and 2005. Patients were distributed to 2 groups: Patients treated by intramedullary nails (group IMN) or plate osteosynthesis (group PLATE) were compared. The expression and extension of symptomatic heterotopic ossifications on 3-6 months follow-up x-rays in antero-posterior (ap) and lateral views were classified radiologically and the maximum expansion was measured in millimeter (mm). Additionally, ventilation time, prophylactic medication like indomethacine and incidence and correlation of head injuries were analysed.

RESULTS

101 patients were included in our study, 79 men and 22 women. The fractures were treated by intramedullary nails (group IMN n = 50) or plate osteosynthesis (group PLATE n = 51). Significantly higher radiologic ossification classes were detected in group PLATE (2.9 +/- 1.3) as compared to IMN (2.2 +/- 1.1; p = 0.013). HO size in mm ap and lateral showed a tendency towards larger HOs in the PLATE group. Additionally PLATE group showed a higher rate of articular fractures (63% vs. 28% in IMN) while IMN demonstrated a higher rate of diaphyseal fractures (72% vs. 37% in PLATE; p = 0.003). Ventilation time, indomethacine and incidence of head injuries showed no significant difference between groups.

CONCLUSION

Fracture care with plate osteosynthesis in polytrauma patients is associated with larger formations of symptomatic heterotopic ossifications (HO) while intramedullary nailing was associated with a higher rate of remote HO. For future fracture care of multiply injured patients these facts may be considered by the responsible surgeon.

IL-6 predicts organ dysfunction and mortality in patients with multiple injuries

Background

Although therapeutic concepts of patients with major trauma have improved during recent years, organ dysfunction still remains a frequent complication during clinical course in intensive care units. It has previously been shown that cytokines are upregulated under stress conditions such as trauma or sepsis. However, it is still debatable if cytokines are adequate parameters to describe the current state of trauma patients. To elucidate the relevance of cytokines, we investigated if cytokines predict development of multiple organ dysfunction syndrome (MODS) or outcome.

Methods

A total of 143 patients with an injury severity score ≥ 16, between 16 and 65 years, admitted to the Hannover Medical School Level 1 Trauma Center between January 1997 and December 2001 were prospectively included in this study. Marshall Score for MODS was calculated for at least 14 days and plasma levels of TNF-α, IL-1β, IL-6, IL-8 and IL-10 were measured. To determine the association between cytokine levels and development of MODS the Spearman rank correlation coefficient was calculated and logistic regression and analysis were performed.

Results and Discussion

Patients with MODS had increased plasma levels of IL-6, IL-8 and IL-10. IL-6 predicted development of MODS with an overall accuracy of 84.7% (specificity: 98.3%, sensitivity: 16.7%). The threshold value for development of MODS was 761.7 pg/ml and 2176.0 pg/ml for mortality during the in patient time.

Conclusion

We conclude that plasma IL-6 levels predict mortality and that they are a useful tool to identify patients who are at risk for development of MODS.

Postinjury multiple organ failure

Postinjury multiple organ failure (MOF) became prevalent as the improvements in critical care during the 1970s made it possible to keep trauma patients alive with single organ injury. Enormous efforts invested in laboratory and clinical research made it possible to better understand the epidemiology and pathophysiology of the syndrome. This has translated to improved strategies in prediction, prevention and treatment of MOF. With changes in population demographics and injury mechanisms and improvements in trauma care, changes in the epidemiology of MOF are also becoming evident. Significant improvements in trauma patient management decreased the severity and mortality of MOF, but the syndrome still remains the most significant contributor of late postinjury mortality and intensive care unit resource utilisation. This review defines the essential MOF-related terminology, summarises the changing epidemiology of MOF, describes our current understanding of the pathophysiology, discusses the available strategies for prevention/treatment based on the identified independent predictors and provides future directions for research.

Patterns of mortality and causes of death in polytrauma patients--has anything changed?

INTRODUCTION

Numerous articles have examined the pattern of traumatic deaths. Most of these studies have aimed to improve trauma care and raise awareness of avoidable complications. The aim of the present review is to evaluate whether the distribution of complications and mortality has changed.

MATERIALS AND METHODS

A review of the published literature to identify studies examining patterns and causes of death following trauma treated in level 1 hospitals published between 1980 and 2008. PubMed was searched using the following terms: Trauma Epidemiology, Injury Pattern, Trauma Deaths, and Causes of Death. Three time periods were differentiated: (n=6, 1980-1989), (n=6, 1990-1999), and (n=10, 2000-2008). The results were limited to the English and/or German language. Manuscripts were analysed to identify the age, injury severity score (ISS), patterns and causes of death mentioned in studies.

RESULTS

Twenty-two publications fulfilled the inclusion criteria for the review. A decrease of haemorrhage-induced deaths (25-15%) has occurred within the last decade. No considerable changes in the incidence and pattern of death were found. The predominant cause of death after trauma continues to be central nervous system (CNS) injury (21.6-71.5%), followed by exsanguination (12.5-26.6%), while sepsis (3.1-17%) and multi-organ failure (MOF) (1.6-9%) continue to be predominant causes of late death.

DISCUSSION

Comparing manuscripts from the last three decades revealed a reduction in the mortality rate from exsanguination. Rates of the other causes of death appear to be unchanged. These improvements might be explained by developments in the availability of multislice CT, implementation of ATLS concepts and logistics of emergency rescue.

Epidemiology of post-injury multiple organ failure in an Australian trauma system

BACKGROUND

The epidemiology of post-injury multiple organ failure (MOF) is reported internationally to have gone through changes over the last 15 years. The purpose of this study is to describe the epidemiology of post-injury MOF in Australia.

METHODS

A 12-month prospective epidemiological study was performed at the John Hunter Hospital (Level-1 Trauma Centre). Demographics, injury severity (ISS), physiological parameters, MOF status and outcome data were prospectively collected on all trauma patients who met inclusion criteria (ICU admission; ISS > 15; age > 18, head Abbreviated Injury Scale (AIS) <3 and survival >48 h). MOF was prospectively defined by the Denver MOF score greater than 3 points. Data are presented as % or Mean +/- SEM. Univariate statistical comparison was performed (Student t-test, Chi2 test), P < 0.05 was considered significant.

