Prognostic factors of liver injury in polytraumatic patients. Results from 895 severe abdominal trauma cases.

BACKGROUND AND AIMS: Prognosis of multiple injured patients is mainly limited by severe haemorrhage. Although mechanisms of altered immune response have been intensively investigated, little is known about the relevance of liver trauma as an independent predictive outcome factor in these patients. METHODS: 10,469 patients from the DGU Trauma Registry (1993-2005) were retrospectively analyzed. Primary admitted patients with an injury severity score > or = 16, without isolated head injury were included. Patients were analyzed according to the injury pattern as liver injury (Abbreviated Injury Scale--AIS abdomen < 3 and AIS liver 2-5; n = 321), non-liver abdominal trauma (AIS abdomen 2-5 or AIS liver < 3; n = 574) and control group without abdominal injuries (AIS abdomen or liver < 3; n = 9,574). RESULTS: Severe liver injury was associated with excessive demands for volume resuscitation and induced a significantly increased risk for sepsis and multi-organ failure (MOF) compared to both other groups (sepsis 19.9% vs. 11.0%; MOF 32.7% vs. 16.6%). Furthermore, deleterious outcome was more frequently associated with severe liver trauma (mortality 34.9%) compared to severe abdominal trauma (12.0%). CONCLUSION: Severe liver trauma is an independent predictor for severe haemorrhage with a substantially increased risk of sepsis, MOF and trauma-related death. While conservative treatment of patients with liver trauma but no haemorrhage is effective, patients with hemodynamic instability seem to be from a subgroup where contemporary treatment modalities are not yet sufficient.

Major trauma with multiple injuries in German children: a retrospective review.

BACKGROUND: The aim of this study was to evaluate the demographics, mechanisms, pattern, injury severity, and the outcome (ie, length of intensive care unit [ICU] stay, length of mechanical ventilation, total length of stay, mortality) in multiple-injured children based on a review from the German trauma registry study ("Traumaregister") of the German Society of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie e.V.). METHODS: One hundred three German trauma centers took part in the German trauma registry study from January 1997 to December 2003. Five hundred seventeen children (aged 0-15 years) with multiple injuries and an Injury Severity Score of more than 15 in comparison to 11,025 adults were included. Sex, age, and mechanisms and pattern of injury were assessed. The mechanisms of trauma and the anatomical distribution of severe injury (Abbreviated Injury Scale of 3 or more) were analyzed. The Injury Severity Score, the Revised Trauma Score, and the Trauma Score Injury Severity Score were calculated to estimate the severity of injury and mortality. RESULTS: The predominant sex was male. Most cases were caused by traffic-related accidents. Head injuries were most common in children, and severe thoracic injuries increased with age. Mean length of ICU treatment, mechanical ventilation, and total length of stay were shorter in children than in adults. A total of 22.6% of the children aged 0 to 5 years died in the hospital in comparison with in-hospital mortality rate of 13.7% in the 6- to 10-, 20.3% in the 11- to 15-, and 17.0% in the 16- to 55-year-old patients. CONCLUSIONS: There were differences between multiple-injured children and adults concerning injury mechanisms and pattern of injuries. Adults needed a longer mechanical ventilation and a longer ICU therapy. Most deaths could be seen in the youngest patients aged 0 to 5 years.

Reduction in mortality of severely injured patients in Germany.

INTRODUCTION: The trauma registry of the German Society of Trauma Surgery is a multicentric prospective record of the treatment of severely injured patients. METHODS: The present study examines the effect of a quality management system on key processes and outcomes, in hospitals included in the trauma registry. The study is based on data of 11 013 severely injured patients (injury severity score = 16) who were treated in 105 hospitals between 1993 and 2005. A variety of parameters relating to early diagnosis and treatment were considered. Outcome quality was measured by a comparison between observed and calculated mortality (revised injury severity classification). RESULTS: During the 13 year long study period mortality could be significantly reduced from 22.8% to 18.7%. The time to initial radiological and ultrasound diagnosis was reduced, the use of computed tomography increased, the time until emergency operations in hemorrhagic shock was reduced, and damage limiting orthopedic interventions were performed more frequently. DISCUSSION: The German Trauma Registry records processes and treatment results in severely injured patients. This information is fed back to participating hospitals. The continuous data feedback is associated with a continuous improvement of process and outcome quality in the treatment of severely injured patients.

