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Multiple trauma management requires organization, teamwork, and rapid clinical intervention. The physician in both the trauma center and the community hospital should have a system for evaluation, treatment, and referral. Certain patients may have uncharacteristic responses to shock and stress, and one must be prepared to re-evaluate treatment plans. Finally, caring for trauma victims also includes knowledge of organ donation and survivor death counseling.
Multiple organ dysfunction syndrome (MODS) is a serious, often fatal, sequel to multiple trauma. Prolonged shock states, severe sepsis, acute pancreatitis, acute renal failure, severe burns, ischemic conditions, and acute respiratory distress syndrome have been implicated in the development of MODS. Despite advances in critical care therapies and infection control practices, severe sepsis remains a major health problem, with an estimated mortality rate of 30-50% (Ely, Kleinpell, & Goyett, 2003). The purposes of this article are to describe the pathophysiologic changes that lead to the development of MODS and discuss strategies to prevent the development of MODS and to treat MODS if it develops.
Multiple factors connected with the trauma itself or with its therapy may cause post-operative complications in injured patients. In a previous study we have reported on a higher mortality rate in patients that received large quantities of blood. The present report concerns 223 cases of trauma by penetrating and non-penetrating injuries in which the possible influence of blood transfusions on subsequent morbidity was assessed. It was verified that transfused patients exhibited more infections and general complications, as well as a higher mortality rate than controls. A progressive effect related to the number of units of blood administered could be demonstrated. The most unfavorable outcomes correspond to the transfusions of more than 1500 ml of blood.
Isolated severe head trauma (SHT) or SHT in combination with multiple injuries are important factors for the prognosis of morbidity and mortality in patients suffering from the consequences of accidents. The prognosis mainly depends on the presence of primary mechanic brain injury and the development of secondary brain damage. Causes for the development of secondary brain damage are the intracranial space demand after traumatic injury and edema formation which may result in iscemia, as well as inflammatory processes. Both isolated SHT and polytrauma with or without brain damage may result in a systemic inflammatory response syndrome (SIRS) due to the synthesis of cytokines and other inflammatory mediators which may cause a single or multiple organ failure (MOF). Often the organism is able to survive isolated traumatic injuries and functional disturbances, but in combination or cumulation they may be lethal. The hypermetabolism after SHT is often regarded as an interaction between the central nervous system and the whole organism by the activation of the neuroendocrine axis. In contrast to the consequences of SHT for the whole organism, multiple injuries after polytrauma may affect brain functions, such as the shock dependent disturbance of the brain perfusion accompanied by brain hypoxia which may lead to an aggravated prognosis. Moreover, coagulation, metabolism and fracture healing are influenced by the onset of SIRS as well. Our knowledge about the bidirectional inflammatory interaction between brain and whole organism is still limited. In this context, the effects of secondary surgical interventions which may additionally, stress a traumatized body have to be considered and are the subject for actual clinical discussions and experimental studies. This article tries to summarize some important aspects on this topic.
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Brain injury occurs with a range of severity: even less severe cases should be carefully observed since they may deteriorate. By definition severe head injury has a Glasgow Coma Scale score of 8 or less; comatose patients are defined as cases who do not obey commands, do not open their eyes and do not speak. Very often (50% of case in our series) brain injury is associated with relevant extracranial injuries that may add to the severity of cases and may worsen outcome. The conceptual framework for treating head injury is based on the evidence that after the impact, the initial damage may be exacerbated by insults capable of further disturbing cerebral metabolism, leading to a final damage defined as secondary damage. Secondary damage represents the final end of many pathways that can be studied at the biochemical level and are centered in a calcium influx into the neuronal cell. Most probably there is a genetic susceptibility to secondary damage leading to a range of cellular dysfunctions for any given level of insult. The management of traumatic brain injury is aimed at interrupting the chain of events leading to secondary brain damage and from this perspective the fact that damage may develop over time can be seen as a window of opportunity for timely treatment. The milestone of treatment is the removal of surgical masses. This surgical treatment can be performed only in a brain that is properly perfused and once coagulation is preserved. Therefore the organization of treatment from rescue to neuro-traumatological centers should provide appropriate restoration of the volume and a normal oxygen delivery to the brain and to the overall organism.