RESULTS

Twenty-nine patients met inclusion criteria (Age 40 +/- 4, ISS 29 +/- 3, Male 62%), five patients developed MOF. The incidence of MOF among trauma patients admitted to ICU was 2% (5/204) and 17% (5/29) in the high-risk cohort. The maximum average MOF score was 6.3 +/- 1, with the average duration of MOF 5 +/- 2 days. Two patients had respiratory and cardiac failure, two patients had failure of respiratory, cardiac and hepatic systems, while one patient had failure of respiratory, hepatic and renal systems. One MOF patient died, all non MOF patients survived. MOF patients had longer ICU stays (20 +/- 4 versus 7 +/- 0.8 P = 0.01), tended to be older (60 +/- 11 versus 35 +/- 4 p = 0.07). None of the previously described independent predictors (ISS, base deficit, lactate, transfusions) were different when the MOF patients were compared with the non-MOF patients.

CONCLUSION

The incidence of MOF in Australia is consistent with the international data. In Australia MOF continues to cause significant late mortality and morbidity in trauma patients. MOF patients have longer ICU stay than high-risk non MOF patients, and use significant resources. Our preliminary data challenges the timeliness of the 10-year-old independent predictors of post-injury MOF. The epidemiology, the clinical presentation and the independent predictors of post-injury MOF require larger scale reassessment for the Australian context.

Validation of postinjury multiple organ failure scores

Most multiple organ failure (MOF) scores were developed over a decade ago, but little has been done in terms of validation and to understand the differences between populations identified by each of them. Given the lack of a gold standard, validation must rely on association with objective adverse outcomes. Thus, we propose to (a) validate two widely accepted MOF scores (Denver and Marshall), examining their association with adverse outcomes in a postinjury population; and (b) compare risk factors, characteristics, and outcomes of patients identified by each score. The Denver MOF score grades (from 0-3) four organ dysfunctions (lung, kidney, liver, and heart) and defines MOF as a total score more than 3. The Marshall score grades, in addition, central nervous system and hematologic dysfunction (total of six organs on a 0- to 4-point scale). Using a prospectively collected data set, MOF was scored daily by both scores for 1,389 consecutive trauma patients with Injury Severity Score of more than 15 admitted from 1992 to 2004. Risk factors, clinical outcomes (death, ventilator-free days), and resource utilization outcomes (mechanical ventilation time, length of stay in the intensive care unit) were evaluated. Both scores were associated with areas under the receiver operating characteristic curves of 80 or greater (ideal value = 100), with values for the Denver score being slightly greater (albeit not significantly) regarding prediction of most outcomes. Values of sensitivity and specificity were more than 70% for death and ventilator-free days (with the Denver score showing a consistent trend toward greater specificity), but either sensitivity or specificity was less than 70% for mechanical ventilation time and length of stay in the intensive care unit, suggesting that these scores are appropriately biased toward clinical outcomes as opposed to resource utilization. Both scores performed well, with the Denver MOF score showing greater specificity, which, coupled with its simplicity, makes it an attractive tool for both the research and clinical environments. Basic concepts of each score can probably be combined to produce an improved MOF score.

Neutrophil-derived circulating free DNA (cf-DNA/NETs): a potential prognostic marker for posttraumatic development of inflammatory second hit and sepsis

The release of "neutrophil extracellular traps" (NETs) has been identified as a novel immune response in innate immunity. Neutrophil extracellular traps are composed of neutrophil-derived circulating free DNA (cf-DNA), histones, and neutrophil cytoplasm-derived proteins such as proteases. Here, we studied the putative predictive value of plasma cf-DNA/NETs for the development of sepsis and mortality after multiple trauma. In a prospective pilot study with 45 multiple trauma (Injury Severity Score>16) patients, cf-DNA was directly quantified in plasma. Blood samples were sequentially obtained daily from admission to our Trauma Center until day 10. Because of limited intensive care unit (ICU) stay of less than 3 days, 8 patients have been excluded, resulting in 37 patients that were evaluated. Time kinetics of cf-DNA/NETs was compared with C-reactive protein (CRP), interleukin (IL) 6, leukocyte counts, and myeloperoxidase. The severity of the injury was calculated on the basis of the Injury Severity Score, as well as Multiple Organ Dysfunction Score, Sequential Organ Failure Assessment, and Simplified Acute Physiology Score II on ICU. Initially high cf-DNA/NETs values (>800 ng/mL) with recurrent increased values between days 5 to 9 were associated with subsequent sepsis, multiple organ failure, and death. In conjunction with cf-DNA/NETs, IL-6 was significantly elevated after admission. However, the development of a second hit was not indicated by IL-6. In contrast to cf-DNA/NETs, no difference in CRP kinetics was observed between patients with and without development of sepsis. Circulating free DNA/NETs kinetics rather followed kinetics of Multiple Organ Dysfunction Score, Sepsis-related Organ Failure Assessment, leukocyte counts, and partially of myeloperoxidase. Circulating free DNA/NETs seems to be a valuable additional marker for the calculation of injury severity and/or prediction of inflammatory second hit on ICU. However, a large clinical trial with severely injured patients should confirm the prognostic value of neutrophil-derived cf-DNA/NETs.

Applicability of the trimodal distribution of trauma deaths in a Level I trauma centre in the Netherlands with a population of mainly blunt trauma

BACKGROUND

Death due to trauma is assumed to follow a trimodal distribution. Since 1995 measures have been taken to regulate organisations involved in trauma care systems in the Netherlands. In estimating the effect of this system we have evaluated the time of death distribution in the University Medical Centre Utrecht (UMCU).

STUDY DESIGN

Prospectively collected databases of all trauma victims between January 1996 and December 2005 were retrospectively reviewed. All traumatic deaths were included. Cause of death was divided into exsanguination, thorax, CNS, organ failure, pneumonia, other and unknown.