Pelvic Ring Fractures: Utility of Clinical Examination in Patients with Impaired Consciousness or Tracheal Intubation.

OBJECTIVE: To define the diagnostic accuracy of clinical examination in patients with impaired consciousness or endotracheal intubation to detect pelvic ring fractures and to identify those with severe bleeding. METHODS: Included in this prospective data collection with retrolective data analysis were a consecutive series of blunt trauma victims with either a Glasgow Coma Scale ≤ 13 or tracheal intubation. Clinical examination comprised testing for stability of the iliac wings. RESULTS: From 784 subjects (injury severity score 23.3 ± 17.4) 93 patients (11.9%) were found to have a pelvic ring fracture. Clinical instability of the pelvic ring was found in 42 patients. There was only one false positive. Fifty-two fractures could not be identified by clinical examination, including nine fractures (17%) that required surgical fracture stabilization (sensitivity of clinical examination 44.1%). Seventeen fractures (18.3%) were associated with a blood loss larger than 20% of circulating blood volume. Sixteen of those were identified by clinical instability of the pelvic ring (sensitivity 94.1%, specificity 97.0%, positive predictive value 38.1%, negative predictive value 99.9%). CONCLUSIONS: Clinical examination for stability of the pelvis in this selected group of patients missed a significant number of pelvic ring fractures including fractures that require surgical stabilization. The finding of a clinically unstable identifies most of the patients with the pelvic ring fracture being a major source of bleeding. A stable pelvis makes pelvic ring fracture as being the source of bleeding quite unlikely.

Prone positioning improves oxygenation in post-traumatic lung injury--a prospective randomized trial.

BACKGROUND: In a prospective randomized trial the effect of prone positioning on the duration of mechanical ventilation was evaluated in multiple trauma patients and was compared with patients ventilated in supine position. METHOD: Multiple trauma patients of the intensive care units of two university hospitals were considered eligible if they met the criteria for acute lung injury or the acute respiratory distress syndrome. Patients in the prone group (N = 21) were kept prone for at least eight hours and a maximum of 23 hours per day. Prone positioning was continued until a PaO2:FiO2 ratio of more than 300 was present in prone as well as supine position over a period of 48 hours. Patients in the supine group (N = 19) were positioned according to standard care guidelines. RESULTS: The duration of ventilatory support did not differ significantly (30 +/- 17 days in the prone group and 33 +/- 23 days in the supine group). Worst case analysis (death and deterioration of gas exchange) displayed ventilatory support for 41 +/- 29 days in the prone group and 61 +/- 35 days in the supine group (p = 0.06). The PaO2:FiO2 ratio increased significantly more in the prone group in the first four days (p = 0.03). The prevalence of Acute Respiratory Distress Syndrome (ARDS) following acute lung injury (p = 0.03) and the prevalence of pneumonia (p = 0.048) were reduced also. One patient in the prone and three patients in the supine group died due to multi organ failure (p = 0.27). CONCLUSIONS: Intermittent prone positioning was not able to reduce the duration of mechanical ventilation in this limited number of patients. However the oxygenation improved significantly over the first four days of treatment, and the prevalence of ARDS and pneumonia were reduced.

Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe.