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BACKGROUND: Multiple organ failure (OF/MOF) was found to be the major complication after blunt multiple trauma during the last 25 years and was correlated with a high mortality rate. Recently, several publications reported a decreased ARDS-related mortality, but there is little information about mortality rates from posttraumatic MOF. The purpose of this study was to describe the development of MOF-related death after blunt multiple trauma during the last 25 years. METHODS: Blunt multiple trauma patients with an Injury Severity Score (ISS) > 15 points were included in this evaluation. According to the year of trauma, the population was divided into five groups: years 1975-1980 (n = 317), years 1981-1985 (n = 308), years 1986-1990 (n = 246), years 1991-1997 (n = 368), and years 1998-1999 (n = 122). Main outcome measurements were death, cause of death, and length of ICU stay. Patients dying within the first 24 hours after trauma were excluded. All data indicated in the Results section are presented as mean +/- SEM. Continuous variables were compared by ANOVA. Ordinal variables were analyzed by chi2 contingency table analysis and, if significant, subsequently by Fisher's exact test (two-tailed test, p < 0.05). RESULTS: Mean ISS remained unchanged between 1975-1980 (ISS 29 +/- 1) and 1998-1999 (ISS 31 +/- 1) (p = 0.56). During the observation period, the mean age increased from 33 +/- 1 years (1975-1980) to 40 +/- 2 years (1998-1999) (p = 0.03). The overall incidence of OF/MOF slightly increased from 25.6% (1975-1980) to 33.6% (1998-1999) (p = 0.1). Length of ICU stay was not different between 1975-1980 (LOS: 14 +/- 1 d) and 1998-1999 (LOS: 19 +/- 2 d) (p = 1.0). The overall mortality decreased significantly, from 28.7% (1975-1980) to 13.9% (1998-1999) (p < 0.001). While the mortality due to severe head injuries remained unchanged (1975-1980, 8.2%; 1998-1999, 9.0%) (p = 0.85), mortality due to OF/MOF decreased significantly (p < 0.001), from 18.0% (1975-1980) to 4.1% (1998-1999). The age of patients dying from OF/MOF increased significantly (p = 0.04) during the observation period, from 44 +/- 3 years (1975-1980) to 63 +/- 6 years (1998-1999). CONCLUSION: Although MOF incidence remains unchanged, there is a significant fall in MOF-related mortality in patients with severe trauma, and death from single organ failure is virtually absent. Severe brain injury is now the leading cause of death in patients with severe multiple injuries admitted to the ICU.
Multiple trauma patients requiring prolonged intensive care are at high risk of MRSA infections. Surgical debridement and proper antibiotic prophylaxis combined with isolation of this compromised host from indigenous bacteria are the mainstays of initial therapy to prevent this complication. If this develops postoperatively, the sites of infection vary among the patients, such as urinary tract, surgical wounds, the abdomen, respiratory tract, vascular catheters, etc. Clinical evidence of sepsis suggests that intra-abdominal and respiratory tract infection are major contributors to mortality. In a postoperative multiple trauma patient, with pneumonia, thoracic empyema, intraabdominal abscess, wound infection and sepsis caused by MRSA, surgical drainage of the abscess with systemic infusion of vancomycin was effective and resulted in full recovery.