RESULTS

Nine thousand eight hundred and five patients were admitted after trauma; of these patients 659 (6.7%) died. Blunt trauma occurred in 615/659 (93.3%) patients. The temporal distribution did not show a trimodal distribution. One predominant peak was observed, <or=1h after arrival at the emergency unit. Within the first day 310/659 (47%) deaths occurred, of which 76/310 (11.5%) <or=1h. CNS injuries were significantly the main cause of death; 334/659 (50.7%, p<0.05). Exsanguination was the main cause of death <or=1h; 31/76 (40.8%, p<0.05). Both CNS injuries and organ failure were the main causes of late death; >or=14 days, 28% and 29%, respectively.

CONCLUSION

No trimodal distribution was confirmed. Only one predominant peak, with a rapid decline, was observed within the first hour after trauma. Even analysed for different causes of death, the trimodal distribution could not be demonstrated. In particular death due to CNS injury showed a complete absence of any peaks.

Multiple organ failure after trauma affects even long-term survival and functional status

BACKGROUND

The aim of this study was to assess the incidence of organ failure in trauma patients treated in an intensive care unit (ICU), and to study the relationship between organ failure and long-term survival and functional status.

METHODS

This is a cohort study of all adult ICU trauma patients admitted to a university hospital during 1998 to 2003. Organ failure was quantified by the Sequential Organ Failure Assessment (SOFA) score. A telephone interview was conducted in 2005 (2 to 7 years after trauma) using the Karnofsky Index to measure functional status, and the Glasgow Outcome Score to measure recovery.

RESULTS

Of the 322 patients included, 47% had multiple organ failure (MOF), and 28% had single organ failure. In a Cox regression, MOF increased the overall risk of death 6.0 times. At follow-up, 242 patients (75%) were still alive. Patients with MOF had 3.9 times greater odds for requiring personal assistance in activities of daily living compared to patients without organ failure. Long-term survival and functional status were the same for patients suffering single organ failure and no organ failure. Complete recovery occurred in 52% of survivors, and 87% were able to look after themselves.

CONCLUSION

Almost half of the ICU trauma patients had MOF. While single organ failure had no impact on long-term outcomes, the presence of MOF greatly increased mortality and the risk of impaired functional status. MOF expressed by SOFA score may be used to define trauma patients at particular risk for poor long-term outcomes.

Systemic inflammation after trauma

Trauma is still one of the main reasons for death among the population worldwide. Mortality occurring early after injury is due to "first hits", including severe organ injury, hypoxia, hypovolaemia or head trauma. Massive injury leads to activation of the immune system and the early inflammatory immune response after trauma has been defined as systemic inflammatory response syndrome (SIRS). "Second hits" such as infections, ischaemia/reperfusion or operations can further augment the pro-inflammatory immune response and have been correlated with the high morbidity and mortality in the latter times after trauma. SIRS can lead to tissue destruction in organs not originally affected by the initial trauma with subsequent development of multi-organ dysfunction (MOD). The initial pro-inflammatory response is followed by an anti-inflammatory response and can result in immune suppression with high risk of infection and sepsis. Trauma causes activation of nearly all components of the immune system. It activates the neuroendocrine system and local tissue destruction and accumulation of toxic byproducts of metabolic respiration leads to release of mediators. Extensive tissue injury may result in spillover of these mediators into the peripheral bloodstream to further maintain and augment the pro-inflammatory response. Hormones like ACTH, corticosteroids and catecholamines as well as cytokines, chemokines and alarmins play important roles in the initiation and persistence of the pro-inflammatory response after severe injury. The purpose of this review is therefore to describe the immunological events after trauma and to introduce important mediators and pathways of the inflammatory immune response.

Prevention and treatment of post-traumatic acute respiratory distress syndrome

Post-Traumatic Acute Respiratory Distress Syndrome (ARDS) is a major cause of morbidity and mortality in the acutely injured patient. The American-European Consensus Conference Report established the most widely accepted definition of ARDS in 1994. In recent years it appears the incidence and impact of the disease are on the decline. This article reviews strategies to prevent and treat post-traumatic ARDS. Well-accepted, proven strategies include lung protective ventilation strategies, as well as conservative transfusion and crystalloid resuscitation policies and the adoption of leukoreduction techniques. Other modalities including hypertonic saline resuscitation, use of albumin and diuretics, positive end expiratory pressure, high-frequency ventilation, prone positioning, recruitment maneuvers, extracorporeal membrane oxygenation, corticosteroids, exogenous surfactant, and inhaled nitric oxide are also reviewed.

Low incidence of multiple organ failure after major trauma

BACKGROUND

In major trauma patients, multiple organ failure (MOF) is considered a leading cause of death. Acute lung injury is deemed a "pacemaker" of MOF. The purpose of this study was to determine if incidence of organ failure and mortality in multiple trauma patients can be reduced by implementation of lung-protective strategies.

METHODS

All critically ill multiple trauma patients admitted to the ICU of a major trauma center in Berlin, Germany from January 1999 to December 2002 were analyzed retrospectively. Patients were ventilated pressure controlled with low tidal volumes and adequate PEEP.

RESULTS

n=287 patients were included. The most frequent injuries were traumatic brain injury (TBI-68%), chest trauma (68%), and lung contusions (55%). Injury severity score (ISS) was 32+/-19 (mean+/-standard deviation), polytraumaschluessel (PTS) 34+/-19, and APACHE II 14+/-7. During their ICU-stay 16 patients died, 9 (56%) from TBI. Single-organ-failure occurred in n=69 patients (24%, mortality 5%), two-organ-failure in n=22 (8%, mortality 14%), and MOF in n=9 (3%, mortality 13%); one patient died from MOF 14 days after trauma. The number of days on mechanical ventilation increased depending on the number of organs failed (R=0.618, p<0.001). Seven patients (2%) fulfilled ARDS criteria for longer than 24h despite optimized ventilatory settings, one died of irreversible shock. Patients with MOF had a significantly increased ICU-LOS (35+/-15 days) compared to patients without organ failure (11+/-11 days; p<0.001).

CONCLUSION

The low incidence of MOF in our series of trauma patients suggests that MOF may be prevented in some patients by implementation of lung-protective strategies. The improved outcome was associated with an increased ICU-LOS.