BACKGROUND: Although early fracture fixation is expedient in patients with multiple injuries, early total care (ETC) may be associated with posttraumatic systemic complications. This study was conducted to prospectively evaluate the concept of damage control by immediate external fracture fixation (damage control orthopedics [DCO]) and consecutive conversion osteosynthesis with regard to time savings, effectiveness, and safety. METHODS: In a prospective controlled trial, a cohort of 1,070 patients with an Injury Severity Score (ISS) of 20.7 were admitted to a Level I trauma center over a 3.5-year period. Patients with an ISS > 15, survival of more than 24 hours, and without interhospital transfer were included. In all patients with major fractures requiring immediate stabilization, external fixation was performed (DCO). Conversion was executed at the earliest possible time as a one-stage procedure after stabilization of organ functions. TRISS was calculated for patients requiring DCO (DCO group) and for patients without major fractures (control group). Time spent on particular and all surgical procedures, blood loss, and complications of DCO were compared with data of consecutive conversion osteosyntheses which were considered as hypothetical ETC procedures (h-ETC) in identical patients. RESULTS: Four hundred nine patients fulfilled the inclusion criteria. Seventy-five (ISS of 37.3) required DCO for 135 fractures, whereas 334 patients (ISS of 30.4) did not require immediate fracture fixation. Mean surgical time was 62 +/- 30 minutes (SEM, 3.5) for DCO. Because of fracture consolidation with external fixation (n = 3) and injury-related death (n = 15), conversion (h-ETC) was performed in 57 patients for 101 fractures. Duration of external fixation averaged 13.7 days (range, 3-46 days). Fifty-five patients (96.5%) required intensive care treatment and 42 patients (73.7%) required mechanical ventilation at the time of conversion. Mean operation time for conversion was 233 +/- 19 minutes (SEM, 18.7) with a value of p < 0.001. Also, blood loss was significantly (p < 0.001) different for DCO (<50 mL) and h-ETC (472 mL; SEM, 63). Pin-track infections were identified in five patients, two patients with acetabular plate osteosynthesis had deep wound infection, and one patient died related to bacterial sepsis with infections of all wound sites. Overall mortality in DCO patients was significantly lower than predicted by TRISS (20% vs. 39.3%), as it was in the 334 patients without immediate fracture fixation (29.5% vs. 24.3%). CONCLUSION: DCO appears to provide a major reduction of operation time and blood loss in the primary treatment period in severely injured patients compared with h-ETC. In addition, we found that DCO is not associated with an increased rate of procedure-related complications. So far, DCO with early and one-stage conversion seems to be a safe strategy of primary fracture treatment in patients with multiple injuries.

Mortality in severely injured elderly trauma patients--when does age become a risk factor?

Age is a well-known risk factor in trauma patients. The aim of the present study was to define the age-dependent cut-off for increasing mortality in multiple injured patients. Pre-existing medical conditions in older age and impaired age-dependent physiologic reserve contributing to a worse outcome in multiple injured elderly patients are discussed as reasons for increased mortality. A retrospective clinical study of a statewide trauma data set from 1993 through 2000 included 5375 patients with an Injury Severity Score (ISS) > or = 16 who were stratified by age. The ISS and Abbreviated Injury Score (AIS) quantified the injury severity. Outcome measures were mortality, shock, multiple organ failure, and severe head injury. Mortality in this series increased beginning at age 56 years, and that increase was independent of the ISS. The mortality rate increased from 7.3% (patients 46-55 years of age) to 13.0% (patients ages 56-65 years) in patients with ISS 16-24; from 23.8% to 32.1% in those with ISS 25-50; and from 62.2% to 82.1% in those with ISS 51-75 (P < or = 0.05). Severe traumatic brain injury (sTBI) was the most frequent cause of death, with a significant peak in patients older than 75 years. The incidence of lethal multiple organ failure increased significantly beginning at age 56 years (P < or = 0.05), but it showed no further increase in patients aged 76 years or older. In contrast, the incidence of lethal shock showed a significant increase from age 76 years (P < or = 0.05), but not at age 56 years. However, from age 56 years, mortality increased significantly in patients who sustained multiple trauma-an increase that was independent of trauma severity.