BACKGROUND: In Germany, abdominal trauma in multiple- trauma patients can be observed in about 25-35% of all cases. Due to major bleeding complications, the initial treatment of blunt abdominal trauma in multiple-trauma patients has high priority. The aim of this study was to discuss management, treatment and outcome of blunt liver injury in multiple-trauma patients treated in our department. METHODS: The clinical records of 1192 multiple-trauma patients [injury severity score (ISS) 3-18] treated at the Surgical Department of the University Clinic of Essen from January 1975 to February 1998 were reviewed. Seventy-five patients with an ISS above 18 operated on due to a blunt liver injury could be included. The mean age was 29.82+/-1.80 years (60 males and 15 females). The degree of injury in this group was high (ISS 37.12+/-1.06). RESULTS: Twenty-three of the 75 (30.6%) patients died during their hospital stay. Deceased patients were older (27+/-2 years versus 37+/-4 years; P<0.01) and had a higher ISS (ISS=34.5+/-1 versus 43.2+/-2; P<0.01). In nine cases, death was strongly related to liver injury. Operational blood loss was higher in the group of multiply injured patients with liver injury and in those patients who did not survive (P<0.05). An increased mortality could be seen in this selected patient group when compared with our large collective of multiply injured patients. The age of the patients, the ISS and operative blood loss were the significant factors that influenced the operative mortality after blunt hepatic injuries in our study.
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Early recognition of blunt abdominal trauma in patients with multiple injuries and in shock is of utmost importance and calls for a rapid screening method. The reliability of diagnostic ultrasonography in detecting hemoperitoneum in patients with multiple trauma was evaluated prospectively. From 1986 to 1990, 291 patients with severe multiple injuries (ISS greater than 20, mean ISS 31.2) were included in the study. Laparotomy was performed on 117 patients (40%). Initial ultrasound (US) findings showed a sensitivity, specificity, and accuracy of 89%, 97%, and 94%, respectively, in detecting intra-abdominal injuries requiring surgical repair. The positive and negative predictive values were 94% and 95%, respectively. A standardized management of frequent repeat US studies can even improve on these numbers. In our department ultrasonography has replaced diagnostic peritoneal lavage (DPL) as the diagnostic study of first choice. Diagnostic peritoneal lavage is reserved for selected cases only.
Multiple organ failure (MOF) following major trauma occurs in response to perfusion deficits, a persistent inflammatory focus, or a persistent focus of dead and/or injured tissue. Several pathophysiologic aspects are considered relevant to current clinical practice. Their application in settings of trauma and surgical sepsis reduces overall mortality and incidence of multiple organ failure. With regard to the pathophysiologic background (I) microcirculatory resuscitation, (II) source control, and (III) metabolic support appear to be important therapeutic principles. (I) Microcirculatory Resuscitation: Since time is a critical factor in damage control, resuscitation and restoration of microvascular perfusion needs to occur as soon as possible if multiple system organ failure is to be avoided during the later time course. (II) Source control: The best treatment for multiorgan failure appears to be prevention. With early, aggressive control or removal of risk factors for multiple organ failure, namely early surgical intervention for control of hemorrhage, control of potential septic sources, decompression, and early fracture stabilization reductions in the incidence and mortality of MOF have been observed. Metabolic support: Malnutrition appears to be an important cofactor in morbidity and mortality. (III) Metabolic support needs to be started early and prior to the phenomenon of nitrogen retention during the hypermetabolic state of multiple organ failure.