The decreasing incidence of late posttraumatic acute respiratory distress syndrome: the potential role of lung protective ventilation and conservative transfusion practice

BACKGROUND

A reduction in the incidence of posttraumatic Acute Respiratory Distress Syndrome (ARDS) has been demonstrated. It is hypothesized that ventilation strategies and restrictive transfusion policies are contributory. The purpose of this study is to examine the changes in ventilation and transfusion parameters over time and their associations with late posttraumatic ARDS.

METHODS

The surgical intensive care unit and blood bank databases from a Level I center during a 6-year period were analyzed. All mechanically ventilated trauma patients were screened for ARDS with onset after 48 hours of admission (late ARDS). Demographic, injury, resuscitation, ventilation parameters, and transfusion data were extracted. Variables were analyzed for significant changes during the duration of the study, and independent associations with ARDS were determined.

RESULTS

There were 2,346 eligible patients and 192 (8.2%) of them met criteria for late ARDS. There was a significant decrease in the incidence of late ARDS by year (14.9% in 2000 to 3.8% in 2005). When comparing the first and second half of the study, there was a significant decrease in the percentage of patients transfused with packed red blood cells (49.0% versus 40.7%), patients with a peak inspiratory pressure > or = 30 mm Hg (64.9% versus 50.1%), and patients ventilated with a tidal volume/kg > or = 10 mL/kg (39.6% versus 21.8%). Early transfusions, peak inspiratory pressure > or = 30 mm Hg, and fluid balance > or = 2 L in the first 48 hours of admission were independently associated with ARDS.

CONCLUSIONS

The increasing use of restrictive transfusion policies and ventilation strategies that potentially limit elevations in early peak inspiratory pressures are associated with a decreased incidence of late posttraumatic ARDS.

Defining the Contribution of Renal Dysfunction to Outcome after Traumatic Injury

Renal failure is frequently considered an ominous development after injury, but its impact on outcome is poorly understood. Renal dysfunction or failure can be defined in many ways, such as elevated serum creatinine or the need for dialysis. The best method to characterize renal dysfunction however, is not known. To determine which definition of renal dysfunction correlates best with outcome, we retrospectively analyzed all injured patients from 1994 to 2000 who had an Injury Severity Score ≥14 and a hospital length of stay >2 days for the development of renal impairment. One hundred sixty-seven patients (4%) developed a serum creatinine ≥2.0 mg/dL and 49 patients required dialysis. Patients with renal dysfunction were older, suffered from more comorbid medical problems, were more seriously injured, and were more likely to have been in shock. A serum creatinine ≥2.0 mg/dL, the maximum creatinine level, and need for dialysis, were highly correlated with death, and the total number of dialysis treatments was not. All measures of renal dysfunction correlated relatively poorly with length of stay. These data demonstrate that the simple measure of serum creatinine ≥2.0 mg/dL is associated with a significantly increased likelihood of death in injured patients and is a stronger predictor than other common indicators of renal impairment.

Real-time assessment of hepatic function is related to clinical outcome in critically ill patients after polytrauma

OBJECTIVES

The aim was to investigate the outcome MODS/MOF in critically ill patients with regard to early hepatic dysfunction.

METHODS

Thirty adult polytrauma patients admitted to the ICU, with ISS >or=16 were prospectively investigated. Real-time liver function was assessed using the MEGX test and arterial ketone body ratio (AKBR) 12-24 h after admittance to ICU, and on days 3, 5, 8, 12.

RESULTS

Six patients (19%) died between days 4 and 29. Non-survivors were older (64.2 vs. 31.5 years), had a significantly higher ISS (40.5 vs. 30; p=0.002) and MODS score (9.5 vs. 5; p=0.001) on admittance to the ICU than survivors. On day 3 MEGX values (31 vs. 71.3 microg/L; p=0.001) and the AKBRs (0.6 vs. 1.3; p=0.001) were significantly lower in non-survivors than in survivors whereas IL-6 levels were significantly higher in the former group (519 vs. 61 microg/L; p=0.05).

CONCLUSIONS

The MEGX test and AKBR are sensitive early indicators of hepatic dysfunction in severely injured polytrauma patients at risk for developing MODS/MOF.

Factors influencing the injury pattern and injury severity after high speed motor vehicle accident--a retrospective study

INTRODUCTION

Motor vehicular accidents (MVA) are the leading cause of death among people under 40 years of age. Despite improvement in car safety and driver awareness of the use of safety devices, fatalities and severe injuries continue to occur.

MATERIAL AND METHODS

From 1997 to 2004, 13,678 patients after MVA were admitted to our institution. Out of this cohort, 584 (4.3%) patients suffered blunt major trauma defined as Injury Severity Score (ISS) >or=16 and at least one life-threatening injury in one body region. Preclinical data were recorded in 458 patients matching the inclusion criteria. The circumstances of the trauma scene such as weather conditions were analysed as well as technical crash data such as direction of impact, security devices used and type and severity of automobile damage. In a retrospective trial, the influence of preclinical variables on the injury pattern and on injury severity was investigated.

RESULTS

314 (68.6%) patients were male and 144 (31.4%) female. Injury severity (p=0.015) and rate of multiple injuries (p=0.012) were higher in patients after side-impact crashes. If automobiles with SIPS were used, injury severity was significantly reduced in case of side-impact crashes (p=0.003). Patients after frontal impact crashes had a higher rate of severe traumatic brain injury (TBI) compared to the overall cohort (p=0.014). Patients suffering blunt aortic (n=29) dissection were involved in frontal crashes with seat belt use (p<0.001). If patients were entrapped, injury severity (p=0.021) and rate of multiple injuries (p=0.018) were significantly higher. Rear-end collisions with trucks without rear protection led to higher mortality rates (p=0.011).

CONCLUSION

According to our data significant association between technical crash data and injury pattern and injury severity can be assumed. In case of high speed MVA in rural areas the trauma mechanism and the circumstances (i.e., impact direction, automobile deformation) should be considered to identify patients at high risk of severe blunt trauma and multiple injuries.