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.

Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary?

BACKGROUND: In unstable pelvic ring fractures free abdominal fluid on ultrasound (US) may be caused by retroperitoneal hematoma that passes into the abdominal cavity or by an additional intraabdominal lesion. In this study a clinical pathway for the therapy of potentially combined lesions was analyzed. PATIENTS AND METHODS: All patients treated in the ED for severe trauma underwent basic sonographical and radiologic diagnostics within 15 minutes. of admission. Data were prospectively documented. According to the treatment protocol unstable pelvic ring fractures with initial free fluid on US received laparotomy. Patients with stable vital conditions had abdominal CT-Scan before surgery. RESULTS: 1472 consecutive severely injured patients (ISS 20, age: 39 years) were included. Eighty subjects had sustained type B (47) or C (33) pelvic ring fracture. Early free abdominal fluid on US was absent in 49 cases. Three patients in this group required celiotomy later on, during ICU treatment. In 31 patients free fluid was present. All of them had laparotomy. Only one patient showed retroperitoneal hematoma alone, while all others had one or more significant lesions (rupture) that required surgical repair. Simultaneously with laparotomy pelvic stabilization was performed by external (19) or internal (6) fixation. In all cases with massive pelvic hemorrhage and free fluid in US bleeding was controlled by internal tamponade and external fixation. CONCLUSION: The finding of intraperitoneal fluid on US in the emergency department strongly correlates with significant intraabdominal lesions requiring surgical intervention. Early laparotomy appears indicated in these cases. Shock control in pelvic bleeding can be sufficiently achieved by internal tamponade and external fixation.

Improved student preparation from implementing active learning sessions and a standardized curriculum in the surgical examination course.

Students' knowledge before and preparation for courses with practical skills training or bedside teaching may be insufficient and reduce efficiency of teaching time at the bedside and in skills training. To study the effect of a new curriculum on students' preparation for courses, a quasi-randomized study was conducted. All medical students were included who participated in the surgical examination course during a period of four semesters. In the intervention group, specified topics for every session, a course book describing only those procedures relevant for the course and a foregoing case-based active learning session were introduced as compared to the traditional way of teaching the surgical examination course. For evaluation a questionnaire for the students was used. A total of 614 questionnaires (return rate 79.6%) were included in the analysis. Student as well as teacher preparation significantly improved in the intervention group from 34.8 to 73.6% and 46.1 to 73.0%, respectively. The case-based learning session and the course book were considered helpful by 77.7 and 96.4% of the students, respectively. The introduction of a timetable with specified topics for every session, a course book and a foregoing case-based learning session significantly improved student preparation for the surgical clinical examination course.

Prolactin modulates survival and cellular immune functions in septic mice.

BACKGROUND: The immunomodulatory properties of the pituitary hormone prolactin have been demonstrated. It was proposed that prolactin is important in maintaining normal immune response in several pathological states. We investigated the effect of prolactin administration on the survival and cellular immune functions during systemic inflammation. MATERIALS AND METHODS: Male NMRI mice were subjected to laparotomy (LAP) or sepsis induced by cecal ligation and puncture (CLP). Mice were treated with either saline (LAP/saline; CLP/saline) or prolactin (LAP/PRL, CLP/RPL; 4 mg/kg s.c.). Survival of septic mice was determined 24 and 48 h after CLP. Forty-eight hours after the septic challenge, the proliferative capacity, cytokine release (IL-2, IL-6, IFN-gamma) and apoptosis of splenocytes were determined. Additionally, monitoring of circulating leukocyte distribution was performed (WBC; CD3+, CD4+, CD8+, B220+, NK1.1+, F4/80+ cells by FASCan). RESULTS: CLP was accompanied by a mortality of 47% and induced a decrease in splenocyte proliferation and apoptosis rate. Administration of prolactin significantly increased the mortality of septic mice (81%). This was paralleled by a further decrease of splenocyte proliferation and an increased splenocyte apoptosis. In addition, administration of prolactin augmented the sepsis-induced inhibition of IL-2 release, attenuated the sepsis-induced inhibition of IFN-gamma release, and did not affect the release of IL-6. However, prolactin did not affect the sepsis-induced changes of circulating leukocyte subpopulations. CONCLUSIONS: We conclude that prolactin has profound immunomodulatory properties and that administration of prolactin in pharmacological doses is associated with a decreased survival and an inhibition of cellular immune functions in septic mice.