OBJECTIVE: Patients with multiple trauma often have injuries that preclude the use of anticoagulation therapy or sequential compression device prophylaxis. Temporary inferior vena cava (IVC) filters (IVCFs) offer protection against pulmonary embolism during the early immediate injury and perioperative period, when risk is highest, while averting potential long-term sequelae of permanent IVCFs. The objective of this study was to evaluate the efficacy of prophylactic, temporary IVCF placement at the intensive care unit bedside under real-time intravascular ultrasound (IVUS) guidance in patients with multiple trauma. INTERVENTIONS: Ninety-four patients with multiple trauma seen between July 1, 2002, and November 1, 2003, underwent placement of OptEase (Cordis Endovascular) retrievable IVCFs under real-time IVUS guidance. Mean (+/-SD) Injury Severity Score was 25.1 +/- 2.2). Abdominal x-ray films were obtained in all patients to verify filter location. Before IVCF retrieval all patients underwent femoral vein color-flow ultrasound scanning to rule out deep vein thrombosis (DVT), and pre-procedure and post-procedure vena cavography to identify possible IVCF thrombus entrapment and post-retrieval inferior vena cava injury. RESULTS: Nineteen patients died of their injuries; no deaths were related to IVCF placement. One pulmonary embolism occurred during follow-up after filter retrieval, and 1 insertion site femoral vein DVT occurred. As verified on abdominal x-ray films, 96.8% (91 of 94) of IVCFs were placed without complications at the L2-3 level. Filter-related complications included 2 groin hematomas (2.1%) and 3 IVCFs misplaced in the right iliac vein (3.2%), early in our experience; the filters were uneventfully retrieved and replaced in the inferior vena cava within 24 hours. Thirty-one patients underwent uneventful retrieval of IVCFs after DVT or pulmonary embolism anticoagulation prophylaxis was initiated. Forty-four filters were not removed, 41 because severity of injury prevented DVT or pulmonary embolism prophylaxis and 3 because of thrombus trapped within the filter. CONCLUSIONS: Prophylactic, temporary IVCF placement at the intensive care unit bedside under IVUS guidance in patients with multiple trauma is simple and safe, and serves as an effective "bridge" to anticoagulation therapy until venous thromboembolism prophylaxis can be initiated. Further investigation of this bedside technique and the role of temporary IVCFs in patients with multiple trauma is warranted. CLINICAL RELEVANCE: Patients with multiple trauma often have injuries that preclude the use of anticoagulation therapy or sequential compression device prophylaxis. Temporary inferior vena cava filters (IVCFs) offer protection against pulmonary embolism during the perioperative and immediate injury period, when risk is highest. Ninety-four patients with multiple trauma underwent prophylactic, temporary IVCF placement at the intensive care unit bedside under real-time intravascular ultrasound. One pulmonary embolism occurred during follow-up after filter retrieval, and 1 insertion site femoral vein deep venous thrombosis occurred. Ninety-one of 94 IVCFs (96.8%) were placed without complication. Thirty-one patients underwent uneventful retrieval of IVCFs after anticoagulation prophylaxis was initiated. Forty-four filters were not removed, because of severity of injury (n = 41) or because of trapped thrombus within the filter (n = 3). Prophylactic, temporary IVCFs placed under intravascular ultrasound guidance at the bedside in patients with multiple trauma is simple, safe, and an effective bridge to anticoagulation therapy.
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Multiple trauma is more than the sum of the injuries. Management not only of the physiologic injury but also of the pathophysiologic responses, along with integration of the child's emotional and developmental needs and the child's family, forms the basis of trauma care. Multiple trauma in children also elicits profound psychological responses from the healthcare providers involved with these children. This overview will address the pathophysiology of multiple trauma in children and the general principles of trauma management by an integrated trauma team. Trauma is a systemic disease. Multiple trauma stimulates the release of multiple inflammatory mediators. A lethal triad of hypothermia, acidosis, and coagulopathy is the direct result of trauma and secondary injury from the systemic response to trauma. Controlling and responding to the secondary pathophysiologic sequelae of trauma is the cornerstone of trauma management in the multiply injured, critically ill child. Damage control surgery is a new, rational approach to the child with multiple trauma. The selection of children for damage control surgery depends on the severity of injury. Major abdominal vascular injuries and multiple visceral injuries are best considered for this approach. The effective management of childhood multiple trauma requires a combined team approach, consideration of the child and family, an organized trauma system, and an effective quality assurance and improvement mechanism.
OBJECTIVE: The aim of this prospective study was to evaluate, whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work up of blunt thoracic trauma and whether these additional informations influence subsequent therapeutical decisions in the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiple injured patients with chest trauma, 9 patients with isolated chest trauma) with an average ISS of 30 and an average AIS thorax of 3 initial CXR and TCT were compared after first assessment in our emergency department of a level I trauma center. RESULTS: In 67 patients (65%) TCT detected major complications of chest trauma, that have been missed on CXR [lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)], in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT and in 14 patients CXR and TCT showed the same pathological results. 11 patients had both CXR and TCT without pathological findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005) and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement or chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1). CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions, pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work up of multiple injured patients with suspected chest trauma, because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.