Analysis of NF-kappaB nuclear translocation in PMN-neutrophils of major trauma patients in the early post-traumatic period: a pilot study

BACKGROUND

Post-traumatic inflammation is connected to polymorphonuclear neutrophil (PMN)-dysfunction characterized by reduced nuclear translocation of NF-kappaB during the post-traumatic period. However, the dynamic of NF-kappaB translocation in PMN of major trauma patients remains unclear. Hence, the aim of this pilot study was to analyze NF-kappaB in PMN from multiply injured patients immediately after trauma.

PATIENTS AND METHODS

Blood samples of major trauma patients (ISS > 16) were drawn on admission within 90 minutes after trauma and at 6, 12, 24, 48, and 72 hours after trauma. Neutrophilic NF-kappaB-translocation was analyzed by EMSA and quantified by densitometry as (arbitrary units). In addition, PMN of healthy volunteers were analyzed either in their native state (-control) or after LPS stimulation (+control).

RESULTS

Twelve patients (NISS: 34 +/- 10 [mean +/- SEM]) were enrolled. NF-kappaB translocation was significantly increased in trauma patients on admission and after 6 hours. Interestingly, a second activity peak was present after 24 hours. In patients who later died, NF-kappaB activity was significantly elevated initially, to be rapidly diminished after 6 hours, while it increased in the survivors group. After 24 hours NF-kappaB activity increased significantly in the survivors group, to become reduced in both groups at a later time.

CONCLUSIONS

Within this pilot study, the dynamic of NF-kappaB translocation in PMN of multiply injured patients immediately after trauma was analyzed for the first time. Enabled by closely matched sequential blood sampling strictly standardized to the traumatic event, an essential biphasic increase of neutrophilic signal transduction could be investigated in the very early post-traumatic period, which preceded the downregulation of the innate immune system.

Application of clinical proteomics in diagnosis and management of trauma patients

Poly-trauma remains a medical entity with major implications, for patient's morbidity, mortality and healthcare economics. Advances in molecular medicine have improved diagnostic techniques in detecting devastating complication after major trauma. Patients at high risk of multiple organ dysfunction syndrome (MODS) or adult respiratory distress syndrome (ARDS), could be identified early, monitored and treated. Proteomics is the systematic evaluation of proteins produced by the cell under normal or pathological circumstances. Investigating protein production will allow us to identify and modify disease natural history and treatment. In this review, we summarise the proteomic methods currently applied in trauma research.

[Management of polytrauma]

The first hours after trauma are decisive. Therefore the treatment chosen demands very strict planning according to concepts of modern quality management. This begins with the fastest possible and most efficient delivery of injured patients to the applicable clinic. Such institutions are permanently ready and have at their service all the necessary diagnostic techniques and surgical and intensive care methods. Effective shock treatment entails standardized procedures accompanied by up-to-date diagnostic and therapeutic measures. After admittance and therapy of life-threatening injuries (immediate measures, damage control surgery), early-stage surgery will follow (soft tissue injuries and fractures). Strategy of damage control orthopedics is growing in acceptance because of the potential danger to life functions due to pro- and anti-inflammatory response induced additional trauma caused by following surgery. Fractures initially stabilized by external fixation can consecutively be treated safely by secondary conversion osteosynthesis. A considerable improvement in quality can be attained through therapeutic procedures approved by all concomitant disciplines and standardized systems with internal and external control methods.

Trauma patients in the intensive care unit: short- and long-term survival and predictors of 30-day mortality

BACKGROUND

The aims of this cohort study were to assess the survival of trauma patients treated in a general intensive care unit (ICU) and to evaluate the simplified acute physiology score (SAPS) II, maximum sequential organ failure assessment (SOFA) score, injury severity score (ISS), age, sex and severe head injury as predictors of 30-day mortality.

METHODS

Three hundred and twenty-five adult patients admitted during 1998-2003 were evaluated retrospectively with update of survival data in January 2005. Kaplan-Meier statistics and Cox proportional hazards regression were used to study survival and to assess predictors of mortality, respectively.

RESULTS

The 30-day mortality was 16.9%, ICU mortality 13.8% and hospital mortality 17.8%. Long-term survival (observation time, 1-7 years) was 77.8%. After 3.5 years, mortality was the same as for the background population. Severe head injury was the main cause of death and increased the risk of 30-day mortality 2.4-fold. In addition, SAPS II and an age above 50 years proved to be significant predictors of mortality in a multivariate analysis. Sex was not associated with mortality, and ISS and the maximum SOFA score were significant predictors in univariate analyses only.

CONCLUSION

Reduced long-term survival was observed up to 3.5 years after acute injury. The 30-day mortality was strongly related to severe head injury, SAPS II and an age above 50 years. These variables may be useful as predictors of mortality, and may contribute to risk adjustment of this subset of trauma patients when treatment results from different centres are compared.

[The trauma surgeon's role in intensive care]

Severe injuries in patients of all ages and injuries in elderly multi-morbid subjects are a relevant medical and economic challenge. Optimal care of the polytraumatized patient can be best delivered by physicians specializing both in causal treatment of the injury or underlying disease and in intensive care. For care of critically ill injured patients, trauma surgeons with a certified specialty in intensive care medicine appear best suited. Of course, directing a surgical or trauma intensive care unit has to be full-time. Specialization of trauma surgeons (e.g., in the USA) has resulted in a considerable improvement in outcomes at least partly related to specialized trauma intensive care. Further improvement of trauma care relies on competent and innovative research not only in the fields of general intensive care, e.g., ventilation, but particularly in the complex aspects of the causality of the traumatic disease. An integrative view of the pathobiochemical, pathophysiological, and immunopathological sequelae of severe trauma under consideration of the various surgical and therapeutic strategies is the actual focus of research in surgical critical care medicine. Organ dysfunctions have to be modulated as they develop. Surgeons and trauma surgeons lead worldwide in this field of research. Obviously, competent research in polytrauma care requires competence in polytrauma intensive care.