Human leukocyte antigen-DR expression in peripheral blood mononuclear cells from healthy donors influenced by the sera of injured patients prone to severe sepsis.

OBJECTIVE: To study the influence of sera from severely injured patients on the human leukocyte antigen (HLA)-DR expression of normal peripheral blood mononuclear cells (PBMC). DESIGN: In vitro study. SETTING: University hospital. PATIENTS AND PARTICIPANTS: Sera from 34 patients were obtained within 8 h after trauma. Seventeen of these patients developed posttraumatic sepsis (sepsis group) and 17 recovered without infectious complications. Sera from ten healthy individuals served as controls. Phytohemagglutinin (PHA)-activated PBMC from 44 healthy donors were used to study the effects of a patient's serum. MEASUREMENTS AND RESULTS: Medium containing 5% of serum from the sepsis group significantly ( p<0.05) reduced the HLA-DR expression (channels, mean +/- standard error of the mean) on monocytes (patients 883+/-22, controls 962+/-15), B (patients 922+/-14, controls 972+/-7) and T cells (patients 932+/-13, controls 968+/-5) of PHA-activated PBMC. Significantly increased accumulation of TNFalpha on (1.8+/-0.4% of PBMC) and within T cells (0.98+/-0.26% of PBMC) was observed by flow cytometry after incubation with medium containing sera of the sepsis group compared with controls (on 0.5+/-0.1%, within 0.27+/-0.05% of PBMC). A significant negative correlation between relative cell counts of intracellular TNFalpha-positive T cells with HLA-DR expression was observed for monocytes ( r= -0.61), B cells ( r= -0.57) and proliferation ( r= -0.68) as estimated by (3)H-thymidine uptake [patients 139971+/-12844 counts per minute (cpm), controls 198973+/-19347 cpm, p<0.05] in the presence of sera from the sepsis group. CONCLUSIONS: Reduced cellular immunity and, therefore, immunodeficiency after trauma appears to be caused by soluble factors influencing T cell function in particular.

Quality of multiple trauma care in 33 German and Swiss trauma centers during a 5-year period: regular versus on-call service.

BACKGROUND: The purpose of this study was to evaluate process and outcome quality of severely injured patients admitted during on-call (OC) versus regular trauma service (RS). METHODS: This was a prospective and multicentric analysis of the Trauma Registry of the German Trauma Society. Patients were evaluated if directly admitted from the scene of accident with an Injury Severity Score of > 15 and if alive on arrival at the emergency department. RESULTS: Seventy percent of patients were admitted during OC; these patients were significantly younger. Blunt trauma predominated, with a 95% incidence. Falls from great heights were significantly more frequent during RS, whereas motor vehicle crashes predominated during OC. No differences were found for emergency department management (e.g., time to abdominal ultrasound, chest radiograph, or cranial computed tomography). However, time to admission to the intensive care unit was substantially longer during RS. No significant differences were found for outcome parameters such as length of intensive care unit stay, hospitalization time, incidence of organ failure, or mortality. CONCLUSION: This study demonstrates a constant quality of care provided 24 hours per day, 7 days per week in the participating hospitals. Differences within individual trauma centers were not compared and need to be assessed by internal quality management.

31-year-old injection drug user with massive skin necrosis and shock.

