The quest for a universal definition of polytrauma: a trauma registry-based validation study.

BACKGROUND: A pilot validation recommended defining polytrauma as patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 × AIS score > 2). This study aimed to validate this definition on larger data set. We hypothesized that patients defined by the 2 × AIS score > 2 cutoff have worse outcomes and use more resources than those without 2 × AIS score > 2 and that this would therefore be a better definition of polytrauma. METHODS: Patients injured between 2009 and 2011, with complete documentation of AIS by New South Wales Trauma Registry and 16 years and older were selected. Age and sex were obtained in addition to outcomes of ISS, hospital length of stay (LOS), intensive care unit (ICU) admission, ICU LOS, and mortality. We compared demographic characteristics and outcomes between patients with ISS greater than 15 who did and did not meet the 2 × AIS score > 2 definition. We then undertook regression analyses (logistic regression for binary outcomes [ICU admission and death] and linear regression for hospital and ICU LOS) to compare outcomes for patients with and without 2 × AIS score > 2, adjusting for sex and age categories. RESULTS: In the adjusted analyses, patients with 2 × AIS score > 2 had twice the odds of being admitted to the ICU compared with those without 2 × AIS score > 2 (odds ratio, 2.5; 95% confidence interval [CI], 2.2-2.8) and 1.7 times the odds of dying (95% CI, 1.4-2.0; p < 0.001 for both models). Patients with 2 × AIS score > 2 also had a mean difference of 1.5 days longer stay in the hospital compared with those without 2 × AIS score > 2 (95% CI, 1.4-1.7) and 1.6 days longer ICU stay (95% CI, 1.4-1.8; p < 0.001 for all models). CONCLUSION: Patients with 2 × AIS score > 2 had higher mortality, more frequent ICU admissions, and longer hospital and ICU stay than those without 2 × AIS score > 2 and represents a superior definition to the definitions for polytrauma currently in use. LEVEL OF EVIDENCE: Diagnostic test/ criteria, level III.

The definition of polytrauma: variable interrater versus intrarater agreement--a prospective international study among trauma surgeons.

BACKGROUND: The international trauma community has recognized the lack of a validated consensus definition of "polytrauma." We hypothesized that using a subjective definition, trauma surgeons will not have substantial agreement; thus, an objective definition is needed. METHODS: A prospective observational study was conducted between December 2010 and June 2011 (John Hunter Hospital, Level I trauma center). Inclusion criteria were all trauma call patients with subsequent intensive care unit admission. The study was composed of four stages as follows: (1) four trauma surgeons assessed patients until 24 hours, then coded as either "yes" or "no" for polytrauma, and results compared for agreement; (2) eight trauma surgeons representing the United States, Germany, and the Netherlands graded the same prospectively assessed patients and coded as either "yes" or "no" for polytrauma; (3) 12 months later, the original four trauma surgeons repeated assessment via data sheets to test intrarater variability; and (4) individual subjective definitions were compared with three anatomic scores, namely, (a) Injury Severity Score (ISS) of greater than 15, (b) ISS of greater 17, and (c) Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions. RESULTS: A total of 52 trauma patients were included. Results for each stage were as follows: (1) κ score of 0.50, moderate agreement; (2) κ score of 0.41, moderate agreement; (3) Rater 1 had moderate intrarater agreement (κ score, 0.59), while Raters 2, 3, 4 had substantial intrarater agreement (κ scores, 0.75, 0.66, and 0.71, respectively); and (4) none had most agreement with ISS of greater than 15 (κ score, 0.16), while both definitions ISS greater than 17 and Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions had on average fair agreement (κ scores, 0.27 and 0.39, respectively). CONCLUSION: Based on subjective assessments, trauma surgeons do not agree on the definition of polytrauma, with the subjective definition differing both within and across institutions.

The practicality of including the systemic inflammatory response syndrome in the definition of polytrauma: experience of a level one trauma centre.

BACKGROUND: The systemic inflammatory response syndrome (SIRS) has been advocated as a significant predictor of outcome in trauma. Recent trauma literature has proposed SIRS as a surrogate for physiological derangements characteristic of polytrauma with some authors recommending its inclusion into the definition of polytrauma. The practicality of daily SIRS collection outside of specifically designed prospective trials is unknown. The purpose of this study was to assess the availability of SIRS variables and its appropriateness for inclusion into a definition of polytrauma. We hypothesised SIRS variables would be readily available and easy to collect, thus represent an appropriate inclusion into the definition of polytrauma. METHOD: A prospective observational study of all trauma team activation patients over 7-months (August 2009 to February 2010) at a University affiliated level-1 urban trauma centre. SIRS data (temperature>38°C or <36°C; Pulse >90 bpm; RR>20/min or a PaCO(2)<32 mmHg; WCC>12.0×10(9)L(-1), or <4.0×10(9)L(-1), or the presence of >10 immature bands) collected from presentation, at 24 h intervals until 72 h post injury. Inclusion criteria were all patients generating a trauma team activation response age >16. RESULTS: 336 patients met inclusion criteria. In 46% (155/336) serial SIRS scores could not be calculated due to missing data. Lowest rates of missing data observed on admission [3% (11/336)]. Stratified by ISS>15 (132/336), in 7% (9/132) serial SIRS scores could not be calculated due to missing data. In 123 patients ISS>15 with complete data, 81% (100/123) developed SIRS. For Abbreviated Injury Scale (AIS)>2 in at least 2 body regions (64/336) in 5% (3/64) serial SIRS scores could not be calculated, with 92% (56/61) of patients with complete data developing SIRS. For Direct ICU admissions [25% (85/336)] 5% (4/85) of patients could not have serial SIRS calculated [mean ISS 15(±11)] and 90% (73/81) developed SIRS at least once over 72 h. CONCLUSION: Based on the experience of our level-1 trauma centre, the practicability of including SIRS into the definition of polytrauma as a surrogate for physiological derangement appears questionable even in prospective fashion.

Compartment syndromes from head to toe.

Compartment syndrome is defined as the dysfunction of organs/tissues within the compartment due to limited blood supply caused by increased pressure within the compartment. The aim of this article is to introduce and discuss acute compartment syndromes that are essential for critical care physicians to recognize and manage. Various pathophysiological mechanisms (ischemia-reperfusion syndrome, direct trauma, localized bleeding) could lead to increased compartmental pressure and decreased blood flow through the intracompartmental capillaries. Although compartment syndromes are described in virtually all body regions, the etiology, diagnosis, treatment, and prevention are best characterized for three key body regions (extremity, abdominal, and thoracic compartment syndromes). Compartment syndromes can be classified as either primary (pathology/injury is within the compartment) or secondary (no primary pathology or injury within the compartment), and based on the etiology (e.g., trauma, burn, sepsis). A recently described phenomenon is the "multiple" compartment syndrome or "poly"-compartment syndrome, which is usually a complication of a severe shock and massive resuscitation. The prevention of compartment syndromes is based on preemptive open management of compartments (primary syndromes) in high-risk patients and/or careful fluid resuscitation (both primary and secondary syndromes) to limit interstitial swelling.