Significance of Elecsys S100 immunoassay for real-time assessment of traumatic brain damage in multiple trauma patients

BACKGROUND

The neuroprotein S100 released into the circulation has been suggested as a reliable marker for primary brain damage. However, safe identification of relevant traumatic brain injury (TBI) may possibly be hampered by S100 release from peripheral tissue. The objective of this study was to measure early S100 levels using the Elecsys S100 immunoassay for real-time assessment of severe TBI in multiple trauma.

METHODS

Consecutively admitted multiple trauma patients (injury severity score >or=16 points) were stratified according to the results of the initial cerebral computed tomography (CCT) examination. S100 serum levels were determined at admission and at 6, 12, 24, 48 and 72 h after trauma. Data were correlated to creatine phosphokinase (CK) and lactate dehydrogenase (LDH) serum levels. Using receiver operating characteristic (ROC) analysis, the discriminating power of S100 measurement was calculated for the detection of CCT+ findings.

RESULTS

Median S100 levels of CCT+ patients (n=9; 37 years) decreased from 3.30 microg/L at admission to 0.41 microg/L 72 h after trauma. They revealed no significant differences to CCT- patients (n=18; 44 years), but remained elevated compared to controls. Median CK and LDH levels correlated with the corresponding S100 levels during the first 24 h after trauma. ROC analysis displayed a maximum area under the curve of only 0.653 at 12 h after trauma. No significant difference was calculated for the differentiation between CCT+ and CCT- patients.

CONCLUSIONS

Measurements of S100 serum levels using the Elecsys S100 immunoassay are not reliable for the real-time detection of severe TBI in multiple trauma patients. Due to soft tissue trauma or bone fractures, S100 is mainly released from peripheral sources such as adipocytes or skeletal muscle cells.

Emergency Department Hypotension is not an Independent Risk Factor for Post-Traumatic Acute Renal Dysfunction

BACKGROUND

Hypotension has been considered to be associated with renal dysfunction. The purpose of this study was to characterize the association of Emergency Department Hypotension (EDHypo) with post-traumatic renal insufficiency (RI) and renal failure (RF).

METHODS

A Level I center Intensive Care Unit database was analyzed. We reviewed all adult trauma patients surviving for more than 24 hours. EDHypo was defined as admission systolic blood pressure of less than 90 mm Hg, RI was defined as a peak serum creatine of > or = 2.0 mg/dL, RF was defined as requiring dialysis.

RESULTS

There were 2,574 admissions studied and RI occurred in 8.3% (213) of these patients whereas RF occurred in 1.1% (28). The mortality rate with RI was 41.0% (89) and 50.0% (14) with RF. There was no significant change in the incidence of RI, RF, or RI associated mortality during the study period. EDHypo was present in 7.9% (203) of patients and the incidence of RI was significantly higher than that of non-EDHypo patients (12.2% vs. 7.9%, p = 0.028). The incidence of RF was not different (1.0% vs. 1.1%). EDHypo was not independently associated with RI or RF but Injury Severity Score > 16, renal injury, age > 55, Body Mass Index > 30, male gender, and Intensive Care Unit (ICU) admission creatine kinase > or = 5,000 U/L had an independent association with RI. No risk factor in patients with RI could reliably predict RF.

CONCLUSIONS

EDhypo is not independently associated with post-traumatic RI or RF but severity of injury, renal injury, age, Body Mass Index, male gender, and elevated creatinine kinase are independently associated with RI. In critically ill trauma patients the incidence of RI and RF and the associated mortality rate has not changed significantly during a 6-year period despite, presumably, better understanding of resuscitative strategies.

TRAUMA RECEPTION AND RESUSCITATION

The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision-making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point-of-care computer technology linked to real-time decision-making and trauma team coordination may achieve error reduction through standardized decision-making and a corresponding reduction in preventable mortality and morbidity.

[The presence of family members in the trauma room]

The fate of multiple trauma patients is witnessed by a considerable number of relatives. Although numerous studies report that the patient's course and treatment success are dependent on the family's confidence as well as its clarification over the clinical situation, scientifically based guidelines for contact with relatives in the context of acute care following severe traumatic injuries do not yet exist. The current guidelines of the European Resuscitation Council recommend the concept of "on scene" presence for the integration of the relatives into acute care in situations of circulatory and heart failure, thus recommending the presence of relatives during acute medical care. This article discusses this concept and argues for a possible assignment of management of trauma care for severe and gravely injured patients.

[The importance of cytokines in the posttraumatic inflammatory reaction]

Alterations in the immune response after multiple trauma, posttraumatic sepsis and surgery are recognized as physiological reactions of the organism to restore homeostasis. The level of these immunological changes correlates with the degree of tissue damage as well as with the severity of haemorrhage and ischaemia. Cytokines are known to be integral components of this immune response. The local release of pro- and antiinflammatory cytokines after severe trauma indicates their potential to induce systemic immunological alterations. It appears that the balance or imbalance of these different cytokines partly controls the clinical course in these patients. Overproduction of either proinflammatory cytokines or antiinflammatory mediators may result in organ dysfunction. Whereas predominance of the proinflammatory response leads to the systemic inflammatory response syndrome (SIRS), the antiinflammatory reaction may result in immune suppression with an enhanced risk of infectious complications. Systemic inflammation, as well as immune suppression, are thought to play a decisive role in the development of multiple organ dysfunction syndrome (MODS). The major proinflammatory cytokines involved in the response to trauma and surgery include tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6 and IL-8. These cytokines, which are predominantly produced by monocytes and macrophages, mediate a variety of frequently overlapping effects, and their actions can be additive. TNF-alpha and IL-1beta are early regulators of the immune response and both induce the release of secondary cytokines, such as IL-6 and IL-8. IL-10 is an antiinflammatory cytokine which reduces the synthesis of proinflammatory mediators. Other important antiinflammatory mediators are soluble TNF receptors and the IL-1 receptor antagonist, which interfere with the effects of TNF-alpha and IL-1beta.Early evaluation of the prognosis of polytraumatized patients and assessment of their clinical status is known to be difficult. Therefore, in several clinical studies, cytokine levels during the posttraumatic course have been determined with the aim of finding predictive markers of patient outcome. The purpose of this review was to highlight our current knowledge on the interaction of posttraumatic immune reactivity and the development of complications. A better understanding of these mechanisms might lead to the introduction of preventive and therapeutic strategies into clinical practice.