Massive tissue necrosis and septic shock have recently been reported in a series of injection drug users in Scotland, England and Ireland. We report the first case outside the UK meeting the criteria for this new entity (septic shock without fever in an injection drug user, local and systemic inflammation, rhabdomyolysis and tissue necrosis at the injection site). Following surgical treatment and antibiotic treatment, the patient was cured and is currently well.

A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers.

OBJECTIVE: The impact of a multidisciplinary quality management system (MQMS) on the early treatment of severely injured patients was tested. DESIGN AND SETTING: Prospective clinical study in two level 1 trauma centers. METHODS AND MATERIALS: MQMS comprised a protocol for documentation, 20 assessment criteria, and the judgement of data by a quality circle. After implementation in Munich (1st period, n=90; 2nd period, n=77) the validation took place in Essen (1st period, n=175; 2nd period, n=150). RESULTS: Improvements in diagnostics were shown by significant time savings in radiological diagnostics and before computed tomography in severe traumatic brain injury. In patients with hemorrhagic shock there was a reduction in time before transfusion (49 to 14 min in Munich; 31 to 22 min in Essen) and before emergency operation (74 to 43 min in Munich; 69 to 45 min in Essen). The time before craniotomy was reduced from 97 to 67 min in Munich. The incidence of delayed diagnosis of life-threatening lesions was diminished from 6% to 3% in Munich (not found in Essen). The TRISS technique showed a reduction in mortality in both hospitals in the second period (Munich: 15.4% TRISS vs. 9.1% observed mortality; Essen: 17.8% vs. 11.3%). CONCLUSIONS: MQMS improved early clinical treatment in severe injury with respect to therapeutic effectiveness and outcome. The effectiveness of the MQMS was shown at two different hospitals

Prehospital intubation in severe thoracic trauma without respiratory insufficiency: a matched-pair analysis based on the Trauma Registry of the German Trauma Society.

OBJECTIVE: On the basis of the data of a multicenter study, the impact of prehospital intubation and ventilation in the therapy of severe thoracic trauma without manifest respiratory insufficiency was analyzed. METHODS: Data were collected prospectively in the Trauma Registry of the German Trauma Society. In a matched-pair analysis, patients with severe thoracic trauma (Abbreviated Injury Scale score of 4) with and without prehospital intubation were compared. Patients were paired with respect to age, injury severity, and prognosis (according to the TRISS method). RESULTS: From a total of 3,814 patients, two groups (with/without prehospital intubation) of 44 matched patients each with comparable average age (36 vs. 36 years), Injury Severity Score (29 vs. 29), and TRISS (95.2 vs. 95.3) were identified. No patient was unconscious at the scene (all Glasgow Coma Scale scores > or = 8) or presented with severe respiratory insufficiency (all > or = 10 breaths/min). Time between injury and hospital admission was significantly longer (73 minutes; p < 0.05) in the group with prehospital intubation compared with the nonintubated group (47 minutes). Furthermore, fluid requirements in the prehospital period were significantly higher in the intubated patients (3,000 mL vs. 1,000 mL). In the prehospital intubation group, the number of patients with mass transfusion (9 vs. 4) as well as with emergency operations (10 vs. 4) were not significantly different from the nonintubated group. The prehospital intubation group showed a similar incidence of lung failure (17 vs. 14), kidney failure (6 vs. 2), and circulation failure (13 vs. 5). Except for two of the primarily nonintubated patients, all were intubated during their stay in the emergency room or on the intensive care unit. Days of ventilation (median, 7 days) as well as the length of stay on the ICU (median, 11 days) were comparable in both groups. Mortality in the prehospital intubation group was not significantly different between groups (six vs. two deceased). CONCLUSION: Prognosis with respect to organ failure, treatment time, and mortality is not adversely affected in the German trauma system, if patients with severe thoracic trauma without manifest respiratory insufficiency and without other indications for intubation are not treated with prehospital intubation.