Coagulopathy and the role of recombinant human activated protein C in sepsis and following polytrauma

Recombinant human activated protein C (rhAPC) also known as drotrecogin alfa (activated) has known antithrombotic, anti-inflammatory, and profibrinolytic properties in severe sepsis. Treatment with rhAPC (Xigris) has been shown to reduce mortality in patients with severe sepsis. The lack of any trials of rhAPC in trauma patients means that a definitive recommendation regarding its use in the polytraumatised patient, in whom severe head trauma or other contraindications for the use of rhAPC have been excluded remains controversial at present. This article describes the current evidence of its efficacy and safety in severe sepsis with relation to surgery and trauma.

Pre-hospital fluid therapy in the critically injured patient--a clinical update

Venous access and fluid therapy should still be considered to be essential elements of pre-hospital advanced life support (ALS) in the critically injured patient. Initiation of fluid therapy should be based on a clinical assessment, most importantly the presence, or otherwise, of a radial pulse. The goal in penetrating injury is to avoid hypovolaemic cardiac arrest during transport, but at the same time not to delay transport, or increase systolic blood pressure. The goal in blunt injury is to secure safe perfusion of the injured brain through an adequate cerebral perfusion pressure, which generally requires a systolic blood pressure well above 100 mmHg. Patients without severe brain injury tolerate lower blood pressures (hypotensive resuscitation). Importantly, using systolic blood pressure targets to titrate therapy is not as easy as it seems. Automated (oscillometric) blood pressure measurement devices frequently give erroneously high values. The concept of hypotensive resuscitation has not been validated in the few studies done in humans. Hence, the suggested targeted systolic blood pressures should only provide a mental framework for the decision-making. The ideal pre-hospital fluid regimen may be a combination of an initial hypertonic solution given as a 10-20 minutes infusion, followed by crystalloids and, in some cases, artificial colloids. This review is intended to help the clinician to balance the pros and cons of fluid therapy in the individual patient.

Response of circulating immune cells to major gunshot injury, haemorrhage, and acute surgery

PURPOSE

The purpose of this study was to use an established porcine model to investigate the effects on immune function of severe gunshot injury.

METHODS

Twelve pigs sustained two standardised rounds, one through right femur and one through left upper abdomen. First aid treatment and acute surgery was started immediately. Blood samples were drawn before shooting and after 75 min. Circulating neutrophils were isolated and reactive oxygen species (ROS) measured. Serum levels of tumour necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6, and IL-10 were determined at 0, 75 min, as well as 2h after incubation with 1 microg/ml endotoxin in an ex vivo whole blood model.

RESULTS

TNF-alpha, IL-1beta, and IL-6 significantly increased at 75 min. ROS in circulating granulocytes tended to increase (NS). Incubation with endotoxin led to a more than 100-fold increase of TNF-alpha pre-trauma, compared to a three-fold increase post-trauma (p<0.0001 between groups). A similar pattern was obtained for IL-1beta, and IL-6. IL-10 was below detection in all samples. The granulocytes maintained their ability to react to the protein kinase C activator phorbol myristate acetate (PMA) after trauma.

CONCLUSION

Severe gunshot injury and peritraumatic stress rapidly activate circulating immune cells, but reduce their capacity to react to a subsequent challenge to endotoxin.

Initial posttraumatic translocation of NF-kappaB and TNF-alpha mRNA expression in peripheral blood monocytes of trauma patients with multiple injuries: a pilot study

Post-traumatic inflammation is connected to monocyte dysfunction characterized by reduced NF-kappaB translocation during the first post-traumatic days. Because the exact dynamic of monocytic NF-kappaB translocation in patients directly after trauma remains unclear, the aim of this pilot study was to measure the intranuclear presence of NF-kappaB in monocytes from patients with multiple injuries initially after the trauma and during the early post-traumatic period and to compare these results with downstream-placed mRNA expression alteration of TNF-alpha, as well as with clinical data. Eleven patients were enrolled with an Injury Severity Score of 16 to 66 points, and blood samples were drawn on admission within 90 min and at 6, 12, 24, 48, and 72 h after trauma. NF-kappaB translocation of monocytic nuclear protein was analyzed by electrophoretic mobility shift assay and was quantified by densitometry as arbitrary units. In addition, monocytes of healthy volunteers were analyzed either native (-, control) or after LPS stimulation (+, control). For determination of downstream mRNA encoding for TNF-alpha, quantitative reverse transcriptase-PCR was performed. For both parameters, the negative control values were set as baseline (=1) and results from positive controls and patients were given as a relative alteration ratio without unit. Initial post-traumatic NF-kappaB translocation was significantly increased in trauma patients on admission (88 +/- 37) and 6 h after trauma (59 +/- 28) compared with the baseline level. In contrast, TNF-alpha mRNA was not increased on admission (1.7 +/- 0.9) and decreased even below baseline after 12 h. The substantial information of our study arises from the analysis of the dynamic of NF-kappaB translocation of monocytes. Enabled by closely matched sequential blood sampling strictly standardized to the traumatic event, an essential increase of monocytic signal transduction and transcription could be elucidated in the very early post-traumatic period, which precedes the down-regulation of the innate immune system.

[External quality management in the clinical treatment of severely injured patients]

The Trauma Registry of the German Society of Trauma Surgery represents a database for interhospital quality management in the field of treating severely injured patients. The presented study analyzes the Trauma Registry's impact on treatment quality in the participating hospitals. Since 1998 annual feedback on treatment quality was given to the hospitals of the Trauma Registry. Based on the data from 2001 (10,997 patients), 21 hospitals were studied that had provided data on more than 99 patients between 1999 and 2001. Besides anonymized assessment of quality-optimizing measures implemented in the hospitals, an analysis of the treatment process based on definite criteria (audit filter) was performed. Of the 21 hospitals, 20 could be included in the presented analysis of quality-optimizing measures. In 17 (85%) hospitals an average of 5 (range: 1-17) changes were implemented. The majority (74%) of improvement measures concerned early clinical treatment (emergency room). During the analyzed period of 1999-2001 (1422/1983/1909 patients each year), significant ( p<0.05) improvements in diagnostics (reduction in radiological/sonographic basic diagnostics from 38+/-49 to 25+/-34 min) and treatment (reduction of time until emergency operation from 56+/-67 to 35+/-25 min or until ICU admission from 162+/-67 to 140+/-82 min) could be demonstrated. At the same time a significant reduction of days of ventilation therapy from 11+/-14 to 9+/-14 was detected. The continuous feedback of the quality of the treatment process led to optimization measures in many hospitals taking part in the Trauma Registry. Furthermore, significant timesavings in the early treatment process could be shown.

Multiple Organ Failure in Trauma Patients

SUMMARY

BACKGROUND As care of the critically ill patient has improved and definitions of organ failure have changed, it has been observed that the incidence of organ failure and the mortality associated with organ failure appear to be decreasing. In addition, many early studies included large heterogeneous populations of both medical and surgical patients that may have influenced the incidence and outcome of organ failure. The purpose of this study is to establish the current incidence and mortality of organ failure in a homogenous population of critically ill trauma patients. METHODS All trauma patients admitted to the intensive care unit (ICU) at an urban Level I trauma center were prospectively studied. Patients were evaluated for the presence of organ failure using definitions proposed by Knaus and by Fry. Newer definitions of organ failure incorporating organ dysfunction and severity-of-illness scores were also obtained in all patients in an attempt to predict outcome. These included lung injury scores (acute respiratory distress syndrome scores), Acute Physiology and Chronic Health Evaluation (APACHE) II and III scores, Injury Severity Score (ISS), and multiple organ dysfunction scores. Primary outcomes assessed were death and the occurrence of organ failure by the various definitions. RESULTS Eight hundred sixty-nine trauma patients were admitted to the ICU and survived longer than 48 hours. Mean APACHE II and APACHE III scores at admission to the ICU and ISS were 12.2 +/- 22, 30.5 +/- 22.7, and 19 +/- 10, respectively. Single organ failure (SOF) occurred in 163 patients (18.7%) and multiple organ failure occurred in 44 patients (5.1%). All SOF was caused by respiratory failure. Respiratory failure occurred first in the majority of patients with multiple organ failure. Mortality was 4.3% with one organ system failure, 32% with two, 67% with three, and 90% when four organ systems failed. None of the patients with SOF died secondary to respiratory failure. Multiple stepwise regression analysis was performed to determine which of the following risk factors are associated with the occurrence of organ failure: mechanism of injury, lactate at 24 hours, ISS, APACHE II, APACHE III, acute respiratory distress syndrome score at admission, multiple organ dysfunction score at admission and total blood products transfused in 24 hours. Of these factors, APACHE III, lactate at 24 hours, and total blood products transfused in 24 hours were associated with the occurrence of organ failure. CONCLUSION The overall incidence of organ failure in a homogeneous trauma population appears to be lower than that reported in studies performed in heterogeneous patient populations in the 1980s. Mortality for SOF is low and appears to be related primarily to the patient's underlying injuries and not to organ failure. Mortality for two or three organ system failures is lower than reported 15 to 20 years ago. Mortality for patients with four or more organ system failures remains high, approaching 100%.

Current concepts of the inflammatory response after major trauma: an update

During the past century explosive developments have taken place in the field of molecular medicine and genetics, vastly expanding our understanding of the normal physiological response to injury. We have been able to characterise specific molecular and cell biological processes and apply some of this knowledge to the treatment of multiply injured patients. Despite the significant steps we have made, there still remains much work to be done in this area. This review article highlights the current concepts of post-traumatic immunological changes and their impact in the management of trauma patients.

Seven hundred fifty-three consecutive deaths in a level I trauma center: the argument for injury prevention

BACKGROUND

The past century has seen improvement in trauma care, with a resulting decrease in therapeutically preventable deaths. We hypothesize that further major reduction in injury mortality will be obtained through injury prevention, rather than improvements in therapy.

METHODS

Seven hundred fifty-three deaths in an American College of Surgeons-verified, Level I trauma center were reviewed as they occurred. Deaths were classified as therapeutically not preventable, possibly preventable, or preventable. These charts were also reviewed for factors that might have prevented or lessened the severity of the injury.

RESULTS

Mean age was 43, mean Glasgow Coma Scale score was 5, mean Revised Trauma Score was 4, mean Injury Severity Score was 41, and mean probability of survival was 0.25 (according to TRISS). Forty-six percent underwent cardiopulmonary resuscitation in the field, 52% died within 12 hours, 74% died within 48 hours, and 86% died within 7 days. Primary causes of death included central nervous system injury in 51%, irreversible shock in 21%, multiple injuries (shock plus central nervous system injury) in 9%, multiple organ failure/sepsis and other causes in 3%, and pulmonary embolus in 0.1%. Seven hundred one (93%) were classified as not preventable with a change in therapy, 32 (4.2%) were classified as potentially preventable with a change in therapy, and 20 were classified as preventable with a change in therapy (2.6%). Forty-six percent had cardiopulmonary resuscitation performed before or immediately on arrival to the hospital. Another 23% had vital signs present on arrival, but had a Glasgow Coma Scale score of <or= 4. Of the 546 unintentionally injured patients, 58% had an identifiable factor that contributed to the presence and/or severity of the injury (intoxication, restraint and helmet use), with 28% of patients having a positive blood alcohol level. Of the 206 patients with intentional injuries, 44% were intoxicated at the time of their death. Commensurate with driving-while-intoxicated prevention program(s), the percentage of intoxicated patients significantly ( p= 0.03) decreased from 45% to 34% over the same 7-year period.

CONCLUSION

Dramatically improving therapy (no errors, cure for multiple organ failure, sepsis, and pulmonary embolus) in a modern trauma system would decrease trauma mortality by 13%. In contrast, more than half of all deaths are potentially preventable with preinjury behavioral changes. Injury prevention is critical to reducing deaths in the modern trauma system.